Advertisement

Journal of General Internal Medicine

, Volume 22, Issue 6, pp 799–804 | Cite as

Factors Associated with Frequency of Emergency Department Visits for Chronic Obstructive Pulmonary Disease Exacerbation

  • Chu-Lin Tsai
  • Sharon K. Griswold
  • Sunday Clark
  • Carlos A. CamargoJr.
Original Article

Abstract

Background

Little is known about the factors associated with frequency of emergency department visits (FEDV) in chronic obstructive pulmonary disease (COPD) patients with recurrent exacerbations.

Objective

To characterize the use of emergency department (ED) services in patients with COPD exacerbation and identify factors associated with FEDV.

Design

A prospective, multicenter cohort study.

Patients

Three hundred eighty-eight patients were included. Fifty-two percent were women and the median age was 69 years (interquartile range 62–76).

Measurements

Using a standard questionnaire, consecutive ED patients with COPD exacerbation were interviewed. The number of ED visits in the previous year was retrospectively collected.

Results

Over the past year, this cohort reported a total of 1,090 ED visits because of COPD exacerbation. Thirteen percent of COPD patients had 6 or more ED visits, accounting for 57% of the total ED visits in the past year. Multivariate analysis showed that patients with an increased FEDV were more likely to be Hispanic (incidence rate ratio [IRR] 1.97, 95% confidence interval [CI] 1.16–3.33), to have more severe COPD as determined by previous hospitalizations (IRR 2.06, 95% CI 1.51–2.82), prior intubations (IRR 1.49, 95% CI 1.02–2.18), prior use of systemic corticosteroids (IRR 1.57, 95% CI 1.16–2.13) and methylxanthine (IRR 1.48, 95% CI 1.04–2.12), and less likely to have a primary care provider (IRR 0.51, 95% CI 0.31–0.82).

Conclusions

Our results suggest that both disease and health care-related factors were associated with FEDV in COPD exacerbation. Multidisciplinary efforts through primary care provider follow-up should be assessed to test the effects on reducing the high morbidity and cost of recurrent COPD exacerbations.

KEY WORDS

chronic obstructive pulmonary disease emergency department visits primary care provider recurrent exacerbation 

Abbreviations

COPD

Chronic obstructive pulmonary disease

ED

Emergency department

Notes

Ackowledgments

The authors thank the EMNet investigators for their ongoing dedication to public health research, with an emphasis on the treatment and prevention of respiratory/allergy emergencies. The cohort studies were supported by an unrestricted grant from Boehringer Ingelheim (Ridgefield, Conn, USA and Burlington, Ontario, Canada).

EMNet Steering Committee: Michelle P. Blanda, MD; Edwin D. Boudreaux, PhD; Carlos A. Camargo, Jr., MD (Chair); Rita K. Cydulka, MD; Theodore J. Gaeta, DO, MPH; Susan Key, RN, MS, CEN; Steven Polevoi, MD; Michael S. Radeos, MD, MPH; and Benjamin C. Sun, MD, MPP.

EMNet Coordinating Center: Christina Ahn; Carlos A. Camargo, Jr., MD (Director); Sunday Clark, MPH, ScD; Lisa A. Dubois; Kate E. Delaney; Adit A. Ginde, MD; Andrea J. Pelletier, MS, MPH; Ashley F. Sullivan, MS, MPH; Chu-Lin Tsai, MD, MPH (all from the Massachusetts General Hospital, Boston, Mass, USA).

Principal Investigators at the 29 Participating Sites: FC Baker III (Maine Medical Center, Portland, Maine, USA); MP Blanda (Summa Health System, Akron, Ohio, USA); ED Boudreaux (Earl K. Long Memorial Hospital, Baton Rouge, La, USA); BE Brenner (The Brooklyn Hospital Center, Brooklyn, NY, USA); CA Camargo, Jr. (Massachusetts General Hospital, Boston, Mass, USA); RK Cydulka (MetroHealth Medical Center, Cleveland, Ohio, USA); TJ Gaeta (New York Methodist Hospital, Brooklyn, NY, USA); B Goldfeder (Shands Hospital at the Univeristy of Florida, Gainesville, Fla, USA); RJ Grant (Hartford Hospital, Hartford, Conn, USA); RO Gray (Hennepin County Medical Center, Minneapolis, Minn, USA); A Guttman (Sir Mortimer B. Davis, Jewish General Hospital, Montreal, Quebec, Canada); LW Kreplick (Christ Hospital and Medical Center, Oak Lawn, Ill, USA); DS Mackey (Lethbridge Regional Hospital, Lethbridge, Alberta, Canada); A Mangione (Albert Einstein Medical Center, Philadelphia, Pa, USA); J Peters (University of Texas Health Sciences Center at San Antonio, San Antonio, Tex, USA); MS Radeos (Lincoln Medical Center, Bronx, NY); PL Rice (Brigham and Women’s Hospital, Boston, Mass, USA); BH Rowe (University of Alberta Hospital, Edmonton, Alberta, Canada); M Sama (St. Joseph Mercy Hospital, Ann Arbor, Mich, USA); D Schreiber (Stanford University Medical Center, Stanford, Calif, USA); NI Shapiro (Beth Israel Deaconess Medical Center, Boston, Mass, USA); PC Shukla (University of Texas Southwestern Medical Center, Dallas, Tex, USA); D Sinclair (Queen Elizabeth II Health Science Centre, Halifax, Nova Scotia, Canada); H Smithline (Baystate Medical Center, Springfield, Mass, USA); PE Sokolove (UC Davis Medical Center, Sacramento, Calif, USA); M Steffens (Palmetto Richland Memorial Hospital, Columbia, SC, USA); CA Terregino (Cooper Hospital/University Medical Center, Camden, NJ, USA); A Travers (Royal Alexandria Hospital, Edmonton, Alberta, Canada); and EJ Weber (UCSF Medical Center, San Francisco, Calif, USA).

