Hospital de día de enfermedades respiratorias: impacto sobre la tasa de ingresos hospitalarios por exacerbaciones de la enfermedad pulmonar obstructiva crónica

doi:10.1016/j.medcli.2010.07.031

Medicina Clínica

Volume 136, Issue 15, 28 May 2011, Pages 665-668

https://doi.org/10.1016/j.medcli.2010.07.031 Get rights and content

Resumen

Fundamento y objetivo

Las exacerbaciones de la enfermedad pulmonar obstructiva crónica (EA-EPOC) constituyen un factor determinante en el deterioro de los pacientes, con gran repercusión sobre el gasto sanitario. El objetivo de este estudio fue evaluar el impacto de la atención de las EA-EPOC en un hospital de día de enfermedades respiratorias (HDER) sobre la tasa de ingresos hospitalarios.

Pacientes y método

Durante 14 meses se recogieron prospectivamente todos los episodios de EA-EPOC atendidos en el HDER y en el Servicio de Urgencias, excluyendo a los pacientes con otra causa de agudización o necesidad de ventilación mecánica invasiva.

Resultados

Se incluyeron 226 episodios (173 pacientes, edad media [DE] de 72 [8] años). En el HDER se atendieron 121 (53,5%). El número de ingresos en el grupo del HDER fue claramente inferior (32,2 frente a 66,7%, p < 0,001), incluso en pacientes con más ingresos el año previo. No hubo diferencias en la gravedad de la exacerbación ni en la tasa de reingresos ni de mortalidad en el seguimiento.

Conclusiones

El manejo de las EA-EPOC en el HDER parece reducir el número de ingresos hospitalarios en comparación con un Servicio de Urgencias.

Abstract

Background and objective

Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are considered to be the most important factor in determining the course of the disease, and have great impact on the health care system. We evaluated the effects of a Respiratory Day Hospital (RDH) on the rate of hospital admissions due to AE-COPD.

Patients and methods

During 14 months, every case of AE-COPD seen at the RDH and emergency services was recruited prospectively. Patients were excluded when another known cause of exacerbation was present and/or when they required invasive mechanical ventilation.

Results

226 episodes (173 patients) were included (72, SD 8 years old). One hundred and twenty one cases received treatment at the RDH (53.5%). Admissions from the RDH group were noticeably lower (32.2 vs. 66.7%, p < 0.001), even in patients with more admissions due to AE-COPD the year before the study. There were no differences either in terms of AE-COPD severity or in readmissions and mortality rates during the follow up.

Conclusions

Management of AE-COPD in a RDH seems to be associated with a lower rate of hospital admissions in comparison with an emergency department.

Section snippets

Introducción

Es bien conocido el importante papel que desempeñan las exacerbaciones sobre el curso clínico de la enfermedad pulmonar obstructiva crónica (EPOC), de modo que son consideradas como un factor independiente en el deterioro funcional y de la calidad de vida de los pacientes¹. Así mismo, desde el punto de vista de la gestión de recursos hospitalarios, su impacto es tal, que contabilizan entre un 1 y 2% de todas las visitas a los Servicios de Urgencias² y casi un 10% de los ingresos en salas de

Pacientes y métodos

Desde octubre de 2007 y durante 14 meses se recogieron prospectivamente todos los episodios de EA-EPOC, definida según la normativa de la Sociedad Española de Neumología y Cirugía torácica (SEPAR)⁷, atendidos en el hospital de día de enfermedades respiratorias (grupo HDER) y en el Servicio de Urgencias (grupo UCIAS) de un hospital universitario. El comité de ética del hospital aprobó la realización del estudio y todos los pacientes dieron su consentimiento informado.

