David H. Au, MD, MS

Up to one‐third of the 700,000 patients admitted annually for an exacerbation of chronic obstructive pulmonary disease (COPD) continue to smoke tobacco.[1, 2] Smokers with COPD are at high risk for poor health outcomes directly attributable to tobacco‐related conditions, including progression of lung disease and cardiovascular diseases.[3, 4, 5] Treatment for tobacco addiction is the most essential intervention for these patients.

Hospital admission has been suggested as an opportune time for the initiation of smoking cessation.[6] Hospitalized patients are already in a smoke‐free environment, and have access to physicians, nurses, and pharmacists who can prescribe medications for support.[7] Documenting smoking status and offering smoking cessation treatment during and after discharge are quality metrics required by the Joint Commission, and recommended by the National Quality Forum.[8, 9] Hospitals have made significant efforts to comply with these requirements.[10]

Limited data exist regarding the effectiveness and utilization of treatments known to reduce cigarette use among COPD patients in nontrial environments. Prescribing patterns of medications for smoking cessation in the real world following admission for COPD are not well studied. We sought to examine the utilization of inpatient brief tobacco counseling and postdischarge pharmacotherapy following discharge for exacerbation of COPD, as well as to (1) examine the association of postdischarge pharmacotherapy with self‐reported smoking cessation at 6 to 12 months and (2) assess differences in effectiveness between cessation medications prescribed.

METHODS

We conducted a cohort study of current smokers discharged following a COPD exacerbation within the Veterans Affairs (VA) Veterans Integrated Service Network (VISN)‐20. This study was approved by the VA Puget Sound Health Care System Institutional Review Board (#00461).

We utilized clinical information from the VISN‐20 data warehouse that collects data using the VA electronic medical record, including demographics, prescription medications, hospital admissions, hospital and outpatient diagnoses, and dates of death, and is commonly used for research. In addition, we utilized health factors, coded electronic entries describing patient health behaviors that are entered by nursing staff at the time of a patient encounter, and the text of chart notes that were available for electronic query.

Study Cohort

We identified all smokers aged 40 years hospitalized between 2005 and 2012 with either a primary discharge diagnosis of COPD based on International Classification of Diseases, 9th Revision codes (491, 492, 493.2, and 496) or an admission diagnosis from the text of the admit notes indicating an exacerbation of COPD. We limited to patients aged 40 years to improve the specificity of the diagnosis of COPD, and we selected the first hospitalization that met inclusion criteria. We excluded subjects who died within 6 months of discharge (Figure 1).

Figure 1

To establish tobacco status, we built on previously developed and validated methodology,[11] and performed truncated natural language processing using phrases in the medical record that reflected patients' tobacco status, querying all notes from the day of admission up to 6 months prior. If no tobacco status was indicated in the notes, we identified the status encoded by the most recent health factor. We manually examined the results of the natural language processing and the determination of health factors to confirm the tobacco status. Manual review was undertaken by 1 of 2 trained study personnel. In the case of an ambiguous or contradictory status, an additional team member reviewed the information to attempt to make a determination. If no determination could be made, the record was coded to unknown. This method allowed us to identify a baseline status for all but 77 of the 3580 patients admitted for COPD.

RESULTS

Among these 1334 subjects at 6 to 12 months of follow‐up, 63.7% reported ongoing smoking, 19.8% of patients reported quitting, and 17.5% of patients had no reported status and were presumed to be smokers. Four hundred fifty (33.7%) patients were dispensed a smoking cessation medication within 90 days of discharge. Patients who were dispensed medications were younger and more likely to be female. Nearly all patients who received medications also received documented predischarge counseling (94.6%), as did the majority of patients who did not receive medications (83.8%) (Table 1).

Of patients dispensed a study medication, 246 (18.4% of patients, 54.7% of all medications dispensed) were dispensed medications within 48 hours of discharge (Table 2). Of the patients dispensed medication, the majority received nicotine patches alone (Table 3), and 18.9% of patients received combination therapy, with the majority receiving nicotine patch and short‐acting nicotine replacement therapy (NRT) or patch and buproprion. A significant number of patients were prescribed medications within 90 days of discharge, but did not have them dispensed within that timeframe (n = 224, 16.8%).

