M. Wildman

Socioeconomic Status and Outcome From Intensive Care in England and Wales

Objective:The objective of this study was to estimate the association between socioeconomic status (SES) and outcome for admissions to intensive care. Research Design:Retrospective cohort study. Subjects:We studied 51,572 admissions to 99 intensive-care units in England and Wales between 1995 and 2000. Measures:The SES of admissions was measured using Carstairs deprivation scores. Outcome was hospital mortality after adjustment for case mix using the APACHE II method. Results:Admissions of lower SES were, on average, younger and less likely to be following surgery. There was evidence of a SES gradient for hospital mortality in admissions after elective surgery after adjusting for case mix (test for trend P <0.001), with higher SES associated with lower mortality. In the least-deprived quintile of SES, the odds ratio for hospital mortality was 0.70 (95% confidence interval, 0.58–0.84) compared with the most deprived quintile. There was no evidence of a SES gradient for hospital mortality in nonsurgical or emergency surgical admissions, and the decision to withdraw active treatment did not differ by SES. Conclusions:There is a SES gradient for hospital mortality in elective surgical admissions that is not explained by differences in case mix or the withdrawal of active treatment. Further research is required to establish if this finding can be explained by unmeasured differences in health status at admission to an intensive-care unit or differences in care and to establish the potential impact these results may have on interpreting comparative surgical performance data.

Survival and quality of life for patients with COPD or asthma admitted to intensive care in a UK multicentre cohort: the COPD and Asthma Outcome Study (CAOS)

Background: Non-invasive ventilation is first-line treatment for patients with acutely decompensated chronic obstructive pulmonary disease (COPD), but endotracheal intubation, involving admission to an intensive care unit, may sometimes be required. Decisions to admit to an intensive care unit are commonly based on predicted survival and quality of life, but the information base for these decisions is limited and there is some evidence that clinicians tend to be pessimistic. This study examined the outcomes in patients with COPD admitted to the intensive care unit for decompensated type II respiratory failure. Methods: A prospective cohort study was carried out in 92 intensive care units and 3 respiratory high dependency units in the UK. Patients aged 45 years and older with breathlessness, respiratory failure or change in mental status due to an exacerbation of COPD, asthma or a combination of the two were recruited. Outcomes included survival and quality of life at 180 days. Results: Of the 832 patients recruited, 517 (62%) survived to 180 days. Of the survivors, 421 (81%) responded to a questionnaire. Of the respondents, 73% considered their quality of life to be the same as or better than it had been in the stable period before they were admitted, and 96% would choose similar treatment again. Function during the stable pre-admission period was a reasonable indicator of function reported by those who survived 180 days. Conclusions: Most patients with COPD who survive to 180 days after treatment in an intensive care unit have a heavy burden of symptoms, but almost all of them—including those who have been intubated—would want similar intensive care again under similar circumstances.

Case mix and outcomes for admissions to UK adult, general critical care units with chronic obstructive pulmonary disease: a secondary analysis of the ICNARC Case Mix Programme Database

IntroductionChronic obstructive pulmonary disease (COPD) is a common cause of admission to intensive care units (ICUs) in the UK. This report describes the case mix and outcomes of these patients and explores associations of measures of case mix available in the first 24 hours with outcome.MethodWe conducted a secondary analysis of a high quality clinical database, the ICNARC Case Mix Programme Database, of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland for the period from 1995 to 2001.ResultsNonsurgical admissions with COPD accounted for 3752 admissions (2.9% of all admissions). Patients were acidotic (median pH 7.26, interquartile range [IQR] 7.18–7.33), hypercapnic (median arterial CO2 tension 8.7, IQR 6.9–10.7) and hypoxic (median arterial O2 tension/fractional inspired oxygen gradient 22.9, IQR 17.2–29.6). Overall, 2775 (73.9%) were definitely intubated and 278 (7.4%) were probably intubated in the first 24 hours in the ICU. The median (IQR) ICU length of stay was 4.0 (1.6–9.4) days and the hospital length of stay was 16 (9–29) days. a total of 827 patients (23.1%) died in the admitting ICU and 1322 (38.3%) died during hospital admission. Age, presence of severe respiratory disease, length of stay in hospital before critical care admission, cardiopulmonary resuscitation within 24 hours before admission, intubation status in first 24 hours in critical care, pH, arterial oxygen tension/fractional inspired oxygen gradient, albumin, cardiovascular organ failure, neurological organ failure and renal organ failure all had independent associations with hospital mortality. Respiratory organ failure had a significant independent association with decreased hospital mortality.ConclusionNonsurgical patients with COPD represent an important group of patients admitted to UK ICUs. The presence of single organ respiratory failure in the first 24 hours in critical care identifies patients with a 70% chance of surviving to leave hospital.

