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Background A large proportion of people with COPD are not referred to pulmonary rehabilitation (PR) despite its proven benefits. No previous studies have examined predictors of referral to PR. Objective To determine the characteristics of people with COPD associated with referral to PR. Methods Cross-sectional analysis of a primary care cohort of 82,696 Welsh people with COPD generated as part of a UK national audit of COPD care. Data represent care received by patients as of 31/03/2017. Referral to PR was defined as any code in the patient record indicating referral to PR in the last 3 years. Potential predictors of referral to PR were chosen based on clinical judgement and data availability. Independent predictors of PR referral were determined using backward stepwise mixed-effects logistic regression with a random effect for practice. Variables assessed were: age, gender, deprivation, MRC recorded in past year, MRC grade, smoking status recorded in past year, smoking status, number of exacerbations in past year, inhaled therapy prescription, influenza vaccination, and comorbidities of diabetes, hypertension, coronary heart disease, stroke, heart failure, lung cancer, asthma, bronchiectasis, depression, anxiety, severe mental illness, osteoporosis, and painful condition. Results A total of 13,297 people (16%) with COPD were referred from primary care for PR. Patients with a comorbidity of bronchiectasis or depression, MRC recorded in the last year, higher MRC grade, more exacerbations in the last year, a greater level of inhaled therapy, an influenza vaccination, or were an ex-smoker had significantly higher odds of referral to PR. Patients that were older, female, more deprived, or had a comorbidity of diabetes, asthma, or painful condition had significantly lower odds of referral to PR. Conclusion Generally appropriate patients are being prioritised for PR referral; however, it is concerning that women, current smokers, and more deprived patients appear to have lower odds of referral.

Introduction Exacerbations of COPD requiring hospital admission are burdensome to patients and health services. Audit enables benchmarking performance between units and against national standards, and supports quality improvement. We summarise 23 years of UK audit for hospitalised COPD exacerbations to better understand which features of audit design have had most impact. Method Pilot audits were performed in 1997 and 2001, with national cross-sectional audits in 2003, 2008 and 2014. Continuous audit commenced in 2017. Overall, 96% of eligible units took part in cross-sectional audit, 86% in the most recent round of continuous audit. We synthesised data from eight rounds of national COPD audit. Results Clinical outcomes were observed to change at the same time as changes in delivery of care: length of stay halved from 8 to 4 days between 1997 and 2014, alongside wider availability of integrated care. Process indicators did not generally improve with sequential cross-sectional audit. Under continuous audit with quality improvement support, process indicators linked to financial incentives (early specialist review (55–66%) and provision of a discharge bundle (53–74%)) improved more rapidly than those not linked (availability of spirometry (40–46%) and timely noninvasive ventilation (21–24%)). Conclusion Careful piloting and engagement can result in successful roll-out of cross-sectional national audit in a high-burden disease. Audit outcome measures and process indicators may be affected by changes in care pathways. Sequential cross-sectional national audit alone was not generally accompanied by improvements in care. However, improvements in process indicators were seen when continuous audit was combined with quality improvement support and, in particular, financial incentives., National audit in COPD is feasible and can improve process indicators, particularly when continuous audit is associated with quality improvement initiatives and financial incentives https://bit.ly/3eiOvOY

Introduction: There is currently no accepted way to risk-stratify hospitalised exacerbations of chronic obstructive pulmonary disease (COPD). We hypothesised that the revised UK National Early Warning Score (NEWS2) calculated at admission would predict inpatient mortality, need for non-invasive ventilation (NIV) and length-of-stay. Methods: We included data from 52,284 admissions for exacerbation of COPD. Data were divided into development and validation cohorts. Logistic regression was used to examine relationships between admission NEWS2 and outcome measures. Predictive ability of NEWS2 was assessed using area under receiver operating characteristic curves (AUC). We assessed the benefit of including other baseline data in the prediction models and assessed whether these variables themselves predicted admission NEWS2. Results: 53% of admissions had low risk, 24% medium risk and 23% a high risk NEWS2 in the development cohort. The proportions dying as an inpatient were 2.2%, 3.6% and 6.5% by NEWS2 risk category, respectively. The proportions needing NIV were 4.4%, 9.2% and 18.0%, respectively. NEWS2 was poorly predictive of length-of-stay (AUC: 0.59[0.57– 0.61]). In the external validation cohort, the AUC (95% CI) for NEWS2 to predict inpatient death and need for NIV were 0.72 (0.68– 0.77) and 0.70 (0.67– 0.73). Inclusion of patient demographic factors, co-morbidity and COPD severity improved model performance. However, only 1.34% of the variation in admission NEWS2 was explained by these baseline variables. Conclusion: The generic NEWS2 risk assessment tool, readily calculated from simple physiological data, predicts inpatient mortality and need for NIV (but not length-of-stay) at exacerbations of COPD. NEWS2 therefore provides a classification of hospitalised COPD exacerbation severity.

Objectives To test the effectiveness of a quality improvement programme to promote adherence to national quality standards (QS) for patients hospitalized with community-acquired pneumonia (CAP), exploring the factors that hindered improvements in clinical practice. Methods An improvement bundle aligned to the QS was deployed using plan-do-study-act methodology in a 600 bed hospital in northern Vietnam from July 2018 to April 2019. Proposed care improvements included CURB65 score guided hospitalization, timely diagnosis and inpatient antibiotic treatment review to limit the spectrum and duration of IV antibiotic use. Interviews with medical staff were conducted to better understand the barriers for QS implementation. Results The study found that improvements were made in CURB65 score documentation and radiology results available within 4 h (P Conclusions Interventions led to some process changes, but these were not utilized by clinicians to improve patient management. Institutional and behavioural barriers documented may inhibit wider national uptake of the QS. National system changes with longer term support and investment to address local behavioural barriers are likely to be crucial for future improvements in the management of CAP, and potentially other hospitalized conditions, in Vietnam.