DISCUSSION

In this observational study, postdischarge pharmacotherapy within 90 days of discharge was provided to a minority of high‐risk smokers admitted for COPD, and was not associated with smoking cessation at 6 to 12 months. In comparison to nicotine patch alone, varenicline was associated with a higher odds of cessation, with decreased odds of cessation among patients treated with short‐acting NRT alone. The overall quit rate was significant at 19.8%, and is consistent with annual quit rates observed among patients with COPD in other settings,[21, 22] but is far lower than quit rates observed after admission for acute myocardial infarction.[23, 24, 25] Although the proportion of patients treated at the time of discharge or within 90 days was low, our findings are in keeping with previous studies, which demonstrated low rates of pharmacologic treatment following hospitalization, averaging 14%.[26] Treatment for tobacco use is likely underutilized for this group of high‐risk smokers. However, a significant proportion of patients who were prescribed medications in the postdischarge period did not have medications filled. This likely reflects both the rapid changes in motivation that characterize quit attempts,[27] as well as efforts on the part of primary care physicians to make these medications available to facilitate future quit attempts.

There are several possible explanations for the findings in our study. Pharmaceutical therapies were not provided at random. The provision of pharmacotherapy and the ultimate success of a quit attempt reflects a complex interaction of patient beliefs concerning medications, level of addiction and motivation, physician behavior and knowledge, and organizational factors. Organizational factors such as the structure of electronic discharge orders and the availability of decision support materials may influence a physician's likelihood of prescribing medications, the choice of medication prescribed, and therefore the adequacy of control of withdrawal symptoms. NRT is often under dosed to control ongoing symptoms,[28] and needs to be adjusted until relief is obtained, providing an additional barrier to effectiveness during the transition out of the hospital. Because most smokers with COPD are highly addicted to nicotine,[29] high‐dose NRT, combination therapy, or varenicline would be necessary to adequately control symptoms.[30] However, a significant minority of patients received short‐acting NRT alone.

Despite a high observed efficacy in recent trials,[31, 32] few subjects in our study received varenicline. This may be related to both secular trends and administrative barriers to the use of varenicline in the VA system. Use of this medication was limited among patients with psychiatric disorders due to safety concerns. These concerns have since been largely disproven, but may have limited access to this medication.[33, 34, 35] Although we adjusted for a history of mental illness, patients who received varenicline may have had more past quit attempts and less active mental illness, which may be associated with improved cessation rates. Despite the high prevalence of mental illness we observed, this is typical of the population of smokers, with studies indicating nearly one‐third of smokers overall suffer from mental illness.[36]

Although the majority of our patients received a brief, nurse‐based counseling intervention, there is considerable concern about the overall effectiveness of a single predischarge interaction to produce sustained smoking cessation among highly addicted smokers.[37, 38, 39, 40] The Joint Commission has recently restructured the requirements for smoking cessation treatment for hospitalized patients, and it is now up to hospitals to implement treatment mechanisms that not only meet the national requirements, but also provide a meaningful clinical effect. Though the optimum treatment for hospitalized smokers with COPD is unknown, previous positive studies of smoking cessation among hospitalized patients underscore the need for a higher‐intensity counseling intervention that begins during hospitalization and continues after discharge.[13, 41] Cessation counseling services including tobacco cessation groups and quit lines are available through the VA; however, the use of these services is typically low and requires the patient to enroll independently after discharge, an additional barrier. The lack of association between medications and smoking cessation found in our study could reflect poor effectiveness of medications in the absence of a systematic counseling intervention. Alternatively, the association may be explained that patients who were more highly addicted and perhaps less motivated to quit received tobacco cessation medications more often, but were also less likely to stop tobacco use, a form of indication bias.

Our study has several limitations. We do not have addiction or motivation levels for a cessation attempt, a potential unmeasured confounder. Although predictive of quit attempts, motivation factors are less predictive of cessation maintenance, and may therefore have an unclear effect on our outcome.[42, 43] Our outcome was gathered as part of routine clinical care, which may have introduced bias if patients over‐reported cessation because of social desirability. In healthcare settings, however, this form of assessing smoking status is generally valid.[44] Exposure to counseling or medications obtained outside of the VA system would not have been captured. Given the financial incentive, we believe it is unlikely that many patients admitted to a VA medical center obtained medications elsewhere.[45] The diagnosis of COPD was made administratively. However, all subjects were admitted for an exacerbation, which is associated with more severe COPD by Global Initiative for Obstructive Lung Disease (GOLD) stage.[46] Patients with more severe COPD are often excluded from studies of smoking cessation due to concerns of high dropout and lower prevalence of smoking among patients with GOLD stage IV disease,[47, 48] making this a strength of our study. Subjects who died may have quit only in extremis, or failed to document their quit attempts. However, our sensitivity analysis limited to survivors did not change the study results. There may have been some misclassification in the use of buproprion, which may also be prescribed as an antidepressant. Finally, although representative of the veterans who seek care within the VISN‐20, our patients were primarily white and male, limiting the ability to generalize outside of this group.