Airway clearance techniques used by people with cystic fibrosis in the UK

OBJECTIVES To describe the current use of airway clearance techniques among people with cystic fibrosis (CF) in the UK, and the baseline characteristics for users of different airway clearance techniques. DESIGN Analysis of the UK CF Registry 2011 data. SETTING AND PARTICIPANTS All people with CF in the UK aged ≥11 years (n=6372). RESULTS Of the 6372 people on the UK CF registry in 2011, 89% used airway clearance techniques. The most commonly used primary techniques were forced expiratory techniques (28%) and oscillating positive expiratory pressure (PEP) (23%). Postural drainage and high-frequency chest wall oscillation were used by 4% and 1% of people with CF, respectively. The male:female ratio of individuals who used exercise as their primary airway clearance technique was 2:1, compared with 1:1 for other techniques. Individuals with more severe lung disease tended to use devices such as non-invasive ventilation or high-frequency chest wall oscillation. CONCLUSIONS Forced expiratory techniques and oscillating PEP are the most common airway clearance techniques used by people with CF in the UK, and postural drainage and high-frequency chest wall oscillation are the least common techniques. This is significant in terms of planning airway clearance technique trials, where postural drainage has been used traditionally as the comparator. The use of airway clearance techniques varies between countries, but the reasons for these differences are unknown.

Accurate reporting of adherence to inhaled therapies in adults with cystic fibrosis: methods to calculate “normative adherence”

Background Preventative inhaled treatments in cystic fibrosis will only be effective in maintaining lung health if used appropriately. An accurate adherence index should therefore reflect treatment effectiveness, but the standard method of reporting adherence, that is, as a percentage of the agreed regimen between clinicians and people with cystic fibrosis, does not account for the appropriateness of the treatment regimen. We describe two different indices of inhaled therapy adherence for adults with cystic fibrosis which take into account effectiveness, that is, “simple” and “sophisticated” normative adherence. Methods to calculate normative adherence Denominator adjustment involves fixing a minimum appropriate value based on the recommended therapy given a person’s characteristics. For simple normative adherence, the denominator is determined by the person’s Pseudomonas status. For sophisticated normative adherence, the denominator is determined by the person’s Pseudomonas status and history of pulmonary exacerbations over the previous year. Numerator adjustment involves capping the daily maximum inhaled therapy use at 100% so that medication overuse does not artificially inflate the adherence level. Three illustrative cases Case A is an example of inhaled therapy under prescription based on Pseudomonas status resulting in lower simple normative adherence compared to unadjusted adherence. Case B is an example of inhaled therapy under-prescription based on previous exacerbation history resulting in lower sophisticated normative adherence compared to unadjusted adherence and simple normative adherence. Case C is an example of nebulizer overuse exaggerating the magnitude of unadjusted adherence. Conclusion Different methods of reporting adherence can result in different magnitudes of adherence. We have proposed two methods of standardizing the calculation of adherence which should better reflect treatment effectiveness. The value of these indices can be tested empirically in clinical trials in which there is careful definition of treatment regimens related to key patient characteristics, alongside accurate measurement of health outcomes.

Moving cystic fibrosis care from rescue to prevention by embedding adherence measurement in routine care

Cystic fibrosis [CF] is a chronic disease in which preventative treatment with nebulised antibiotics can reduce pulmonary exacerbations that otherwise require rescue therapy. However, adherence is low. Making adherence to maintenance treatment visible is a crucial step towards improving adherence. In this article, we discuss how adherence data can be used to support Quality Improvement in CF through behaviour change in both people with cystic fibrosis and their clinical teams.

