J Steer

The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease

Background Despite exacerbations of chronic obstructive pulmonary disease (COPD) being both common and often fatal, accurate prognostication of patients hospitalised with an exacerbation is difficult. For exacerbations complicated by pneumonia, the CURB-65 prognostic tool is frequently used but its use in this population is suboptimal. Methods Consecutive patients hospitalised with an exacerbation of COPD were recruited. Admission clinical data and inhospital death rates were recorded. Independent predictors of outcome were identified by logistic regression analysis and incorporated into a clinical prediction tool. Results 920 patients were recruited: mean (SD) age was 73.1 (10.0) years; 53.9% were female subjects; mean (SD) forced expiratory volume in one second was 43.6 (17.2) % predicted; and 96 patients (10.4%) died in hospital. The five strongest predictors of mortality (extended MRC Dyspnoea Score, eosinopenia, consolidation, acidaemia, and atrial fibrillation) were combined to form the Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) Score. The Score, which underwent internal bootstrap validation, showed excellent discrimination for mortality (area under the receiver operator characteristic curve =0.86, 95% CI 0.82 to 0.89) and performed more strongly than other clinical prediction tools. In the subgroup of patients with coexistent pneumonia (n=299), DECAF was a significantly stronger predictor of mortality than CURB-65. Conclusions The DECAF Score is a simple yet effective predictor of mortality in patients hospitalised with an exacerbation of COPD and has the potential to help clinicians more accurately predict prognosis, and triage place and level of care to improve outcome in this common condition.

Predicting outcomes following hospitalization for acute exacerbations of COPD.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a frequent cause of hospital admission and are associated with significant morbidity, mortality, high readmission rates and high resource utilization. More accurate prediction of survival and readmission in patients hospitalized with AECOPD should help to optimize clinical management and allocation of resources, including targeting of palliative care and strategies to reduce readmissions. We have reviewed the published retrospective and prospective studies in this field to identify the factors most likely to be of value in predicting in-hospital and post-discharge mortality, and readmission of patients hospitalized for AECOPD. The prognostic factors which appear most important vary with the particular outcome under consideration. In-hospital mortality is related most clearly to the patients acute physiological state and to the development of acute comorbidity, while post-discharge mortality particularly reflects the severity of the underlying COPD, as well as specific comorbidities, especially cardiac disease. Important factors influencing the frequency of readmission include functional limitation and poor health-related quality of life. Large prospective studies which incorporate all the potentially relevant variables are required to refine prediction of the important outcomes of AECOPD and thus to inform clinical decision making, for example on escalation of care, facilitated discharge and provision of palliative care.

P117 Comparison of indices of nutritional status in prediction of in-hospital mortality and early readmission of patients with acute exacerbations of COPD

Introduction and objectives In patients hospitalised with an acute exacerbation of COPD (AECOPD), low body mass index (BMI) predicts in-hospital death. The Malnutrition Universal Screening Tool (MUST) incorporates BMI and patient-reported weight loss over the previous 6 months to provide an overall assessment of malnutrition risk. It predicts mortality in elderly hospitalised patients1 but, to our knowledge, the prognostic value of this tool in AECOPD has not been previously reported. Methods We prospectively identified patients hospitalised with AECOPD. We investigated the ability of BMI, self-reported weight loss and MUST score to predict in-hospital mortality and 28-day readmission. BMI <18.5 kgm−2 was considered underweight (World Health Organisation, 2004). Odds Ratios (OR) were calculated using normal BMI, weight loss <5%, and MUST score 0 as reference values. Results 608 patients were included; mean (SD) age 72.8 (10.2) years, 55.8% female, mean (SD) FEV1 (if performed within 2 years of admission, n=398) 43.5 (18) % predicted. 61 (10%) patients died in-hospital (6.9% in those with simple exacerbations, 16.5% in exacerbations associated with pneumonia). Of patients surviving to discharge, 95 (17.4%) were readmitted within 28 days (Abstract P117 Table 1). In-hospital mortality was predicted by BMI <18.5 kgm−2 (OR 2.5, 95% CI 1.27 to 4.91, p=0.008) whereas weight loss >10% predicted early readmission (OR 3.90, 95% CI 2.09 to 7.28, p<0.001). A high risk of malnutrition (MUST ≥2) was the only measurement that significantly predicted both in-hospital mortality (OR 2.10, 95% CI 1.18 to 3.74, p=0.011) and early readmission to hospital (OR 1.71, 95% CI 1.04 to 2.83, p=0.034). BMI within the overweight range appeared to be protective against early readmission (OR 0.54, 95% CI 0.29 to 0.99, p=0.046). Conclusion In patients hospitalised with AECOPD, indices of nutritional status are important predictors of outcome. Of interest, BMI and self-reported weight loss predict different outcome measures (in-hospital death and early readmission respectively). A high risk of malnutrition (MUST score ≥2) is potentially a useful predictor of both in-hospital mortality and early hospital readmission and we suggest that it should be assessed routinely.Abstract P117 Table 1 Nutritional measurements and their relationship to outcome BMI (kgm−2) Weight loss % MUST <18.5 18.5–24.9 25–29.9 >30 <5 5–10 >10 0 1 ≥2 % 17.8 37.5 25 19.7 79.3 11.2 9.5 64.8 10.4 24.8 OR for in-hospital mortality 2.50* 1 1.03 0.89 1 1.52 1.59 1 1.46 2.10* OR for early readmission 0.86 1 0.54* 0.80 1 1.36 3.90* 1 1.24 1.71** Significance <0.05.

