Effects of Self. Exacerbations using Rescue Therapy

Transcription

1 Effects of Self Management of COPD Exacerbations using Rescue Therapy Amira Obeid Sandy Cherry Sarah Crotty Amanda Wixey & Dr Simon Gompertz A collaboration between NHS South Birmingham & University Hospitals Birmingham

2 Key Project Features Initial pilot May 2006 to April 2007 involving 18 patients managed by 2 community matrons anecdotally suggested 44 admissions avoided. 48 patients recruited from 12 practices 1 st February 31 st July Attempt to realise benefits across PCT. Funded by Integrated Medicines Management Project NPC. COPD Treatment optimised. Self management advice, COPD action plan & rescue steroids & antibiotics on standby. Comparisons for admissions during the same period in the preceding year.

3 Rationale - NICE self-management Patients with a self-management strategy at risk of having an AECOPD should be given a course of antibiotic and steroid tablets to keep at home have the use of these tablets monitored be advised to contact a healthcare professional if they do not improve

4 What is known about exacerbations Effects on Quality of Life (Seemungal 1998) Effects on Lung Function (Donaldson et al 2002) Early intervention increases speed of recovery (Wilkinson et al 2004) Implications of Hospital Admissions (National COPD Audit 2008) O i id h i l Opportunity to avoid hospital admissions

5 Effect on Lung Function Frequent 40.1 ml/year (n=16) Infrequent 32.1 ml/year (n=16) P<0.05 Copyright 2002 BMJ Publishing Group Ltd. Donaldson, G C et al. Thorax 2002;57:

6 Effect on Quality of Life * SGRQ S Annual exacerbation frequency *mean difference 15.1, p< Am. J. Respir. Crit. Care Med., 1998; 157; SEEMUNGAL TAR

7 Treatment of exacerbations South B ham guidelines produced by local COPD steering group Increase frequency of bronchodilators nebulised dbronchodilators may be considered d acutely for patients with more severe exacerbations Prednisolone at 30mg for 7-14 days for exacerbations interfering with ADLs no benefit beyond 14 days

8 Treatment of exacerbations Antibiotics empirically ONLY FOR PURULENT EXACERBATIONS (yellow, yellow-green or green sputum) Amoxicillin 500mg TDS 7 days or Doxycycline 200mg for 1 st 24 hours then 100mg for 6 days

9 NHS South Birmingham criteria for self-management -FEV 1 of <50% and 2 or more exacerbations in the previous 12 months. - Ability to recognise and respond appropriately to the early signs of an acute exacerbation. - Ability to demonstrate an understanding of the patient self-management card and the indications for self- initiation of appropriate medication - Access to a telephone to notify the practice at the earliest opportunity that they have started their home supply of medication (preferably within 24hours)

10 My Patient Action Plan Green Light = I feel fine I can walk... on the flat before stopping I can walk... on a gentle incline before stopping I cough about... tablespoons/eggcups ps of phlegm a day I sleep... hours, and wake up... times with my breathing Things that make my breathing worse are... Amber Light = I feel worse than usual 1. I feel more breathless sitting still 2. I feel more breathless doing routine things 3. I m waking up more often short of breath 4. My puffers don t work so well as usual 5. I m coughing more phlegm 6. The phlegm has changed colour to more green or yellow IF YOU SCORE 2 FROM 6 FOLLOW THE AMBER PLAN Red Light = Danger Signs Green Plan Don t smoke Exercise gently Take all my medicines edc es and puffers Have my flu jab yearly and pneumonia jab Amber Plan Increase your inhaled medicines to.... &... (use a spacer for all your puffers) If you have been given steroids to keep at home and agree with 1 or 2 or 3 then start the steroid course If you have been given antibiotics to keep at home and agree with 6 then start the antibiotic course. You may need to start both together. ARRANGE TO SEE YOUR GP WITHIN 24 HOURS Red Action Very short of breath even when sitting still Unable to talk because of shortness of breath Chest Pain Unusual confusion or excessive drowsiness Worsening leg swelling Discuss with a GP urgently, or call 999

11 Effect on admissions i and dbed days for COPD, amongst tthe project participants, during the 6 month study period, compared to the same 6 months in the preceding year Feb 07 to July Feb 08 to July COPD admissions Bed days

12 Effect on costs for COPD admissions, amongst the project participants, during the 6 month study period compared to the same 6 months in the preceding year Total cost 30,000 25,000 20,000 Total cost 15,000 10,000 5,000 0 Feb 07 to July 07 Feb 08 to July 08

13 Project Results 3 admissions 62 bed days during study period 1 st February 31 st July Compared to 11 admissions 156 bed days preceding 1 st February -31 st July Unscheduled secondary care costs during study 8,344 compared to 28,291 the preceding year. 128 rescue packs supplied, no hospital deaths & 4 deaths in community (all causes) during study.

14 Discussion of Study Better health & avoided effects of hospitalisation during study period. Small un-blinded study No record of how many participants had their regular treatment optimised during study -this may have contributed to improved outcomes. Confounding variables LABD, LES, Case Management.

15 Discussion continued? Overuse of rescue medication & associated risks versus benefits further study needed d 128 rescue packs supplied (0-8, average 2.6 pp) no hospital deaths & 4 deaths in community (all causes) during study. Moderate to Severe COPD Group studied. COPD Audit (2008) 15% of admitted population dead with in 3/12

16 Recent Evidence COPE II Study - Self treatment of exacerbations with steroids and antibiotics leads to fewer exacerbation days and lower costs (Effing et al 2009)

17 Congruence with Draft National COPD Strategy (2010) 293. Supports self management education, action plan, & assessment of individual / or carers ability to self manage exacerbations with rescue therapy Individualised self management, with Action Plans, to include increased dinhaled medication i (mild exacerbation) or oral corticosteroids and/or antibiotics (more severe exacerbation) Where patients self manage with rescue therapy they should contact HCP within 2 days. Action Plan should be reviewed within 6 weeks.

18 Thank You

19 References The Royal College of Physicians; The British Thoracic Society; British Lung Foundation (2008) Clinical Audit of COPD exacerbations admitted to acute NHS units across UK. November DoH (2008) Consultation on a Strategy for Services for COPD in England. February Donaldson C G, Seemungal T A R, Bhowmik A, and Wedzicha J A (2002). Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002; 57: doi: /thorax / Effing T; Kerstjens, H; van der Valk, P et al (2009) Cost effectiveness of self treatment of exacerbarions on the severity of exacerbations in patients with COPD. COPE II Study. Thorax, (64) pp National Collaborating Centre for Chronic Conditions (2004) Chronic obstructive pulmonary disease: the clinical management of chronic obstructive pulmonary disease in adults in primary & secondary care. Thorax 59, supplement 1, NICE (2004) COPD - Management of COPD in adult in primary & secondary care. Fb February. Seemungal TAR et al (1998) Effects of exacerbation on Quality of Life in Patients with COPD. American Journal Respiratory Critical Care Medicine (157) p Wilkinson T; Donaldson G; Hurst J; Seemungal T; Wededzicha J (2004) Early Therapy Improves Outcomes of Exacerbations of Chronic Obstructive Pulmonary Disease. St Bartholomew s Hospital. London.