Background The COVID-19 pandemic has raised a wide range of challenges for health systems around the world and the National Health Service in England has been no exception. A significant proportion of infected cases require intensive care unit support and have a high mortality rate. In the early stages of the pandemic, there was neither an evidence base nor a clinical consensus on the optimal management of patients in this setting.Interventions Responding to requests for assistance to address this evidence gap, UCLPartners, an Academic Health Science Partnership, working in collaboration with other organisations including National Institute of Health Research Applied Research Collaboration North Thames, developed a clinical academic team to synthesise clinical learning in real time. This was then disseminated using existing networks and social media to local, regional, national and international clinical teams.Conclusion An Academic Health Science Partnership was able to respond quickly through adapting and expediting traditional methods of evidence gathering, supporting organisations to work collaboratively across their networks and so meet an urgent clinical need to the benefit of clinicians and patients.

Introduction Pulmonary rehabilitation has been shown to improve dyspnoea, fatigue, quality of life and exercise capacity in individuals with chronic obstructive pulmonary disease (COPD). Our aim was to determine the characteristics of people with COPD associated with completion of pulmonary rehabilitation. Methods This was a cross-sectional analysis of 7060 people with COPD enrolled in pulmonary rehabilitation between January 1, 2017 and March 31, 2017. Data were from a UK national audit of COPD care. Factors associated with pulmonary rehabilitation completion were determined using mixed effects logistic regression with a random intercept for pulmonary rehabilitation service. Factors chosen for assessment based on clinical judgement and data availability were age, sex, country, socioeconomic status, body mass index, referral location, programme type, start within 90 days, smoking status, oxygen therapy, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) dyspnoea grade, any exercise test and any health status questionnaire. Results 4635 (66%) people with COPD completed a pulmonary rehabilitation programme. People that were aged ≥60 years, resident in Wales, referred within 90 days, an ex- or never-smoker, received an exercise test, or received a health status questionnaire had significantly greater odds of completing pulmonary rehabilitation. People that were in the most deprived quintile, underweight or very severely obese, enrolled in a rolling rather than a cohort programme, had a higher GOLD stage and had a higher MRC grade had significantly lower odds of completing pulmonary rehabilitation. Conclusions People with COPD were more likely to complete pulmonary rehabilitation when best practice guidelines were followed. People with more severe COPD symptoms and those enrolled in rolling rather than cohort programmes were less likely to complete pulmonary rehabilitation. Referring people with COPD in the earlier stages of disease, ensuring programmes follow best practice guidelines and favouring cohort over rolling programmes could improve rates of pulmonary rehabilitation completion., Referring people with COPD to pulmonary rehabilitation (PR) in the earlier stages of disease, ensuring PR programmes follow best practice guidelines and favouring cohort over rolling PR programmes could improve rates of PR completion https://bit.ly/34BfeEb

Background: The COPD Best Practice Tariff (BPT) is a pay-for-performance scheme in England that incentivises review by a respiratory specialist within 24 hours of admission and completion of a list of key care components prior to discharge, known as a discharge bundle, for patients admitted with acute exacerbation of COPD (AECOPD). We investigated whether the two components of the COPD BPT were associated with lower 30-day mortality and readmission in people discharged following AECOPD. Methods: Longitudinal study of national audit data containing details of AECOPD admissions in England and Wales between 01 February 2017 and 13 September 2017. Data were linked with national admissions and mortality data. Mixed-effects logistic regression, using a random intercept for hospital to adjust for clustering of patients, was used to determine the relationship between the COPD BPT criteria (combined and separately) and 30-day mortality and readmission. Models were adjusted for age, sex, socioeconomic status, length of stay, smoking status, Charlson comorbidity index, mental illness and requirement for oxygen or noninvasive ventilation during admission. Results: 28 345 patients discharged from hospital following AECOPD were included. 37% of admissions conformed to the two COPD BPT criteria. No relationship was observed between BPT conforming admissions and 30-day mortality (OR: 1.09 (95% CI 0.92 to 1.29)) or readmissions (OR: 0.96 (95% CI 0.90 to 1.02)). No relationship was observed between either of the individual COPD BPT components and 30-day mortality or readmissions. However, a specialist review at any time during admission was associated with lower inpatient mortality (OR: 0.69 (95% CI 0.58 to 0.81)). Conclusion: Completion of the combined COPD BPT criteria does not appear associated with a reduction in 30-day mortality or readmission. However, specialist review was associated with reduced inpatient mortality. While it is difficult to argue that discharge bundles do not improve care, this analysis questions whether the pay-for-performance model improves mortality or readmissions. Data availability statement: Data may be obtained from a third party and are not publicly available. Data collected on behalf of HQIP by all NCAPOP projects are routinely reported and these reports are available in the ‘Resources’ section of the HQIP website (https://www.hqip.org.uk/resources/). The reported data are also placed on the data.gov.uk website. Data are also placed upon MyNHS and NHS Choices. For details of how to apply for data that is not in the public domain, please see HQIP’s data access webpages (https://www.hqip.org.uk/national-programmes/accessing-ncapop-data/).