Our study had several strengths. We examined a large cohort of patients admitted to a complete care organization, including patients from a diverse group of VA settings comprising academically and nonacademically affiliated centers. We performed an unbiased collection of patients, including all smokers discharged for COPD. We had access to excellent completeness of medications prescribed and filled as collected within the VA system, enabling us to observe medications dispensed and prescribed at several time points. We also had near complete ascertainment of outcomes including by using natural language processing with manual confirmation of smoking status.

In summary, we found that provision of medications to treat ongoing tobacco use among patients discharged for COPD was low, and receipt of medications was not associated with a reduction in smoking tobacco at 6 to 12 months postdischarge. However, among those treated, varenicline appears to be superior to the nicotine patch, with short‐acting nicotine replacement potentially less effective, a biologically plausible finding. The motivation to quit smoking changes rapidly over time. Providing these medications in the hospital and during the time after discharge is a potential means to improve quit rates, but medications need to be paired with counseling to be most effective. Collectively, these data suggest that systems‐based interventions are needed to increase the availability of intense counseling and the use of tailored pharmacotherapy to these patients.

Up to one‐third of the 700,000 patients admitted annually for an exacerbation of chronic obstructive pulmonary disease (COPD) continue to smoke tobacco.[1, 2] Smokers with COPD are at high risk for poor health outcomes directly attributable to tobacco‐related conditions, including progression of lung disease and cardiovascular diseases.[3, 4, 5] Treatment for tobacco addiction is the most essential intervention for these patients.

Hospital admission has been suggested as an opportune time for the initiation of smoking cessation.[6] Hospitalized patients are already in a smoke‐free environment, and have access to physicians, nurses, and pharmacists who can prescribe medications for support.[7] Documenting smoking status and offering smoking cessation treatment during and after discharge are quality metrics required by the Joint Commission, and recommended by the National Quality Forum.[8, 9] Hospitals have made significant efforts to comply with these requirements.[10]

Limited data exist regarding the effectiveness and utilization of treatments known to reduce cigarette use among COPD patients in nontrial environments. Prescribing patterns of medications for smoking cessation in the real world following admission for COPD are not well studied. We sought to examine the utilization of inpatient brief tobacco counseling and postdischarge pharmacotherapy following discharge for exacerbation of COPD, as well as to (1) examine the association of postdischarge pharmacotherapy with self‐reported smoking cessation at 6 to 12 months and (2) assess differences in effectiveness between cessation medications prescribed.

METHODS

We conducted a cohort study of current smokers discharged following a COPD exacerbation within the Veterans Affairs (VA) Veterans Integrated Service Network (VISN)‐20. This study was approved by the VA Puget Sound Health Care System Institutional Review Board (#00461).

We utilized clinical information from the VISN‐20 data warehouse that collects data using the VA electronic medical record, including demographics, prescription medications, hospital admissions, hospital and outpatient diagnoses, and dates of death, and is commonly used for research. In addition, we utilized health factors, coded electronic entries describing patient health behaviors that are entered by nursing staff at the time of a patient encounter, and the text of chart notes that were available for electronic query.

Study Cohort

We identified all smokers aged 40 years hospitalized between 2005 and 2012 with either a primary discharge diagnosis of COPD based on International Classification of Diseases, 9th Revision codes (491, 492, 493.2, and 496) or an admission diagnosis from the text of the admit notes indicating an exacerbation of COPD. We limited to patients aged 40 years to improve the specificity of the diagnosis of COPD, and we selected the first hospitalization that met inclusion criteria. We excluded subjects who died within 6 months of discharge (Figure 1).