Longitudinal change in quality of life following hospitalisation for acute exacerbations of COPD.

Background Current guidelines for management of patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (COPD) recommend that clinical decisions, including escalation to assisted ventilation, be informed by an estimate of the patients’ likely postdischarge quality of life. There is little evidence to inform predictions of outcome in terms of quality of life, psychological well-being and functional status. Undue nihilism might lead to denial of potentially life-saving therapy, while undue optimism might prolong suffering when alternative palliation would be more appropriate. This study aimed to detail longitudinal changes in quality of life following hospitalisation for acute exacerbations of COPD. Methods We prospectively recruited two cohorts (exacerbations requiring assisted ventilation during admission and exacerbations not ventilated). Admission clinical data, and mortality and readmission details were collected. Quality of life, psychological well-being and functional status were formally assessed over the subsequent 12 months. Time-adjusted mean change in quality of life was examined. Results 183 patients (82 ventilated; 101 not ventilated) were recruited. On average, overall quality of life improved by a clinically important amount in those not ventilated and did not decline in ventilated patients. Both groups showed clinically important improvements in respiratory symptoms and an individuals sense of control over their condition, despite the tendency for functional status to decline. Conclusions On average, postdischarge quality of life improved in non-ventilated and did not decline in ventilated patients. Certain quality of life domains (ie, symptoms and mastery) improved significantly. Better understanding of longitudinal change in postdischarge quality of life should help to inform decision-making.

Early Supported Discharge/Hospital At Home For Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Review and Meta-Analysis.

abstract A systematic review and meta-analysis was performed to assess the safety, efficacy and cost of Early Supported Discharge (ESD) and Hospital at Home (HAH) compared to Usual Care (UC) for patients with acute exacerbation of COPD (AECOPD). The structure of ESD/HAH schemes was reviewed, and analyses performed assuming return to hospital during the acute period (prior to discharge from home treatment) was, and was not, considered a readmission. The pre-defined search strategy completed in November 2014 included electronic databases (Medline, Embase, Amed, BNI, Cinahl and HMIC), libraries, current trials registers, national organisations, key respiratory journals, key author contact and grey literature. Randomised controlled trials (RCTs) comparing ESD/HAH to UC in patients admitted with AECOPD, or attending the emergency department and triaged for admission, were included. Outcome measures were mortality, all-cause readmissions to 6 months and cost. Eight RCTs were identified; seven reported mortality and readmissions. The structure of ESD/HAH schemes, particularly selection criteria applied and level of support provided, varied considerably. Compared to UC, ESD/HAH showed a trend towards lower mortality (RRMH = 0.66; 95% CI 0.40–1.09, p = 0.10). If return to hospital during the acute period was not considered a readmission, ESD/HAH was associated with fewer readmissions (RRMH = 0.74, 95% CI: 0.60–0.90, p = 0.003), but if considered a readmission, the benefit was lost (RRMH = 0.84; 95% CI 0.69–1.01, p = 0.07). Costs were lower for ESD/HAH than UC. ESD/HAH is safe in selected patients with an AECOPD. Further research is required to define optimal criteria to guide patient selection and models of care.