Background: NEWS2 is a risk score based on routinely collected physiologic measures. We assessed if NEWS2 can be used to predict short-term outcomes for acute exacerbation of COPD (AECOPD) admissions. Methods: Data were collected from 167 English Hospitals participating in the National Asthma and COPD Audit Programme (NACAP) for AECOPD admissions discharged between 01/10/2018 and 30/09/2019. NEWS2 was recorded on arrival to hospital. A mixed-effects logistic regression examined the association between NEWS2 risk category (low, medium, high) and AECOPD outcomes (inpatient mortality, received NIV, length of stay > median [4 days]) using a random effect for hospital. Regression models were adjusted for age, sex, deprivation, GOLD stage, smoking status, history of cardiovascular disease, and history of mental illness. Results: Of the 78302 patients included in the study 4% died during admission, 10% required NIV, and 41% had a length of stay longer than the median. There was a significant increase in odds of death, requirement for NIV, and longer length of stay for each increase in risk category (table). Conclusion: Admission NEWS2 classified as high, medium, and low risk appears to predict short-term outcomes for AECOPD admissions.

Driving improvements in patient safety has been a core goal of the Academic Health Science Networks (AHSNs) in England since their inception in 2013. The National Patient Safety Collaborative Programme, nested within the 15 geographically located AHSNs, was established in 2014 in response to the Berwick review. In 2019, the new NHS national patient safety strategy was published, which placed the AHSNs as a key vehicle for delivering its ambitions. This paper explores the achievements of, and opportunities presented by, the collaborative in addressing some of the key patient safety challenges facing physicians and their wider teams. Case studies illustrate the AHSNs' contribution to support national ambitions, including the adoption of the National Early Warning Score (NEWS) 2, and the impact of regionally-led work on patient outcomes, such as reducing mortality from sepsis and acute kidney injury. We set out current activities, opportunities for physician engagement and plans for future work.

IntroductionMany patients with chronic obstructive pulmonary disease (COPD) experience a sustained worsening in symptoms termed an acute exacerbation (AECOPD). AECOPDs impact on patients’ quality of life and lung function, are costly to health services and are an important topic for research. Electronic health records (EHR) are increasingly being used to study AECOPD, requiring accurate detection of AECOPD in EHRs to ensure generalisable results. The aim of this protocol is to provide an overview of studies that validate AECOPD definitions used in EHRs and administrative claims databases.Methods and analysisMedline and Embase will be searched for terms related to COPD exacerbation, EHRs and validation. All studies published between 1 January 1990 and 30 September 2019 written in English that validate AECOPD in EHRs and administrative claims databases will be considered. Inclusion criteria: EHR data must be routinely collected; the AECOPD detection algorithm must be compared against a reference standard; and a measure of validity must be calculable. Two independent reviewers will screen articles for inclusion, extract study details and assess risk of bias using QUADAS-2. Disagreements will be resolved by consensus or arbitration by a third reviewer. This protocol has been developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.Ethics and disseminationThis will be a review of previously published literature therefore no ethical approval is required. Results from this review will be published in a peer-reviewed journal. The results can be used in future research to identify occurrences of AECOPD.PROSPERO registration numberCRD42019130863.

Ali Hakamy,1,2 Tricia M McKeever,2 Michael C Steiner,3 C Michael Roberts,4 Sally J Singh,3 Charlotte E Bolton1 1Nottingham Respiratory Research Unit, NIHR Nottingham Biomedical Research Centre, 2Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, 3Leicester Respiratory Biomedical Research Unit, Institute for Lung Health, University Hospitals of Leicester NHS Trust, Leicester, 4Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK Abstract: Our aim was to evaluate the use and impact of the practice walk test on enrolment, completion, and clinical functional response to pulmonary rehabilitation (PR) using the 2015 UK National Chronic Obstructive Pulmonary Disease (COPD) Pulmonary Rehabilitation audit data. Patients were assessed according to whether a baseline practice walk test was performed or not. Study outcomes included use of the practice walk test, baseline and change in incremental shuttle walk test distance (ISWD) or 6-minute walk test distance (6MWD), and enrolment to and completion of PR program. Of 7,355 patients, only 1,666 (22.6%) had a baseline practice test. At baseline, the practice walk test group walked further as compared to the no practice walk test group: ISWD, 17.9m [95% confidence interval (CI) 8.2–27.5m] and 6MWD, 34.8m (95% CI 24.7–44.9m). The practice walk test group were 2.2 times (95% CI 1.8–2.6) more likely to enroll and 17% (95% CI 1.03–1.34) more likely to complete PR. Although the change in ISWD and 6MWD with PR was lower in the practice walk test group, they walked further at discharge assessment. Only 22.6% of the patients in the 2015 National PR audit had a practice walk test at assessment. Those who did had better enrolment, completion, and better baseline walking distance, from which the prescription is set. Keywords: pulmonary rehabilitation, COPD, functional performance test, functional exercise test