Figure 1

To establish tobacco status, we built on previously developed and validated methodology,[11] and performed truncated natural language processing using phrases in the medical record that reflected patients' tobacco status, querying all notes from the day of admission up to 6 months prior. If no tobacco status was indicated in the notes, we identified the status encoded by the most recent health factor. We manually examined the results of the natural language processing and the determination of health factors to confirm the tobacco status. Manual review was undertaken by 1 of 2 trained study personnel. In the case of an ambiguous or contradictory status, an additional team member reviewed the information to attempt to make a determination. If no determination could be made, the record was coded to unknown. This method allowed us to identify a baseline status for all but 77 of the 3580 patients admitted for COPD.

RESULTS

Among these 1334 subjects at 6 to 12 months of follow‐up, 63.7% reported ongoing smoking, 19.8% of patients reported quitting, and 17.5% of patients had no reported status and were presumed to be smokers. Four hundred fifty (33.7%) patients were dispensed a smoking cessation medication within 90 days of discharge. Patients who were dispensed medications were younger and more likely to be female. Nearly all patients who received medications also received documented predischarge counseling (94.6%), as did the majority of patients who did not receive medications (83.8%) (Table 1).

Of patients dispensed a study medication, 246 (18.4% of patients, 54.7% of all medications dispensed) were dispensed medications within 48 hours of discharge (Table 2). Of the patients dispensed medication, the majority received nicotine patches alone (Table 3), and 18.9% of patients received combination therapy, with the majority receiving nicotine patch and short‐acting nicotine replacement therapy (NRT) or patch and buproprion. A significant number of patients were prescribed medications within 90 days of discharge, but did not have them dispensed within that timeframe (n = 224, 16.8%).

DISCUSSION

In this observational study, postdischarge pharmacotherapy within 90 days of discharge was provided to a minority of high‐risk smokers admitted for COPD, and was not associated with smoking cessation at 6 to 12 months. In comparison to nicotine patch alone, varenicline was associated with a higher odds of cessation, with decreased odds of cessation among patients treated with short‐acting NRT alone. The overall quit rate was significant at 19.8%, and is consistent with annual quit rates observed among patients with COPD in other settings,[21, 22] but is far lower than quit rates observed after admission for acute myocardial infarction.[23, 24, 25] Although the proportion of patients treated at the time of discharge or within 90 days was low, our findings are in keeping with previous studies, which demonstrated low rates of pharmacologic treatment following hospitalization, averaging 14%.[26] Treatment for tobacco use is likely underutilized for this group of high‐risk smokers. However, a significant proportion of patients who were prescribed medications in the postdischarge period did not have medications filled. This likely reflects both the rapid changes in motivation that characterize quit attempts,[27] as well as efforts on the part of primary care physicians to make these medications available to facilitate future quit attempts.

There are several possible explanations for the findings in our study. Pharmaceutical therapies were not provided at random. The provision of pharmacotherapy and the ultimate success of a quit attempt reflects a complex interaction of patient beliefs concerning medications, level of addiction and motivation, physician behavior and knowledge, and organizational factors. Organizational factors such as the structure of electronic discharge orders and the availability of decision support materials may influence a physician's likelihood of prescribing medications, the choice of medication prescribed, and therefore the adequacy of control of withdrawal symptoms. NRT is often under dosed to control ongoing symptoms,[28] and needs to be adjusted until relief is obtained, providing an additional barrier to effectiveness during the transition out of the hospital. Because most smokers with COPD are highly addicted to nicotine,[29] high‐dose NRT, combination therapy, or varenicline would be necessary to adequately control symptoms.[30] However, a significant minority of patients received short‐acting NRT alone.

Despite a high observed efficacy in recent trials,[31, 32] few subjects in our study received varenicline. This may be related to both secular trends and administrative barriers to the use of varenicline in the VA system. Use of this medication was limited among patients with psychiatric disorders due to safety concerns. These concerns have since been largely disproven, but may have limited access to this medication.[33, 34, 35] Although we adjusted for a history of mental illness, patients who received varenicline may have had more past quit attempts and less active mental illness, which may be associated with improved cessation rates. Despite the high prevalence of mental illness we observed, this is typical of the population of smokers, with studies indicating nearly one‐third of smokers overall suffer from mental illness.[36]