Promoting adherence to nebulized therapy in cystic fibrosis: poster development and a qualitative exploration of adherence

Background Cystic fibrosis (CF) health care professionals recognize the need to motivate people with CF to adhere to nebulizer treatments, yet little is known about how best to achieve this. We aimed to produce motivational posters to support nebulizer adherence by using social marketing involving people with CF in the development of those posters. Methods The Sheffield CF multidisciplinary team produced preliminary ideas that were elaborated upon with semi-structured interviews among people with CF to explore barriers and facilitators to the use of nebulized therapy. Initial themes and poster designs were refined using an online focus group to finalize the poster designs. Results People with CF preferred aspirational posters describing what could be achieved through adherence in contrast to posters that highlighted the adverse consequences of nonadherence. A total of 14 posters were produced through this process. Conclusion People with CF can be engaged to develop promotional material to support adherence, providing a unique perspective differing from that of the CF multidisciplinary team. Further research is needed to evaluate the effectiveness of these posters to support nebulizer adherence.

Rescue therapy within the UK Cystic Fibrosis Registry: An exploration of predictors of intravenous antibiotic use amongst adults with CF: Predictors of i.v. antibiotic use in CF

Intravenous (i.v.) antibiotics are needed for rescue when preventative therapy fails to achieve stability among adults with cystic fibrosis (CF). Understanding the distribution of i.v. days can provide insight into the care that adults with CF need. We aim to determine the baseline characteristics that are associated with higher i.v. use, in particular to test the hypothesis that prior‐year i.v. use is associated with future‐year i.v. use.

Determinants of objective adherence to nebulised medications among adults with cystic fibrosis: an exploratory mixed methods study comparing low and high adherers

ABSTRACT Objectives: Adherence to nebulised treatment is typically low among people with cystic fibrosis (CF). This study sought to identify factors differentiating high or low nebuliser adherence patterns (i.e. ≥80% or <50% of all nebulised treatments over one year) among adults with CF. Design: A mixed methods cross-sectional exploratory comparison of low and high adherers to nebulised medications. Methods: Of 36 eligible adults invited from a UK CF centre, 20 were recruited (10 high, 10 low adherers). Adherence was objectively measured using electronic data capture. Participants completed a self-report questionnaire comprising measures of hypothesised predictors (habit, self-control, life chaos, perceived treatment burden, capability, motivation and opportunity), then took part in a semi-structured interview. Quantitative data were compared between groups, and interview data were thematically analysed. Results: High adherers reported stronger habit and greater opportunities, though habit and perceived opportunity scores were highly positively correlated. No other quantitative measure distinguished between groups. Habitual instigation tendency attenuated the relationship between treatment complexity and perceived treatment burden. Indeed, in interviews, high adherers reported that routinisation and greater automaticity made treatment burden more manageable. Conclusions: High adherers seized more opportunities for nebuliser use, adapted their lives more effectively to using nebulisers and were more likely to make nebuliser use habitual. Nebuliser adherence interventions among adults with CF might usefully target development of routines for instigating nebuliser use, and identification of opportune moments for nebuliser use.

P278 Is there a role for telemedicine in cystic fibrosis? A systematic review

Background As a result of new medical advances people with CF are now able to live longer but still require frequent specialist care input and support. To cope with an ever increasing complex condition and demand for care, CF centres are having to rethink the way they work. Telemedicine is an evolving field which has the advantage of remote monitoring and real time review and may provide a solution. Objectives To determine whether telemedicine has a role in the management of CF in terms of: 1) Feasibility and acceptability, 2) Early pulmonary exacerbation detection, and 3) Self-management and improving adherence to prescribed therapies. Methods A systematic search was undertaken to identify relevant studies. This involved seven electronic databases, the top four peer reviewed journals reporting on CF and telemedicine, and the three major conference proceedings in CF and telemedicine. Clinical trial registers were searched to find ongoing studies as supplementary evidence. A mixed methods synthesis was performed to combine results from quantitative and qualitative studies. Results 34 studies in total were included in the results synthesis. These consisted of mainly small pilot and feasibility studies. There were 7 RCTs largely reporting interim results rather than efficacy data. Rates of adherence to telemedicine varied between 10.16 to 59% but were generally poor with barriers including frequent measures being a burden, forgetting, and denial of results. There was a general consensus that pulmonary exacerbations can be detected early but no statistical tests of significance performed. There were also only 2 studies predominantly reporting qualitative evidence. After corroborating the results using thematic synthesis this led to 3 main themes (expectations, technical aspects, and impacts of telemedicine) linked to these were barriers and facilitators. Conclusion The findings indicate that telemedicine in CF is feasible but the uptake amongst people with CF may be challenging. This is probably not surprising since adherence to treatment is often poor. Nevertheless telemedicine has the potential to play an important role in the early detection of pulmonary exacerbations and further studies are required.