The study aimed to explore patients’ experience of living with chronic obstructive pulmonary disease and their perspective of their community healthcare for chronic obstructive pulmonary disease to extract affective responses in order to develop potential items for a patient-reported experience measure for chronic obstructive pulmonary disease. Qualitative face-face interviews were conducted, in the community, with 64 patients with chronic obstructive pulmonary disease recruited from General Practices and Breathe-Easy community groups in the Outer North East, East and City areas of London and Essex, UK. A two phase analysis of the qualitative data was conducted to identify themes arising from patients’ description of living with chronic obstructive pulmonary disease and their perceptions of their community healthcare and subsequently the affective responses underlying the themes raised by patients, which gave emotional colour to the themes, bringing the thematic analysis closer to the subjective patient experience. Five themes were identified from the interview data: ‘Journey to diagnosis’; ‘Smoking’; ‘Usual care’; ‘My everyday life’; and ‘Exacerbations’. Twenty-one affective responses were identified and categorised as either ‘negative’, ‘positive’ or ‘bivalent’. ‘Frustration’, a negative affective response was prevalent in four themes. ‘Gratitude’, ‘hope’ and ‘happiness/enjoyment’ were among the more positive responses more prevalent across several themes. By conducting a novel two-way analysis (thematic and affective) it was possible to identify themes and affective responses that were aligned to those themes. This enabled the development of 38 chronic obstructive pulmonary disease-specific experience items to take forward for further testing including item reduction and validity and reliability in the next stage of the patient-reported experience measure development., Chronic lung disease: Giving importance to patients’ emotions An exploration of patient perceptions of living with chronic lung disease will help develop a new patient reported experience scale. Healthcare services are aiming to provide effective patient-centered care for those with chronic obstructive pulmonary disease (COPD). Such care strategies require structured, validated patient feedback scales to facilitate accurate communication between patients, carers and healthcare professionals. Susan Walker at Anglia Ruskin University in Chelmsford, UK, and co-workers analyzed qualitative data from interviews with 64 COPD patients in London and Essex regarding their emotions and perceptions of living with COPD, with the aim of creating a patient reported experience measure, or PREM. Initial results identified five themes—including ‘journey to diagnosis’ and ‘everyday life’—and twenty-one affective responses, ranging from negative to positive. The team will take these results forward for further validation.

The secondary care work stream of the National COPD Audit Programme aims to improve care and outcomes for patients with exacerbation of chronic obstructive pulmonary disease (COPD) wherever and whenever they are admitted to hospital. To achieve this, prospective audit is combined with real-time feedback of data to individual units, together with support for quality improvement and high-level change levers. COPD exacerbations comprise a large proportion of the acute take. Only by working collaboratively across emergency, acute and general medicine, respiratory, geriatric and other teams can individual trusts deliver optimal care. This review provides background to the national COPD audit programme, relevant to all those caring for people with COPD exacerbations in secondary care.

Background: The Best Practice Tariff (BPT) for COPD provides a financial reward when acute exacerbation (AECOPD) admissions in England receive specialist review within 24 hours of admission and a discharge bundle before discharge. Aim: Investigate if AECOPD admissions that conform to the BPT have better outcomes. Methods: An audit of patients admitted to hospital in England and Wales for AECOPD was conducted: 01/02/17-13/09/17. Data were linked with Hospital Episode Statistics and ONS mortality data. The first admission for each patient was included. Conforming to the BPT was defined as a patient receiving respiratory specialist review within 24 hours of admission and a care bundle before discharge. Better patient outcomes of AECOPD were defined as length of stay ≤4 days, no readmission within 30 days of discharge, and alive 30 days after admission. Mixed-effects logistic regression was used to examine the association between conforming to the BPT and AECOPD outcomes (random effect for hospital). Models were adjusted for age, sex, deprivation, admission severity, smoking status, Charlson comorbidity index and mental health issues. Results: 28,345 patients from 181 hospitals were included. 10,530 (37%) admissions conformed to the BPT. Odds ratios for outcomes of AECOPD admissions conforming to the BPT are shown. Conclusion: Conforming to the BPT was not associated with mortality or readmissions, however BPT compliant admissions may be shorter.

Respiratory illness features heavily in the NHS Long Term Plan.1 The well described drivers to improve outcomes in the most prevalent respiratory conditions, COPD and asthma, include variation in care standards and outcome2, and higher rates of mortality and hospitalisation than most other European countries3,4. In this paper we discuss how the National Asthma and COPD Audit Programme (NACAP) can support the aspirations within the long term plan to improve outcomes for people with COPD and asthma.

BackgroundRandomised control trial (RCT)-derived survival figures for acute exacerbation of chronic obstructive pulmonary disease admissions managed with non-invasive ventilation (NIV) have not been replicated in UK clinical audits. Subsequent guidelines have emphasised the need for timely NIV application.MethodsData from the 2008 and 2014 national chronic obstructive pulmonary disease audits was used to analyse the association between time to NIV and mortalityResults1032 patients received NIV in 2008, and 1612 in 2014. Overall mortality rates reduced between the audits from 24.9% in 2008 to 16.8% in 2014 but time to NIV lengthened. In 2014, 20.9% of patients received NIV within 60 min versus 24.9% in 2008 (p=0.001). The proportion of patients receiving NIV between 3 and 24 hours increased from 31.3% in 2008 to 39% in 2014 (p=0.001). Patients admitted with hypercapnic acidotic respiratory failure who received NIV within 3 hours had lower in-patient mortality than those who received NIV between 3 and 24 hours, 15.9% versus 18.4%, but this did not reach statistical significance (p=0.425), but acidotic patients receiving NIV >24 hours after admission had significantly higher mortality (28.9%, p=0.002). A second cohort admitted with hypercapnia but normal range pH, who developed later acidosis, had higher mortality (24.6%), compared with those acidotic on admission (18% p≤0.001) and an extremely high mortality when NIV was given >24 hours after admission (42.6%).ConclusionSurvival rates for those treated with NIV has improved between the two audits but remains lower than reported in RCTs. Patients who developed acidosis after admission and received NIV later in the hospital stay have even higher mortality and deserve further study and clinical attention.