Although the majority of our patients received a brief, nurse‐based counseling intervention, there is considerable concern about the overall effectiveness of a single predischarge interaction to produce sustained smoking cessation among highly addicted smokers.[37, 38, 39, 40] The Joint Commission has recently restructured the requirements for smoking cessation treatment for hospitalized patients, and it is now up to hospitals to implement treatment mechanisms that not only meet the national requirements, but also provide a meaningful clinical effect. Though the optimum treatment for hospitalized smokers with COPD is unknown, previous positive studies of smoking cessation among hospitalized patients underscore the need for a higher‐intensity counseling intervention that begins during hospitalization and continues after discharge.[13, 41] Cessation counseling services including tobacco cessation groups and quit lines are available through the VA; however, the use of these services is typically low and requires the patient to enroll independently after discharge, an additional barrier. The lack of association between medications and smoking cessation found in our study could reflect poor effectiveness of medications in the absence of a systematic counseling intervention. Alternatively, the association may be explained that patients who were more highly addicted and perhaps less motivated to quit received tobacco cessation medications more often, but were also less likely to stop tobacco use, a form of indication bias.

Our study has several limitations. We do not have addiction or motivation levels for a cessation attempt, a potential unmeasured confounder. Although predictive of quit attempts, motivation factors are less predictive of cessation maintenance, and may therefore have an unclear effect on our outcome.[42, 43] Our outcome was gathered as part of routine clinical care, which may have introduced bias if patients over‐reported cessation because of social desirability. In healthcare settings, however, this form of assessing smoking status is generally valid.[44] Exposure to counseling or medications obtained outside of the VA system would not have been captured. Given the financial incentive, we believe it is unlikely that many patients admitted to a VA medical center obtained medications elsewhere.[45] The diagnosis of COPD was made administratively. However, all subjects were admitted for an exacerbation, which is associated with more severe COPD by Global Initiative for Obstructive Lung Disease (GOLD) stage.[46] Patients with more severe COPD are often excluded from studies of smoking cessation due to concerns of high dropout and lower prevalence of smoking among patients with GOLD stage IV disease,[47, 48] making this a strength of our study. Subjects who died may have quit only in extremis, or failed to document their quit attempts. However, our sensitivity analysis limited to survivors did not change the study results. There may have been some misclassification in the use of buproprion, which may also be prescribed as an antidepressant. Finally, although representative of the veterans who seek care within the VISN‐20, our patients were primarily white and male, limiting the ability to generalize outside of this group.

Our study had several strengths. We examined a large cohort of patients admitted to a complete care organization, including patients from a diverse group of VA settings comprising academically and nonacademically affiliated centers. We performed an unbiased collection of patients, including all smokers discharged for COPD. We had access to excellent completeness of medications prescribed and filled as collected within the VA system, enabling us to observe medications dispensed and prescribed at several time points. We also had near complete ascertainment of outcomes including by using natural language processing with manual confirmation of smoking status.

In summary, we found that provision of medications to treat ongoing tobacco use among patients discharged for COPD was low, and receipt of medications was not associated with a reduction in smoking tobacco at 6 to 12 months postdischarge. However, among those treated, varenicline appears to be superior to the nicotine patch, with short‐acting nicotine replacement potentially less effective, a biologically plausible finding. The motivation to quit smoking changes rapidly over time. Providing these medications in the hospital and during the time after discharge is a potential means to improve quit rates, but medications need to be paired with counseling to be most effective. Collectively, these data suggest that systems‐based interventions are needed to increase the availability of intense counseling and the use of tailored pharmacotherapy to these patients.

Up to one‐third of the 700,000 patients admitted annually for an exacerbation of chronic obstructive pulmonary disease (COPD) continue to smoke tobacco.[1, 2] Smokers with COPD are at high risk for poor health outcomes directly attributable to tobacco‐related conditions, including progression of lung disease and cardiovascular diseases.[3, 4, 5] Treatment for tobacco addiction is the most essential intervention for these patients.

Hospital admission has been suggested as an opportune time for the initiation of smoking cessation.[6] Hospitalized patients are already in a smoke‐free environment, and have access to physicians, nurses, and pharmacists who can prescribe medications for support.[7] Documenting smoking status and offering smoking cessation treatment during and after discharge are quality metrics required by the Joint Commission, and recommended by the National Quality Forum.[8, 9] Hospitals have made significant efforts to comply with these requirements.[10]

Limited data exist regarding the effectiveness and utilization of treatments known to reduce cigarette use among COPD patients in nontrial environments. Prescribing patterns of medications for smoking cessation in the real world following admission for COPD are not well studied. We sought to examine the utilization of inpatient brief tobacco counseling and postdischarge pharmacotherapy following discharge for exacerbation of COPD, as well as to (1) examine the association of postdischarge pharmacotherapy with self‐reported smoking cessation at 6 to 12 months and (2) assess differences in effectiveness between cessation medications prescribed.

