Evaluation of Hospital Admission Status for Emergency Department Patients Seen for Chronic Obstructive Pulmonary Disease Exacerbation: A Retrospective Observational Study

摘要

Background: Chronic obstructive pulmonary disease (COPD) is a common and preventable condition. The disease accounts for a large economic burden in the US health care system. Better control and prevention of COPD exacerbations can help prevent presentations to already-crowded emergency departments (EDs) and hospitals. The objective of our study was to identify variables associated with hospital admission status in ED patients presenting with COPD exacerbation.Methods: We conducted a retrospective observational study of patients seen at 1 of 3 US EDs from 2012 to 2014 with a primary diagnosis related to COPD exacerbation. Hospital admission status was modeled using patient characteristic data via adaptive least absolute shrinkage and selection operator logistic regression. Study results are presented as adjusted odds ratios with 95% CIs. Planned post hoc model dependency and external data sensitivity analyses were conducted.Results: The study sample included 1,165 unique patients with COPD with an ED encounter related to exacerbation at 1 of the 3 reviewed hospitals. Approximately half of these patients had a hospital admission. Variables inversely associated with an admission included oxygen saturation and number of prior ED encounters for COPD exacerbation. Variables positively associated with admission were initial ED heart rate, patient age, and documented comorbidities of anxiety and/or depression. These mental health comorbidities had the strongest association with admission status.Conclusion: Understanding the characteristics of admitted patients may help direct resources and outpatient services to prevent encounters. Of note, the study revealed mental health variables as being strongly associated with admission status. Keywords: Anxiety , depression , emergency service–hospital , patient admission , pulmonary disease–chronic obstructive INTRODUCTIONChronic obstructive pulmonary disease (COPD) is a common and preventable condition. In 2010, the estimated number of COPD cases was 384 million, with a global prevalence of 11.7%.~(1) COPD is a leading cause of morbidity and is the fourth leading cause of death in the world.~(2,3) Driving factors related to the burden of COPD are increasing rates of smoking in developing countries and aging populations in developed countries.~(4)COPD is associated with a large economic burden in the US health care system. According to Guarascio et al, in 2010 the estimated direct cost of COPD in the US was $30 billion, with indirect costs of $20 billion.~(5) Singh and Yu reported that the average emergency department (ED) charge was $2,812, and the hospitalization charge was $29,043 for COPD-related illness in 2012.~(6) US data from 2015 to 2016 showed a marked increase in the percentage of adults with a COPD diagnosis receiving ED services.~(7) The cost burden has also been reported in other areas of the world. In 2019, Kirsch et al reported that hospital admissions for COPD accounted for more than 50% of total direct health care costs in a large German sample.~(8)The identification of risk factors associated with exacerbations has been an area of interest for researchers. Better control and prevention of exacerbations can help prevent presentations to already crowded EDs and hospitals as well as address the significant financial weight associated with these visits. While most COPD exacerbations are managed outside of the hospital, the percentage of COPD exacerbations that require hospitalization present an opportunity for health care improvement. Studies have identified risk factors for COPD exacerbations such as decreased forced expiratory volume, anxiety, depression, duration of disease, sex, age, socioeconomic level, and previous admission for exacerbation.~(9-14) Patient age and number of prior exacerbations have been commonly reported predictors of a future exacerbation. Biomarkers, specifically serum/sputum eosinophil levels and C-reactive protein, have also been used to predict exacerbations.~(15,16)Compared to risk factors for COPD acute exacerbation, markedly less research has been done on factors related to hospitalization for COPD exacerbation. Parshall and Doherty (2006) found that a greater heart rate in the ED was predictive of a hospital admission.~(17) Additionally, risk factors such as time of presentation after onset of symptoms, prior admissions for COPD exacerbation, level of dyspnea, and presence of comorbid conditions have been reported as predictive indicators of hospitalization for COPD exacerbations.~(18-21) The aim of our study was to expand on existing research in identifying targetable variables associated with admission status in a sample of US patients with COPD.METHODSWe conducted a retrospective observational study of data from 3 community teaching hospital EDs located in the same US Midwestern city. All facilities were within the same health care system and used the same electronic health record (EHR). The study received approval from th