Background \ud Pulmonary rehabilitation (PR) improves exercise capacity and health status in patients with COPD, but many patients assessed for PR do not complete therapy. It is unknown whether socioeconomic deprivation associates with rates of completion of PR or the magnitude of clinical benefits bequeathed by PR.\ud \ud Methods\ud PR services across England and Wales enrolled patients to the National PR audit in 2015. Deprivation was assessed using Index of Multiple Deprivation (IMD) derived from postcodes. Study outcomes were completion of therapy and change in measures of exercise performance and health status. Univariate and multivariate analyses investigated associations between IMD and these outcomes.\ud \ud Results\ud 210 PR programmes enrolled 7413 patients. Compared with the general population, the PR sample lived in relatively deprived neighbourhoods. There was a statistically significant association between rates of completion of PR and quintile of deprivation (70% in the least and 50% in the most deprived quintiles). After baseline adjustments, the risk ratio (95% CI) for patients in the most deprived relative to the least deprived quintile was 0.79 (0.73 to 0.85), p

Integrated care systems, supported by electronic information exchange, are seen as key enablers to the future of the NHS.1,2 The failure of a centralised NHS IT programme3,4 has been followed by a move to local and regional solutions that provide an opportunity for clinicians to influence strategy and design. However, although primary care has been at the forefront of electronic care record use, connectivity outside the practice environment remains challenging internationally.5 A recent World Health Organization report on digital connectivity highlights the need to inform clinicians by sharing experiences of developing electronic information exchanges if we are to come to an understanding of what is needed and what is possible.6 Successful information flow requires that information be recorded electronically, managed, governed, regulated, linked via a master index, and be made available to users through one or more interconnected software applications. Clinician input has helped provide solutions to most of these challenges7,8 but technological solutions to connectivity remain a mystery to most clinicians and yet are a key determinant of how data can be used for patient care. A broad understanding of the issues can promote clinician engagement in the choices that need to be made to support nascent integrated care systems. There are two main technological approaches for sharing information

Chronic obstructive pulmonary disease (COPD) care across Europe has high heterogeneity with respect to cost and the services available. Variations in length of stay (LOS) may be attributed to patient characteristics, resource and organisational characteristics, and/or the so-called hospital cluster effect. The European COPD Audit in 13 countries included data from 16 018 hospitalised patients. The recorded variables included information on patient and disease characteristics, and resources available. Variables associated with LOS were evaluated by a multivariate, multilevel analysis. Mean±sd LOS was 8.7±8.3 days (median 7 days, interquartile range 4–11 days). Crude variability between countries was reduced after accounting for clinical factors and the clustering effect. The main factors associated with LOS being longer than the median were related to disease or exacerbation severity, including GOLD class IV (OR 1.77) and use of mechanical ventilation (OR 2.15). Few individual resource variables were associated with LOS after accounting for the hospital cluster effect. This study emphasises the importance of the patients' clinical severity at presentation in predicting LOS. Identifying patients at risk of a long hospital stay at admission and providing targeted interventions offers the potential to reduce LOS for these individuals. The complex interactions between factors and systems were more important that any single resource or organisational factor in determining differences in LOS between hospitals or countries., LOS determined by COPD exacerbation severity and interactions within hospitals constituting effective patient care http://ow.ly/XD9hy

Despite the increasing popularity of e-learning systems across a variety of educational programmes, there is relatively little understanding of how students and trainees distribute their learning efforts over time. This study aimed to analyse the usage patterns of an e-learning resource designed to support specialty training. Data were collected from e-learning Anaesthesia, a web-based training programme offered by the Royal College of Anaesthetists in partnership with e-Learning for Healthcare. We constructed the time series of 45,020 records of knowledge and self-assessment sessions accessed by 2491 trainees between August 2008 and February 2010. Analysis of the time series suggested that e-learning usage was characterised by concentrations of rapidly occurring sessions within short time frames of intense activity, separated by disproportionally long periods of reduced activity. Non-uniform temporal fluctuations of usage were pronounced especially for self-assessment sessions, the timing of which was highly correlated with examination dates. While on average trainees’ involvement in knowledge sessions was larger than in self-assessment sessions, for both sessions average hourly activity and length remained stable between 9:00 am and 10:00 pm during weekdays. Average daily activity decayed as the weekend approached, but average session length did not vary significantly across the week. Combined with previous research on distributed practice, learning time distribution and test-enhanced learning, our study has implications for the improvement of long-term retention through the redistribution of knowledge sessions uniformly over time and the sustainment of frequent information retrieval and repeated testing. Findings on hourly and daily periodicities also suggest how new learning materials could be broken down into suitable components that fit learners’ time constraints.