Se excluyeron los pacientes

Resultados

Se evaluaron de forma prospectiva 226 episodios de EA-EPOC en 173 pacientes (1,30 episodios/paciente) con una edad media (DE) de 72 (8) años. De todos los episodios, 121 se atendieron en el HDER (53,5%). En este grupo y con respecto a UCIAS, destacaba un número superior de episodios en situación de insuficiencia respiratoria crónica (todos ellos portadores de oxigenoterapia crónica domiciliaria) y que habían requerido más ingresos por EA-EPOC en el año previo al episodio estudiado. En cuanto a

Discusión

Nuestro estudio pone de manifiesto el gran impacto que conlleva la atención en un HDER de los pacientes con EA-EPOC, pues se puede reducir la probabilidad de ingreso hospitalario entre un 75 y un 94%, sin que esto se asocie con un aumento significativo de la tasa de reingresos ni de la mortalidad. Igualmente, los resultados demuestran que dicha disminución ocurre incluso en pacientes que han requerido un número superior de ingresos hospitalarios por EA-EPOC en el año previo al episodio

Financiación

Este trabajo ha sido financiado parcialmente por el Fondo de Investigación Sanitaria (FIS 06/90282, FIS 06/0326).

Conflicto de intereses

Los autores declaran no tener ningún conflicto de intereses.

Agradecimientos

Este trabajo ha sido posible gracias a la inestimable colaboración de la Sra. Nuria Torà, y de todo el personal de enfermería del Hospital de día de Neumología y del Servicio de Urgencias del Hospital de Sabadell, a quienes agradecemos su inagotable capacidad de trabajo y generosidad.

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There are more references available in the full text version of this article.

Cited by (12)