METHODS

We conducted a cohort study of current smokers discharged following a COPD exacerbation within the Veterans Affairs (VA) Veterans Integrated Service Network (VISN)‐20. This study was approved by the VA Puget Sound Health Care System Institutional Review Board (#00461).

We utilized clinical information from the VISN‐20 data warehouse that collects data using the VA electronic medical record, including demographics, prescription medications, hospital admissions, hospital and outpatient diagnoses, and dates of death, and is commonly used for research. In addition, we utilized health factors, coded electronic entries describing patient health behaviors that are entered by nursing staff at the time of a patient encounter, and the text of chart notes that were available for electronic query.

Study Cohort

We identified all smokers aged 40 years hospitalized between 2005 and 2012 with either a primary discharge diagnosis of COPD based on International Classification of Diseases, 9th Revision codes (491, 492, 493.2, and 496) or an admission diagnosis from the text of the admit notes indicating an exacerbation of COPD. We limited to patients aged 40 years to improve the specificity of the diagnosis of COPD, and we selected the first hospitalization that met inclusion criteria. We excluded subjects who died within 6 months of discharge (Figure 1).

Figure 1

To establish tobacco status, we built on previously developed and validated methodology,[11] and performed truncated natural language processing using phrases in the medical record that reflected patients' tobacco status, querying all notes from the day of admission up to 6 months prior. If no tobacco status was indicated in the notes, we identified the status encoded by the most recent health factor. We manually examined the results of the natural language processing and the determination of health factors to confirm the tobacco status. Manual review was undertaken by 1 of 2 trained study personnel. In the case of an ambiguous or contradictory status, an additional team member reviewed the information to attempt to make a determination. If no determination could be made, the record was coded to unknown. This method allowed us to identify a baseline status for all but 77 of the 3580 patients admitted for COPD.

RESULTS

Among these 1334 subjects at 6 to 12 months of follow‐up, 63.7% reported ongoing smoking, 19.8% of patients reported quitting, and 17.5% of patients had no reported status and were presumed to be smokers. Four hundred fifty (33.7%) patients were dispensed a smoking cessation medication within 90 days of discharge. Patients who were dispensed medications were younger and more likely to be female. Nearly all patients who received medications also received documented predischarge counseling (94.6%), as did the majority of patients who did not receive medications (83.8%) (Table 1).

Of patients dispensed a study medication, 246 (18.4% of patients, 54.7% of all medications dispensed) were dispensed medications within 48 hours of discharge (Table 2). Of the patients dispensed medication, the majority received nicotine patches alone (Table 3), and 18.9% of patients received combination therapy, with the majority receiving nicotine patch and short‐acting nicotine replacement therapy (NRT) or patch and buproprion. A significant number of patients were prescribed medications within 90 days of discharge, but did not have them dispensed within that timeframe (n = 224, 16.8%).

DISCUSSION

In this observational study, postdischarge pharmacotherapy within 90 days of discharge was provided to a minority of high‐risk smokers admitted for COPD, and was not associated with smoking cessation at 6 to 12 months. In comparison to nicotine patch alone, varenicline was associated with a higher odds of cessation, with decreased odds of cessation among patients treated with short‐acting NRT alone. The overall quit rate was significant at 19.8%, and is consistent with annual quit rates observed among patients with COPD in other settings,[21, 22] but is far lower than quit rates observed after admission for acute myocardial infarction.[23, 24, 25] Although the proportion of patients treated at the time of discharge or within 90 days was low, our findings are in keeping with previous studies, which demonstrated low rates of pharmacologic treatment following hospitalization, averaging 14%.[26] Treatment for tobacco use is likely underutilized for this group of high‐risk smokers. However, a significant proportion of patients who were prescribed medications in the postdischarge period did not have medications filled. This likely reflects both the rapid changes in motivation that characterize quit attempts,[27] as well as efforts on the part of primary care physicians to make these medications available to facilitate future quit attempts.

