COPD Exacerbations Can Be Treated at Home
Instead of admitting all patients whose exacerbation of COPD would normally justify hospitalization, a triage team at a British teaching hospital randomly selected two thirds of the patients for "hospital at home" treatment. In the first three months after this initial assessment, about 31 percent of the patients were admitted to the hospital because of another exacerbation of COPD, regardless of whether they had received at-home or inpatient care, the researchers reported in the Nov. 18 BMJ (PDF).
Lung function, measured as the predicted forced expiratory volume in one second (FEV1) after use of a bronchodilator, was initially similar between the groups, about 36 percent. The predicted FEV1 values improved after two weeks to about 42 percent in both groups, remaining near this level three months after treatment.
As part of the study, all patients received aerosolized ipratropium bromide and albuterol sulfate by nebulizer, oral prednisolone, and antibiotics for five days. With the exception of these therapies, care of the hospitalized patients was managed by staff respiratory physicians. Patients were released from the hospital after their symptoms subsided; half of these patients stayed at least five days.
Nine percent of home care and 8 percent of hospital-based patients died within three months of enrolling in the study. The researchers attributed two of the nine deaths in the home care group to pneumoniaunrelated to COPDthat was not clinically evident when the patients enrolled in the study.
When selecting patients for the study during February 1998 to August 1999, the triage team focused on adults in relatively good overall health despite having COPD. Patients who required full-time nursing care or whose acute exacerbation of COPD was complicated by conditions such as respiratory acidosis, suspected lung cancer, or pneumonia were not eligible for the trial.
Nurses specializing in the care of COPD patients assessed potential study enrollees who came to the hospital seeking treatment for an acute exacerbation of COPD. Only patients whose symptoms had escalated for at least 24 hours were considered candidates for the study.
Of the 583 patients evaluated, 192 met the strict eligibility criteria and 150 agreed to participate in the trial. Through random assignment, 30 men and 20 women were selected for admission to the hospital, and 45 men and 55 women were selected to receive home care. The average patient age was 70 years in both treatment groups.
During the initial assessment, the nurses determined that at least 90 percent of the patients later assigned to the two study groups had been using an inhaled beta-agonist. Seventy-five percent of home care and 84 percent of hospital-based patients had been using inhaled corticosteroids. Inhaled anticholinergic agents had been used by 53 percent of home care and 62 percent of hospital-based patients.
Once assigned to the home care group, patient were sent home from the hospital accompanied by a nursing specialist. A nurse visited each patient twice daily during the first three days of home care and as needed thereafter. The nurse or patient could request that the patient be admitted to the hospital at any time during the course of home treatment.
In addition to medical care, 24 of the home care patients needed social services such as cleaning help, meal deliveries, or day or night sitters. Three patients in the hospital group also required social support after discharge. The researchers did not compare the costs associated with home and hospital care but suggested that a cost-benefit comparison be done in the future.
According to the researchers, exacerbations of COPD in 96 percent of the home care patients "settled" within two weeks of treatment. However, a fairly large portion of home care patients, 9 percent, also required hospitalization during the first two weeks of treatment.
The research team was unable to predict which home care patients would most likely need hospitalization because of another exacerbation of COPD. However, the team noted that the predicted FEV1 measurement after bronchodilator use during the initial assessment was generally lower in the home care patients who were later hospitalized than in the cohort that did well at home.