Conflict of interest statement

Dr. Camargo has received financial support (research grants, consulting, lectures) from AstraZeneca (Wilmington, Del, USA), Boehringer Ingelheim (Ridgefield, Conn, USA), GlaxoSmithKline (Research Triangle Park, NC, USA), Novartis (East Hanover, NJ, USA), and Schering Plough (Kenilworth, NJ, USA). All other authors declare that they have no conflicts of interest.

References

  1. 1.
    Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance—United States, 1971–2000. MMWR Surveill Summ 2002;51:1–16.Google Scholar
  2. 2.
    Urbano FL, Pascual RM. Contemporary issues in the care of patients with chronic obstructive pulmonary disease. J Manag Care Pharm 2005;11:S2–13; quiz S14–6.PubMedGoogle Scholar
  3. 3.
    Spencer M, Briggs AH, Grossman RF, Rance L. Development of an economic model to assess the cost effectiveness of treatment interventions for chronic obstructive pulmonary disease. Pharmacoeconomics 2005;23:619–37.PubMedCrossRefGoogle Scholar
  4. 4.
    Chapman KR, Bourbeau J, Rance L. The burden of COPD in Canada: results from the Confronting COPD survey. Respir Med 2003;97(suppl C):S23–31.PubMedCrossRefGoogle Scholar
  5. 5.
    Seemungal TA, Donaldson GC, Paul EA, Bestall JC, Jeffries DJ, Wedzicha JA. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157:1418–22.PubMedGoogle Scholar
  6. 6.
    Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002;57:847–52.PubMedCrossRefGoogle Scholar
  7. 7.
    Soler-Cataluna JJ, Martinez-Garcia MA, Roman Sanchez P, Salcedo E, Navarro M, Ochando R. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 2005;60:925–31.PubMedCrossRefGoogle Scholar
  8. 8.
    Tsai CL, Clark S, Cydulka RK, Rowe BH, Camargo CA Jr. Factors associated with hospital admission among emergency department patients with chronic obstructive pulmonary disease exacerbation. Acad Emerg Med 2007;14:6–14.PubMedCrossRefGoogle Scholar
  9. 9.
    Garcia-Aymerich J, Monso E, Marrades RM, et al. Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study. Am J Respir Crit Care Med 2001;164:1002–7.PubMedGoogle Scholar
  10. 10.
    Kessler R, Faller M, Fourgaut G, Mennecier B, Weitzenblum E. Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999;159:158–64.PubMedGoogle Scholar
  11. 11.
    Cydulka RK, Rowe BH, Clark S, Emerman CL, Camargo CA Jr. Emergency department management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: the Multicenter Airway Research Collaboration. J Am Geriatr Soc 2003;51:908–16.PubMedCrossRefGoogle Scholar
  12. 12.
    American Thoracic Society. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;152:S77–121.Google Scholar
  13. 13.
    Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. Am J Respir Crit Care Med 2001;163:1256–76.PubMedGoogle Scholar
  14. 14.
    Radeos MS, Cydulka RK, Rowe BH, Barr RG, Camargo CA Jr. Validation of clinical diagnosis of COPD among patients presenting to the emergency department. Am J Respir Crit Care Med 2001;163:A912.Google Scholar
  15. 15.
    CACI. The sourcebook of zip code demographics. Fairfax, Va: CACI; 2002.Google Scholar
  16. 16.
    Canada H. Federal census data: Statistics Canada. Ottawa, Ontario, Canada: Health Canada; 1996.Google Scholar
  17. 17.
    Glynn RJ, Buring JE. Ways of measuring rates of recurrent events. BMJ 1996;312:364–7.PubMedGoogle Scholar
  18. 18.
    Tsai CL. Appropriate statistical treatment of frequent emergency department visits in health services research. Ann Emerg Med 2007;49:385.PubMedCrossRefGoogle Scholar
  19. 19.
    Greenland S. Modeling and variable selection in epidemiologic analysis. Am J Public Health 1989;79:340–9.PubMedGoogle Scholar
  20. 20.
    Miettinen OS. Proportion of disease caused or prevented by a given exposure, trait or intervention. Am J Epidemiol 1974;99:325–32.PubMedGoogle Scholar
  21. 21.