Practical respiratory management in amyotrophic lateral sclerosis: evidence, controversies and recent advances

In amyotrophic lateral sclerosis, the onset of respiratory muscle weakness is silent, but survival following symptom recognition may only be a few weeks. Consequently, respiratory function and symptoms should be assessed every 2-3 months. Noninvasive ventilation improves symptoms, quality of life and survival, without increasing carer burden. Lung volume recruitment helps to reverse and prevent atelectasis, improving gas exchange, while techniques to enhance sputum clearance reduce the risk of mucus plugging and lower respiratory tract infections. When noninvasive support fails, often due to severe bulbar impairment, tracheostomy ventilation prolongs life. Most patients receiving tracheostomy ventilation at home report satisfactory quality of life, but at the expense of high carer burden. Diaphragmatic pacing is associated with an increased risk of death.

S168 Evaluation of the MRC dyspnoea scale and a novel extended version in prediction of in-hospital death and early readmission in acute exacerbations of COPD

Introduction and objectives Acute exacerbations of COPD (AECOPD) requiring hospitalisation are associated with substantial in-hospital mortality and frequent readmissions. The MRC Dyspnoea Scale (MRCD) is a strong predictor of mortality in stable disease and may predict in-hospital mortality in AECOPD.1 We investigated the relative value, for predicting mortality and early readmission, of both the MRCD and an extended MRCD scale (eMRCD),2 which dichotomises MRCD 5 according to whether the individual can wash and dress independently (5a) or not (5b). Methods We prospectively assessed MRCD and eMRCD (based on the patients clinically stable state over the preceding 3 months) in patients hospitalised with AECOPD. The ability of the two scales to predict (a) in-hospital mortality and (b) readmission within 28 days of discharge was evaluated. Results 639 patients were identified; mean (SD) age 73 (10) years, 55.6% female and mean (SD) FEV1 (n=412) 43.5 (18) % predicted. The distribution of scores for the MRCD and eMRCD are shown in Abstract S168 Table 1. Due to a small number of individuals with MRCD scores 1 (n=4) and 2 (n=26), groups 1–3 were combined. Abstract S168 Table 1 Compared to the reference category (MRCD 1–3), MRCD 5, eMRCD 5a and eMRCD 5b predicted both in-hospital mortality and early readmission (Abstract S168 Table 1). Of importance, eMRCD 5b was a stronger predictor of in-hospital death then eMRCD 5a (OR 2.30, 95% CI 1.25 to 4.26, p=0.008) however, the predictive strength of 5a and 5b, with regards to early readmission, was similar (OR 1.32, 95% CI 0.67 to 2.58, p=0.42). Paired comparisons between groups showed that MRCD 5 (OR 5.29, 95% CI 2.87 to 9.80, p<0.001), eMRCD 5a (OR 3.56, 95% CI 1.77 to 7.14, p<0.001) and eMRCD 5b (OR 8.20, 95% CI 4.15 to 16.20, p<0.001) were all stronger predictors of in-hospital mortality than MRCD 4, whereas only MRCD 5b was a stronger predictor of readmission (OR 2.24, 95% CI 1.20 to 4.18, p=0.011).Abstract S168 Table 1 MRC Dyspnoea Scores and their association with in-hospital mortality and early readmission OR—OR MRC Dyspnoea Score n In-hospital mortality% OR for in-hospital mortality n* 28-day readmission % OR for 28-day readmission 1–3 133 2.3 1 130 8.5 1 4 265 5.3 2.42 251 15.1 1.93 5 241 22.8 12.81‡ 186 25.3 3.66‡ 5a 139 16.5 8.59† 116 23.3 3.28† 5b 102 31.4 19.81‡ 70 28.6 4.33‡* Patients surviving to discharge, total=567.† = p<.05.‡ = p<.001. Conclusion The MRCD during the stable state prior to hospitalisation predicts both in-hospital death and readmission within 28 days. Extending the scale to include an assessment of the patients capacity to manage personal care (the eMRCD) improves the ability to predict in-hospital mortality and readmission, compared to the traditional instrument.

Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation

Background Previous models of Hospital at Home (HAH) for COPD exacerbation (ECOPD) were limited by the lack of a reliable prognostic score to guide patient selection. Approximately 50% of hospitalised patients have a low mortality risk by DECAF, thus are potentially suitable. Methods In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days. Results Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI −2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1–7), UC=5 (IQR 2–12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD. Conclusion HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge. Trial registration number Registered prospectively ISRCTN29082260.