There are several possible explanations for the findings in our study. Pharmaceutical therapies were not provided at random. The provision of pharmacotherapy and the ultimate success of a quit attempt reflects a complex interaction of patient beliefs concerning medications, level of addiction and motivation, physician behavior and knowledge, and organizational factors. Organizational factors such as the structure of electronic discharge orders and the availability of decision support materials may influence a physician's likelihood of prescribing medications, the choice of medication prescribed, and therefore the adequacy of control of withdrawal symptoms. NRT is often under dosed to control ongoing symptoms,[28] and needs to be adjusted until relief is obtained, providing an additional barrier to effectiveness during the transition out of the hospital. Because most smokers with COPD are highly addicted to nicotine,[29] high‐dose NRT, combination therapy, or varenicline would be necessary to adequately control symptoms.[30] However, a significant minority of patients received short‐acting NRT alone.

Despite a high observed efficacy in recent trials,[31, 32] few subjects in our study received varenicline. This may be related to both secular trends and administrative barriers to the use of varenicline in the VA system. Use of this medication was limited among patients with psychiatric disorders due to safety concerns. These concerns have since been largely disproven, but may have limited access to this medication.[33, 34, 35] Although we adjusted for a history of mental illness, patients who received varenicline may have had more past quit attempts and less active mental illness, which may be associated with improved cessation rates. Despite the high prevalence of mental illness we observed, this is typical of the population of smokers, with studies indicating nearly one‐third of smokers overall suffer from mental illness.[36]

Although the majority of our patients received a brief, nurse‐based counseling intervention, there is considerable concern about the overall effectiveness of a single predischarge interaction to produce sustained smoking cessation among highly addicted smokers.[37, 38, 39, 40] The Joint Commission has recently restructured the requirements for smoking cessation treatment for hospitalized patients, and it is now up to hospitals to implement treatment mechanisms that not only meet the national requirements, but also provide a meaningful clinical effect. Though the optimum treatment for hospitalized smokers with COPD is unknown, previous positive studies of smoking cessation among hospitalized patients underscore the need for a higher‐intensity counseling intervention that begins during hospitalization and continues after discharge.[13, 41] Cessation counseling services including tobacco cessation groups and quit lines are available through the VA; however, the use of these services is typically low and requires the patient to enroll independently after discharge, an additional barrier. The lack of association between medications and smoking cessation found in our study could reflect poor effectiveness of medications in the absence of a systematic counseling intervention. Alternatively, the association may be explained that patients who were more highly addicted and perhaps less motivated to quit received tobacco cessation medications more often, but were also less likely to stop tobacco use, a form of indication bias.

Our study has several limitations. We do not have addiction or motivation levels for a cessation attempt, a potential unmeasured confounder. Although predictive of quit attempts, motivation factors are less predictive of cessation maintenance, and may therefore have an unclear effect on our outcome.[42, 43] Our outcome was gathered as part of routine clinical care, which may have introduced bias if patients over‐reported cessation because of social desirability. In healthcare settings, however, this form of assessing smoking status is generally valid.[44] Exposure to counseling or medications obtained outside of the VA system would not have been captured. Given the financial incentive, we believe it is unlikely that many patients admitted to a VA medical center obtained medications elsewhere.[45] The diagnosis of COPD was made administratively. However, all subjects were admitted for an exacerbation, which is associated with more severe COPD by Global Initiative for Obstructive Lung Disease (GOLD) stage.[46] Patients with more severe COPD are often excluded from studies of smoking cessation due to concerns of high dropout and lower prevalence of smoking among patients with GOLD stage IV disease,[47, 48] making this a strength of our study. Subjects who died may have quit only in extremis, or failed to document their quit attempts. However, our sensitivity analysis limited to survivors did not change the study results. There may have been some misclassification in the use of buproprion, which may also be prescribed as an antidepressant. Finally, although representative of the veterans who seek care within the VISN‐20, our patients were primarily white and male, limiting the ability to generalize outside of this group.

Our study had several strengths. We examined a large cohort of patients admitted to a complete care organization, including patients from a diverse group of VA settings comprising academically and nonacademically affiliated centers. We performed an unbiased collection of patients, including all smokers discharged for COPD. We had access to excellent completeness of medications prescribed and filled as collected within the VA system, enabling us to observe medications dispensed and prescribed at several time points. We also had near complete ascertainment of outcomes including by using natural language processing with manual confirmation of smoking status.