Implementation of an Integrated Care Model for Frequent-Exacerbator COPD Patients: A Controlled Prospective Study
2021, Archivos de Bronconeumologia
Citation Excerpt :
In the last decade, the importance of providing special care to the frequent-exacerbator COPD patient was emphasized. Various care models targeting these patients reported a reduction of health-care resources utilization in terms of emergency room (ER) visits and hospital admission as well as improvement of quality of life among this group of patients.13–16 The majority of these programs provided schedule visits and on-demand visits14–16; while other programs considered further telemonitoring through medical call centers.13,15
Frequent-exacerbator COPD (fe-COPD) associated with frequent hospital admissions have high morbidity, mortality and use of health resources. These patients should be managed in personalized integrated care models (ICM). Accordingly, we aimed to evaluate the long-term effectiveness of a fe-COPD ICM on emergency room (ER) visits, hospital admissions, days of hospitalization, mortality and improvement of health status.
Prospective-controlled study with analysis of a cohort of fe-COPD patients assigned to ICM and followed-up for maximally 7 years that were compared to a parallel cohort who received standard care. All patients had a confirmed diagnosis of COPD with a history of ≥2 hospital admissions due to exacerbations in the year before enrollment. The change in CAT score and mMRC dyspnea scale, hospital admissions, ER visits, days of hospitalization, and mortality were analyzed.
141 patients included in the ICM were compared to 132 patients who received standard care. The ICM reduced hospitalizations by 38.2% and ER visits by 69.7%, with reduction of hospitalizations for COPD exacerbation, ER visits and days of hospitalization (p < 0.05) compared to standard care. Further, health status improved among the ICM group after 1 year of follow-up (p = 0.001), effect sustained over 3 years. However, mortality was not different between groups (p = 0.117). Last follow-up CAT score > 17 was the strongest independent risk factor for mortality and hospitalization among ICM patients.
An ICM for fe-COPD patients effectively decreases ER and hospital admissions and improves health status, but not mortality.
La EPOC con agudizaciones frecuentes (EPOC-AF), que se asocia a ingresos hospitalarios recurrentes, presenta altas tasas de morbilidad y mortalidad, y un importante uso de los recursos sanitarios. Estos pacientes deberían ser tratados en modelos de atención integral (MAI) personalizada. Por este motivo, nuestro objetivo fue evaluar la efectividad a largo plazo de un MAI para EPOC-AF valorando las visitas a urgencias, los ingresos hospitalarios, los días de hospitalización, la mortalidad y la mejora del estado de la salud.
Estudio prospectivo controlado que analizó una cohorte de pacientes con EPOC-AF incluidos en un MAI y en seguimiento durante un máximo de 7 años en comparación con una cohorte paralela que recibió atención estándar. Todos los pacientes tenían diagnóstico confirmado de EPOC y antecedentes de ≥ 2 ingresos hospitalarios por agudizaciones durante el año anterior a su inclusión en el estudio. Se analizaron los cambios en la puntuación del CAT© y en la escala de disnea del MRC, en los ingresos hospitalarios, las visitas a urgencias, los días de hospitalización y la mortalidad.
Se compararon 141 pacientes incluidos en el MAI con 132 pacientes que recibieron atención estándar. El MAI redujo las hospitalizaciones en un 38,2% y las visitas a urgencias en un 69,7%, mostrando reducción de las hospitalizaciones por exacerbación de la EPOC, las visitas a urgencias y los días de hospitalización (p < 0,05) en comparación con la atención estándar. Además, el estado de salud mejoró en los pacientes del grupo del MAI después de un año de seguimiento (p = 0,001), un efecto que se mantuvo durante 3 años. Sin embargo, la mortalidad no fue diferente entre ambos grupos (p = 0,117). Una puntuación en el CAT© > 17 en el último control de seguimiento fue el factor independiente de riesgo más fuertemente asociado a la mortalidad y la hospitalización de los pacientes en el MAI.
Un MAI para pacientes con EPOC-AF reduce eficazmente los ingresos hospitalarios y en urgencias, y mejora el estado de salud, pero no la mortalidad.
Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD
2020, American Journal of Kidney Diseases
Citation Excerpt :
All interventions relied on integrated shared care from ED and specialty providers to manage complex oncologic complications and make decisions about disposition. Eighteen ambulatory care interventions for addressing chronic disease complications were reported in 20 studies.12,68-86 Most (n = 11) were specialist-run day hospitals or rapid access clinics in cancer and chronic respiratory disease populations, where patients could be assessed and treated urgently by their chronic disease care team for acute-care issues (eg, Respiratory Day Hospital68 or Medical Oncology Rapid Access Clinic78).
Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population.
Scoping review of quantitative and qualitative studies.
Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes).
MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019.
Intervention and study characteristics were extracted using standardized tools.
Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews.
77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed.
Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD.
Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.
Cost-Effectiveness Analysis of Pneumococcal and Influenza Vaccines Administered to Children Less Than 5 Years of Age in a Low-Income District of Bogota, Colombia
2018, Value in Health Regional Issues
Citation Excerpt :