This study investigates whether it is possible to map norms of professionalism among medical student and faculty cohorts. The purpose is to provide ongoing information regarding the validity of this approach in multiple settings both within the United Kingdom (UK) and internationally. Its methodology is based on the Dundee Polyprofessionalism Inventory I: Academic Integrity, which solicits recommended sanctions as an indication of the severity with which particular lapses are regarded. The inventory was administered to cohorts in the UK, and results were compared with previously reported results from Saudi Arabia, Pakistan and Egypt. There are a great number of similarities — or congruence — between staff and students within institutions and also across institutions (and indeed countries). However there are also a number of areas in which there are notable differences between median sanctions suggested by staff and students for particular “lapses.” There are fewer areas in which there are greater than two levels of difference of median suggested sanction for students and staff across national boundaries (London and Scotland) or staff across the same national boundaries. The paper presents data from three UK schools and three other countries that indicate a broad base of congruence but also important inter-school and regional differences that may be a function of different national and ethnic cultures. The applicability of the resource needs to be further explored to confirm its usefulness as a tool in professionalism learning.

Summary Evaluation of healthcare is evolving, with the patient perspective increasingly sought to provide a more patient centred service. Self-report questionnaires are being used to gather information about patients9 health-related quality of life; outcomes with, and experience of a treatment, and perceptions of the care delivered by the healthcare team. Patient satisfaction measures may be familiar to clinicians and researchers, as they are used routinely in many clinical settings. Patient satisfaction measures have a ceiling effect, masking the negative healthcare experience. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are measures that that provide a patient-centric view of healthcare. In this article, we aim to untangle for the reviewer, the distinctions between patient satisfaction, PROMs and PREMs measures with a focus on chronic obstructive pulmonary disease (COPD) and introduce work in progress around the development of a new PREM for COPD.

[][1] Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality in Europe [1, 2], which has a major resource impact on both primary and secondary healthcare [3]. COPD has a huge impact on people with the condition, causing a gradual decline in functional ability and greater dependence upon health and social care support with both ageing and disease progression [4]. Patients with COPD are also likely to suffer with significant co-morbidities that further impair their quality of life and independent living [5]. Evidence is growing from audits in individual countries that COPD patient care varies widely between different hospitals and across Europe and is frequently not consistent with published guidelines [6–8]. There are many different service models and it remains unknown which deliver the best results for patients. In all likelihood, the care given to COPD patients can be improved if there is better understanding of care and service organisation factors in European hospitals that promote better outcomes. The recent European Respiratory Society (ERS) European COPD audit, conducted in 2010–2011, provides data on quality of care from over 400 hospitals in 13 countries [9]. This study confirmed that the quality of patient care varies not just between European countries in different health systems, but that there is even greater variability between hospitals within individual countries [10]. Discharge from hospital is a key moment for patients, and data on medications, oxygen and rehabilitation relating to discharge were collected in the audit. The scope of the audit did not, however, include out-of-hospital care or specifically the views and experiences of hospital care of COPD patients themselves. Therefore, an event was designed to address this deficiency with the following aims: 1. To better understand … [1]: /embed/graphic-1.gif

The role of pulmonary rehabilitation ### Referral and assessment of patients for pulmonary rehabilitation #### Specific situations at assessment ##### Smoking

In March 2010, the European Respiratory Society funded a pilot audit programme of the process and outcomes of hospital care for patients admitted with exacerbations of COPD and on the organisation of care at hospital level. Originally it was intended to involve just five countries in this pilot scheme but such was the enthusiasm from national societies that 13 participated in the data collection programme. In March 2012, ERS published a document containing the results at national level for 19,021 cases entered into the audit database and subsequently site specific data has been distributed to each of the 422 hospitals that participated as shown in figure 1. Figure 1 Hospitals participating in the European COPD Audit. These data are unique in that they have been collected by clinicians prospectively identifying cases then recording in hospital care processes and patient outcomes at 90 days after admission date. In order to collect the data, many individuals had to use their time and skills but the success of the data collection is testimony to the enthusiasm of clinicians to better understand the quality of care delivered in their own institutions. The results are salutary and deserve our attention. In essence, they describe a standard of care with significant variation in adherence to guideline standards both within countries and between them. Arterial blood gases are taken on admission in only 12% cases in one country ranging to 96% in another whilst antibiotics are given to only 54% cases in country A yet 95% in country B. Unsurprisingly, outcomes vary equally widely with median length of stay at national level varying 5–15 days. At this stage in the data analysis, it is not possible to say why this occurs and there may be a number of explanations. There are certainly significant differences in case mix between …

Objective The views of patients with Chronic Obstructive Pulmonary Disease (COPD) about three key services (non-invasive ventilation [NIV], early discharge schemes and rehabilitation) were sought in order to inform recommendations for the delivery of optimum care within a national programme of hospital COPD service development. Design Four focus groups were run involving 36 COPD patients, facilitated by two researchers. Tape recordings were transcribed and emergent grouped themes identified. Setting Four locations across the UK. Results Of the three service areas considered, two (NIV and early discharge) were unknown to the majority of patients despite their strong evidence base and national recommendations for implementation. Where patients were familiar with a service they made consistent and useful recommendations for improving care. Those recently hospitalized reported insufficient information provision for them to make personal informed choices about key management interventions. Conclusion Patients have important views on services with which they are familiar and if consulted can significantly contribute to their development. This report has identified a lack of knowledge amongst the majority of patients consulted about recent key NHS medical and service developments. At a group level this impairs the contributions that patients may make to forming service profiles. At an individual level, lack of prior knowledge places patients in a vulnerable position when admitted to hospital and asked to make informed decisions about their care.