Specialist emergency care and COPD outcomes

Introduction In exacerbation of chronic obstructive pulmonary disease (ECOPD) requiring hospitalisation greater access to respiratory specialists improves outcome, but is not consistently delivered. The UK National Confidential Enquiry into Patient Outcome and Death 2015 enquiry showed over 25% of patients receiving acute non-invasive ventilation (NIV) for ECOPD died in hospital. On 16 June 2015 the Northumbria Specialist Emergency Care Hospital (NSECH) opened, introducing 24/7 specialty consultant on-call, direct admission from the emergency department to specialty wards and 7-day consultant review. A Respiratory Support Unit opened for patients requiring NIV. Before NSECH the NIV service included mandated training and competency assessment, 24/7 single point of access, initiation of ventilation in the emergency department, a door-to-mask time target, early titration of ventilation pressures and structured weaning. Pneumonia or hypercapnic coma complicating ECOPD have never been considered contraindications to NIV. After NSECH staff-patient ratios increased, the NIV pathway was streamlined and structured daily multidisciplinary review introduced. We compared our outcomes with historical and national data. Methods Patients hospitalised with ECOPD between 1 January 2013 and 31 December 2016 were identified from coding, with ventilation status and radiological consolidation confirmed from records. Age, gender, admission from nursing home, consolidation, revised Charlson Index, key comorbidities, length of stay, and inpatient and 30-day mortality were captured. Outcomes pre-NSECH and post-NSECH opening were compared and independent predictors of survival identified via logistic regression. Results There were 6291 cases. 24/7 specialist emergency care was a strong independent predictor of lower mortality. Length of stay reduced by 1  day, but 90-day readmission rose in both ventilated and non-ventilated patients. Conclusion Provision of 24/7 respiratory specialist emergency care improved ECOPD survival and shortened length of stay for both non-ventilated and ventilated patients. The potential implications in respect to service design and provision nationally are substantial and challenging.

P190 Specialist emergency care and copd outcomes

Introduction On 16/06/15 the Northumbria Specialist Emergency Care Hospital (NSECH) opened, introducing 24/7 speciality consultant on-call, direct transfer from the emergency department to speciality wards and 7 day consultant review. A Respiratory support unit opened for non-invasive ventilation (NIV), with enhanced staffing ratios. Pre-NSECH the NIV service included mandated training and competency assessment, 24/7 single point of access, initiation of ventilation in the Emergency Department, a door-to-mask time target, early titration of pressures, and structured weaning. Pneumonia or hypercapnic coma complicating ECOPD is not considered a contra-indication to NIV. Post-NSECH staff-patient ratios increased, the NIV pathway was streamlined and structured review introduced. The NCEPOD 2015 enquiry and 2013 BTS NIV audit showed ≥34% of patients receiving acute NIV died. Methods Patients hospitalised with ECOPD between 1/1/13 and 31/12/16 were identified using ICD10 J44 codes. Ventilation status was confirmed from rolling audit data, combined with a coding search (J96) and verification from patient records. Age, gender, admission from nursing home, consolidation, Charlson index, key comorbidities, length of stay and inpatient and 30 day mortality were captured. Population characteristics and outcomes were compared pre- and post-NSECH. Independent predictors of mortality were identified by logistic regression. Inpatient and 30 day mortality, adjusted for baseline performance and prognostic indices, was plotted (VLAD: Variable Life Adjusted Display). Results 6291 patients were identified. Pre- and post-NSECH, demographic and clinical indices were similar. Among ventilated patients, 96.5% and 98% received NIV respectively. Inpatient plus 30 day mortality was lower post-NSECH for the whole cohort, and for ventilated and non-ventilated subgroups. Independent predictors of mortality in a) the whole cohort were: NSECH [Beta=0.64; p=0.0001], age, admission from nursing home and Charlson Index; and b) in ventilated patients were: NSECH [Beta=0.51; p=0.0016], age and male gender. The VLAD plot showed sustained improvement in observed/expected mortality post-NSECH. Post-NSECH median length of stay fell by one day in both sub-groups. Conclusions Introduction of 24/7 specialist emergency care was associated with a substantial fall in ECOPD mortality from strong baseline performance. Improved outcome was not limited to high-risk patients receiving ventilation. Furthermore, mortality day 0–30 post discharge also fell. Abstract P190 Table 1 Pre-NSECH Post-NSECH P value Inpatient Mortality All patients (%) 223/3943 (5.66) 90/2348 (3.83) 0.0012 Ventilated (%) 71/540 (13.15) 32/346 (9.25) 0.086 Not ventilated (%) 152/3403 (4.47) 58/2002 (2.90) 0.0035 Inpatient+30 day combined mortality All patients (%) 309/3943 (7.84) 123/2348 (5.24) <0.0001 Ventilated (%) 98/540 (18.15) 36/346 (10.40) 0.0015 Not ventilated (%) 211/3403 (6.20) 87/2002 (4.35) 0.0037