As in the previous examples of Brazil [60] and Uruguay [67], one of the possible explanations could relate to the effects of changes in climate patterns. In the past years, Colombia has experienced a strong El Niño Southern Oscillation cold phase, known as La Niña [71], which could contribute to the increase in ARI hospitalizations and mortality [70,72]. These observed increases in severity might also be explained by socioeconomic factors.
The Colombian health authorities introduced the pneumococcal conjugated vaccine and the seasonal influenza vaccine into the national immunization schedule for children in 2009 and 2007, respectively. Despite this, the health authorities continue to be concerned about the high economic and disease burden among children from low-income households caused by these vaccine-preventable diseases.
1) To evaluate the potential health outcomes of four vaccination strategies for subsidized children younger than 5 years in a low-income district in Colombia from a public, direct medical health care perspective. 2) To perform univariate, multivariate, and probabilistic sensitivity analysis to evaluate the robustness of these results.
We built a Markov deterministic cohort model to evaluate five consecutive cohorts across four alternative situations: 1) no vaccination; 2) vaccination with the 10-valent pneumococcal conjugate vaccine (PCV10 vaccine); 3) vaccination with the trivalent inactivated vaccine (TIV) annually; and 4) combined vaccination with PCV10 vaccine and TIV.
The introduction of PCV10 vaccine and TIV and their combined use in particular would be highly cost-effective in comparison to no vaccination. For the combined vaccination with PCV10 vaccine and TIV, the incremental cost-effectiveness ratio would be $1,280 per disability-adjusted life-year (DALY) averted, the total incremental cost of the vaccination program would be $776,800, and it would avert four deaths and 332 DALYs for the five cohorts.
The introduction of PCV10 vaccine and TIV would be highly cost-effective from a public, direct medical health care perspective. Despite these results, we have not observed decreases in severity or hospitalizations. Our findings highlight the need for further studies of the immunization campaign indicators and socioeconomic indicators for this low-income community.
Is a Respiratory Day Hospital Useful in Patients with Severe Disease?
2017, Archivos de Bronconeumologia
Roflumilast added to triple therapy in patients with severe COPD: A real life study
2015, Pulmonary Pharmacology and Therapeutics
Citation Excerpt :
Another interesting finding of our study is the similar benefit in reducing hospital admissions in the group of patients treated with roflumilast and those in the early withdrawal group. Two situations should be considered in this phenomenon: 1) the existing pharmacological treatments, even roflumilast, focused on diminishing exacerbations have not been shown to produce a consistent reduction in the rates of hospital admissions [20,21]; and 2) non-pharmacological therapy as the management of patients in a specific integrated care program, also known as respiratory day hospital, seems to be effective in terms of reducing hospital admissions but not the rate of exacerbations [22]. The frequency of side effects and adverse events leading to withdrawal of therapy observed in our registry was greater than those reported in clinical trials [5–7,17,23].
Roflumilast is used in severe chronic obstructive pulmonary disease (COPD) patients with frequent exacerbations. However, limited information is available on its impact in a “real-life” population that may be receiving triple therapy.
This study aimed to evaluate the effectiveness and safety of roflumilast in COPD patients already receiving triple therapy (long-acting β-agonist/inhaled corticosteroids and long-acting muscarinic antagonist).
Prospective registry that included COPD patients who were prescribed roflumilast added to triple therapy. The yearly rate of all COPD exacerbations before and after roflumilast and side effects related to the drug were registered.
Among 55 patients prescribed 500 mg of roflumilast. Only 50.9% (n = 28) completed 1 year of therapy (roflumilast group). A reduction of all exacerbations with roflumilast was observed (2.75 ± 0.29 vs. 3.57 ± 0.26; P = 0.022), with a particular benefit in patients with ≥4 exacerbations prior to initiating therapy (3.55 ± 0.51 vs. 5.00 ± 0.30; P = 0.034). Side effects (mainly gastrointestinal) and treatment discontinuation occurred in 69.1% and 49.1% of the overall population, respectively.
Roflumilast, when added to triple therapy, reduces exacerbations in a “real-life” population of severe COPD patients with frequent exacerbations. However, side effects are more common and lead more frequently to discontinuation of therapy than has been reported in trials.
Preventing COPD exacerbations: Budget impact of a respiratory day hospital and long-term azithromycin therapy
2014, Respiratory Medicine

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Resumen

Fundamento y objetivo

Pacientes y método

Resultados

Conclusiones

Abstract

Background and objective

Patients and methods

Results

Conclusions

Section snippets

Introducción

Pacientes y métodos

Resultados

Discusión

Financiación

Conflicto de intereses

Agradecimientos

Outcomes and health-related quality of life following hospitalization for an acute exacerbation of COPD

Respirology.

Características epidemiológicas de las exacerbaciones por EPOC y asma en un hospital general

Arch Bronconeumol.

El coste de la enfermedad pulmonar obstructiva crónica en España. Opciones para una optimización de recursos

Arch Bronconeumol

Efectividad y eficiencia de una consulta monográfica hospitalaria para pacientes con EPOC e insuficiencia respiratoria

Arch Bronconeumol.

Eficacia de un programa específico para pacientes con EPOC que presentan frecuentes agudizaciones

Arch Bronconeumol.