    Donaldson GC, Seemungal TA, Patel IS, Lloyd-Owen SJ, Wilkinson TM, Wedzicha JA. Longitudinal changes in the nature, severity and frequency of COPD exacerbations. Eur Respir J 2003;22:931–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Pesola GR, Xu F, Ahsan H, Sternfels P, Meyer IH, Ford JG. Predicting asthma morbidity in Harlem emergency department patients. Acad Emerg Med 2004;11:944–50.PubMedCrossRefGoogle Scholar
  23. 23.
    Kim S, Emerman CL, Cydulka RK, Rowe BH, Clark S, Camargo CA Jr. Prospective multicenter study of relapse following emergency department treatment of COPD exacerbation. Chest 2004;125:473–81.PubMedCrossRefGoogle Scholar
  24. 24.
    Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med 2000;7:637–46.PubMedGoogle Scholar
  25. 25.
    McCusker J, Cardin S, Bellavance F, Belzile E. Return to the emergency department among elders: patterns and predictors. Acad Emerg Med 2000;7:249–59.PubMedGoogle Scholar
  26. 26.
    Purdie FR, Honigman B, Rosen P. The chronic emergency department patient. Ann Emerg Med 1981;10:298–301.PubMedCrossRefGoogle Scholar
  27. 27.
    Sun BC, Burstin HR, Brennan TA. Predictors and outcomes of frequent emergency department users. Acad Emerg Med 2003;10:320–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Richman IB, Clark S, Sullivan AF, Camargo CA Jr. National Study of the Relation of Primary Care Shortages to Emergency Department Utilization. Acad Emerg Med. 2007;14:279–82.PubMedCrossRefGoogle Scholar
  29. 29.
    Institute of Medicine (U.S.). Committee on the Consequences of Uninsurance. Coverage matters: insurance and health care. Washington, DC: National Academy Press; 2001.Google Scholar
  30. 30.
    National Center for Health Statistics (U.S.). National Hospital Ambulatory Medical Care Survey. Emergency department summary. Hyattsville, Md: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2001.Google Scholar
  31. 31.
    National Center for Health Statistics (U.S.). National Hospital Ambulatory Medical Care Survey. Emergency department summary. Hyattsville, Md: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2004.Google Scholar
  32. 32.
    Bureau of the Census (U.S.). Health insurance coverage. Washington, DC: Bureau of the Census, United States; 2001.Google Scholar
  33. 33.
    Bureau of the Census (U.S.). Health insurance coverage. Washington, DC: Bureau of the Census, United States; 2005.Google Scholar
  34. 34.
    Lung Health Study Research Group. Effect of inhaled triamcinolone on the decline in pulmonary function in chronic obstructive pulmonary disease. N Engl J Med. 2000;343:1902–9.CrossRefGoogle Scholar
  35. 35.
    Niewoehner DE, Rice K, Cote C, et al. Prevention of exacerbations of chronic obstructive pulmonary disease with tiotropium, a once-daily inhaled anticholinergic bronchodilator: a randomized trial. Ann Intern Med 2005;143:317–26.PubMedGoogle Scholar
  36. 36.
    Sin DD, Bell NR, Svenson LW, Man SF. The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study. Am J Med 2002;112:120–5.PubMedCrossRefGoogle Scholar
  37. 37.
    National Asthma Education and Prevention Program. Expert panel report II: Guidelines for the diagnosis and management of asthma. Bethesda, Md: National Institutes of Health; 1997.Google Scholar
  38. 38.
    Boudreaux ED, Emond SD, Clark S, Camargo CA Jr. Acute asthma among adults presenting to the emergency department: the role of race/ethnicity and socioeconomic status. Chest 2003;124:803–12.PubMedCrossRefGoogle Scholar
  39. 39.
    Baker DW, Stevens CD, Brook RH. Determinants of emergency department use: are race and ethnicity important? Ann Emerg Med 1996;28:677–82.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Chu-Lin Tsai
    • 1
    • 2
    • 4
  • Sharon K. Griswold
    • 3
  • Sunday Clark
    • 2
  • Carlos A. CamargoJr.
    • 1
    • 2
  1. 1.Department of EpidemiologyHarvard School of Public HealthBostonUSA
  2. 2.Department of Emergency MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Department of Emergency MedicineThomas Jefferson University HospitalPhiladelphiaUSA
  4. 4.Department of Emergency MedicineMassachusetts General HospitalBostonUSA

Personalised recommendations