SummaryBackgroundEarly discharge for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) has been shown to be effective by clinical trials. To evaluate its implementation and efficacy in clinical practice, data concerning early discharge schemes (EDS) from the 2003 National COPD Audit were collected and analysed.MethodsAll acute Trusts in the UK were surveyed in Autumn 2003 by two means: one a questionnaire relating to organisation of care and second an audit of 40 clinical cases admitted with AECOPD.ResultsData were available for both organisation of care and clinical activity for 233 units, of which 103 (44%) had EDS. Models of care included admission prevention in the accident and emergency department (5%), rapid discharge in

The authors describe the indications and adverse effects of nebulisers and show how careful assess ment can identify those patients who will benefit. Copyright © 2007 Wiley Interface Ltd

Studies report high in-hospital and post-discharge mortality of chronic obstructive pulmonary disease (COPD) exacerbations varying depending upon patient characteristics, hospital resources and treatment standards. This study aimed to investigate the patient, resource and organisational factors associated with in-hospital and 90-day post-discharge mortality and readmission of COPD exacerbations within the European COPD Audit. The audit collected data of COPD exacerbation admissions from 13 European countries.On admission, only 49.7% of COPD patients had spirometry results available and only 81.6% had blood gases taken. Using logistic regression analysis, the risk associated with in-hospital and post-discharge mortality was higher age, presence of acidotic respiratory failure, subsequent need for ventilatory support and presence of comorbidity. In addition, the 90-day risk of COPD readmission was associated with previous admissions. Only the number of respiratory specialists per 1000 beds, a variable related to hospital resources, decreased the risk of post-discharge mortality.The European COPD Audit identifies risk factors associated with in-hospital and post-discharge mortality and COPD readmission. Addressing the deficiencies in acute COPD care such as making spirometry available and measuring blood gases and providing noninvasive ventilation more regularly would provide opportunities to improve COPD outcomes.

BACKGROUND Recent studies raise concerns over the preparedness of newly qualified doctors for the role of the pre-registration house officer (PRHO). This study aimed to assess self-perception of preparedness, objective assessment of core clinical skills and the effect of an extended clinical induction programme prior to commencing full duties. METHODS A group of 26 newly qualified doctors from 1 district general hospital underwent an extended 5-day, ward-based induction programme. The participants completed questionnaires on their own perceptions of their preparedness for PRHO duties and underwent an objective structured clinical examination (OSCE) of 4 core clinical skills prior to induction, on completion of induction and 1 month into working life. RESULTS At the outset PRHOs had low perceptions of their own capabilities in all clinical scenarios and skills. Most perceptions improved after induction, although in 2 clinical areas they felt even less confident. One month into post there were significant improvements in all areas. Only 1 PRHO passed all 4 clinical skills assessments at the pre-induction assessment. Seven (26%) failed on 1 or more skills at the post-induction assessment. However, all participants were deemed competent in all skills at the 1-month assessment. CONCLUSION Newly qualified doctors do not feel prepared for PRHO duties and objectively are not competent in basic clinical skills. An extended induction improves preparedness in some but not all clinical areas and improves performance of objectively assessed clinical skills.

Compared with most European countries the UK has a relatively long tradition of participation in clinical audit following the publication in 1989 of a government document ‘Working for Patients’ [...]

AIM To obtain patient-generated data relating to the management of their chronic obstructive pulmonary disease (COPD) in Primary Care before hospitalisation with exacerbation. BACKGROUND Previous audits of COPD have shown high rates of hospital admission and readmission. There is significant interest in understanding the reasons so that useful preventative strategies may be developed. As part of the 2008 UK COPD audit, which comprised 9716 cases of COPD admission across 97% of acute units, we obtained a sample of patient-generated data to assess understanding of COPD, use of healthcare resources, access to care and self-management in Primary Care prior to hospitalisation with exacerbation. We anticipated the data would provide useful insight for directing improvement strategies. METHOD A paper-based, anonymised survey was completed by patients identified as having exacerbation by participating hospital teams. Response rate was an estimated 46%. FINDINGS Understanding and awareness of COPD was very variable. Patients noticed symptoms of COPD exacerbation, particularly change in sputum, for some time prior to hospitalisation but tended not to react promptly to these changes. A minority had self-care plans, many bypassed Primary Care Services and there was variable access to a named health professional or advice. Patients using home oxygen and nebulisers were at particular risk of admission. CONCLUSION We conclude these sick patients use a lot of resources and the data suggest a need to support and educate them in the proactive management of exacerbation. There needs to be better 'exacerbation planning' so patients know how to recognise and treat flare-up but also whom to contact in the event of decline. Targetted support should be considered for the most vulnerable, particularly those using home oxygen and nebulisers, who have very high rates of hospitalisation.

PurposeThe purpose of this paper is to examine perceptions of local service change and concepts of change amongst participants in a UK nationwide randomised controlled trial of informal, structured, reciprocated, multidisciplinary peer review with feedback to promote quality improvement: the National Chronic Obstructive Pulmonary Disease Resources and Outcomes Project (NCROP).Design/methodology/approachThe paper takes the form of a qualitative study, involving semi‐structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control NCROP sites. Thematic analysis resulted in adoption of Joss and Kogan's quality indicators as an analytic framework.FindingsThe paper finds that peer review was associated with positive changes, which may lead to sustained service improvement. Differences existed in perceptions of change among clinicians and between clinicians and managers. “Generic changes” (e.g. changes in interpersonal relations or cultural changes), were often not perceived as change.Research limitations/implicationsThe study highlights the significance of generic change in evaluations of change processes. Most participants were clinicians limiting inter‐professional comparisons. Some clinical staff failed to recognise changes they accomplished or their significance, perceiving change differently to others within their professional group. These findings have implications for policy and research. They should be considered when developing frameworks for assessing quality improvements and staff engagement with change.Originality/valueThis is the first qualitative study exploring participants' experience of peer review for quality improvement in healthcare. The study adds to previous research into UK health service improvement, which has had a more restricted focus on inter‐professional differences.

Introduction: there is little information about the relationship between age and management of COPD exacerbation (AECOPD), although older persons are known to be at a greater risk of hospital admission. Methods: we have investigated responses from the clinical and patient questionnaire elements of the 2008 UK COPD audit, splitting the data into age decile. Results: age ranged from 27 to 102. Patient-reported data suggested older patients had inferior knowledge of COPD, undertook less self-care and were less likely to recognise symptoms of exacerbation prior to hospitalisation. Clinicianreported data showed that although older patients had severe disease and symptoms, greater co-morbidity at presentation and higher mortality, fewer were seen in hospital or followed up subsequently by respiratory specialists. Older patients were more likely to have a DNR order signed within 24 h of admission, irrespective of co-morbidities or performance status. The observations were particularly applicable to those aged 80 or above. Conclusions: clinicians should consider increasing age as a specific risk factor in the management of COPD. Acute units and community teams should review carefully their protocols and pathways for how they assess, manage, discharge and follow-up older patients with COPD exacerbation.

The 2008 U.K. national chronic obstructive pulmonary disease (COPD) audit examined the use of supported discharge programmes (SDPs) in clinical practice against British Thoracic Society guidelines. 98% of acute U.K. trusts participated. SDPs were available in 142 of 239 (59%) units. 1630 of 8971 (18%) patients with COPD were treated within SDPs. Median (IQR) stay in hospital for patients within SDPs and those not accepted for SDPs was 3 (1-6) days and 6 (3-11) days (p0.001), and mortality within 90 days of admission was 4.3% and 6.7%, respectively. SDPs within the U.K. are safe and effective and reduce length of hospital stay without adverse effects on mortality.

Probablemente existen mas datos de auditoria nacionales e nternacionales recogidos por los clinicos sobre el tratamiento ospitalario de los pacientes ingresados por exacerbaciones de la nfermedad pulmonar obstructiva cronica (EPOC) que de cualquier tra enfermedad pulmonar. Las grandes series de datos de Espana1 del Reino Unido2 procedentes de mas de 400 hospitales de 3 paises europeos que se incluyen en la auditoria de la European espiratory Society (ERS)3 son sorprendentemente uniformes en sus esultados sobre la amplia diversidad existente en el proceso de la sistencia y en los resultados obtenidos en los pacientes en distinos paises y dentro de un mismo pais. A pesar de la amplia difusion e las guias de tratamiento, que se basan de manera importante n la evidencia respecto a la efectividad obtenida en la investigaion, la mayoria de los pacientes ingresados en hospitales europeos o reciben la asistencia estandar recomendada4. Aunque las guias o son protocolos, es dificil justificar por que en toda Europa mas el 40% de los pacientes tratados por exacerbaciones de la EPOC no isponen de resultados de espirometria solicitados por el equipo edico responsable de su ingreso para confirmar el diagnostico, ientras que se administran antibioticos al 90% de pacientes que o cumplen los criterios de la guia para su empleo4. Si examinamos a duracion de la hospitalizacion, las tasas de reingreso o el uso de xigeno, las diferencias continuan siendo de entre 2 y 3 veces entre as distintas unidades, y el reto que se plantea, pues, a la medicina espiratoria es el de como pasar de la obtencion de datos a una ejor asistencia de los pacientes. La auditoria es un proceso de mejora de la calidad. Los datos btenidos nos informan de donde estan los problemas cuando se omparan con la asistencia ideal establecida en las directrices, pero sto no es mas que el principio. Los pasos cruciales son planificar as mejoras e instaurar su aplicacion. La vinculacion de la organizaion y los recursos con los datos del proceso clinico y los resultados porta una perspectiva que puede informar el plan de mejora. Los esultados de la auditoria en pacientes tratados con ventilacion no nvasiva (VNI) son mucho peores que los de los ensayos controados y aleatorizados. En algunas unidades hospitalarias europeas

Introduction: We investigated the effects on collaborative work within the UK National Health Service (NHS) of an intervention for service quality improvement: informal, structured, reciprocated, multidisciplinary peer review with feedback and action plans. The setting was care for chronic obstructive pulmonary disease (COPD).Theory and methods: We analysed semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control sites, as part of a UK randomised controlled study, the National COPD Resources and Outcomes Project (NCROP), using Scott's conceptual framework for action (inter-organisational, intra-organisational, inter-professional and inter-individual). Three areas of care targeted by NCROP involved collaboration across primary and secondary care.Results: Hospital respiratory department collaborations with commissioners and hospital managers varied. Analysis suggested that this is related to team responses to barriers. Clinicians in unsuccessful collaborations told 'atrocity stories' of organisational, structural and professional barriers to service improvement. The others removed barriers by working with government and commissioner agendas to ensure continued involvement in patients' care. Multidisciplinary peer review facilitated collaboration between participants, enabling them to meet, reconcile differences and exchange ideas across boundaries.Conclusions: The data come from the first randomised controlled trial of organisational peer review, adding to research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. NCROP peer review may only modestly improve collaboration but these data suggest it might be more effective than top-down exhortations to change when collaboration both across and within organisations is required.