In summary, we found that provision of medications to treat ongoing tobacco use among patients discharged for COPD was low, and receipt of medications was not associated with a reduction in smoking tobacco at 6 to 12 months postdischarge. However, among those treated, varenicline appears to be superior to the nicotine patch, with short‐acting nicotine replacement potentially less effective, a biologically plausible finding. The motivation to quit smoking changes rapidly over time. Providing these medications in the hospital and during the time after discharge is a potential means to improve quit rates, but medications need to be paired with counseling to be most effective. Collectively, these data suggest that systems‐based interventions are needed to increase the availability of intense counseling and the use of tailored pharmacotherapy to these patients.

Dyspnea, defined as a subjective experience of breathing discomfort,[1] is the seventh most frequent reason adult patients present to the emergency room and the most frequent cause for emergency room visits in patients 65 years or older.[2] Moreover, dyspnea is experienced by 49% of patients hospitalized with a medical condition[3, 4, 5] and by 70% of patients who are seriously ill.[6]

Based on evidence that patients are not treated consistently and effectively for relief of their shortness of breath, the American College of Chest Physicians (ACCP) statement on dyspnea management in patients with advanced lung or heart disease recommended that patients should be asked to rate their dyspnea, and the rating should be routinely documented in the medical record to guide management.[7] Although clinicians may question the utility of routine assessment of dyspnea using a standardized scale, studies have found that the prevalence of dyspnea reported from chart review is much lower than when patients are directly interviewed.[8] This may be the result of underrecognition of dyspnea or poor documentation by physicians, or that patients may not communicate their symptoms unless the physician specifically asks. As is the case with pain, routine assessment of dyspnea severity could lead to improved clinical management and greater patient‐centered care. However, unlike in the case of pain, regulatory bodies, such as the Joint Commission for Accreditation of Healthcare Organization, do not require routine dyspnea assessment.[9]

Currently, there are more than 40,000 hospitalists in the United States, and the vast majority of hospitals with >200 beds have a hospitalist group.[10] Hospitalists care for over 60% of inpatients[11] and play a major role in the management of patients with acute cardiopulmonary diseases. If standardized approaches for the assessment and documentation of dyspnea are to be implemented, hospitalists would be a key stakeholder group for utilizing enhanced clinical information about dyspnea. Therefore, we evaluated attitudes and practices of hospitalists in regard to the assessment and management of dyspnea, including the potential benefits and challenges related to the implementation of standardized assessment. We hypothesized that hospitalists would believe that a dyspnea scale for assessment of severity could improve their management of patients with cardiovascular diseases. Further, we hypothesized that physicians who agreed with the general statement that dyspnea is an important clinical problem would be more likely to believe that routine dyspnea assessment would be valuable.

METHODS

RESULTS

Overall, 178 (69.8%) of 255 identified hospitalists completed the survey, and all 9 participating hospitals had a response rate greater than 50%. The median number of years in practice was 6 (range, 038 years). A majority (77.5%) of respondents agreed with the statement that dyspnea is 1 of the major symptoms of patients with cardiopulmonary disease, and that its treatment is central to the management of these patients (77.0%) (Figure 1).

Figure 1

DISCUSSION

In this survey of 178 most hospitalists from a diverse group of 9 US hospitals, we found that most indicate that severity of dyspnea has a profound influence on their clinical practice (including their decision whether to intensify treatments such as diuretics or bronchodilators, to pursue additional diagnostic testing, add opioids or other nonpharmacological treatments) and ultimately their decision regarding the timing of hospital discharge. More importantly, whereas less than half reported experience with standardized assessment of dyspnea severity, most stated that such data would be very useful in their practice.

Despite being a highly prevalent symptom in diverse patient populations, several studies have shown that documentation of dyspnea is sporadic and evaluation of dyspnea quality of care is not routinely performed.[13, 14, 15] Statements from a number of professional societies, including the ACCP, the American Thoracic Society and the Canadian Respiratory Society, recommend that dyspnea management should rely on patient reporting, and that dyspnea severity should be recorded.[1, 4, 7] Assessment is an essential step to guide interventions; however, simply asking about the presence or absence of dyspnea is insufficient.

Several rating scales have been validated and might be implementable in the acute care setting, including the Numerical Rating Scale and the Visual Assessment Scale.[16, 17, 18, 19, 20] Our survey shows that standardized documentation of dyspnea severity in clinical practice is uncommon. However, most hospitalists in our study believed that assessment of dyspnea, using a standardized scale, would positively impact their management of patients with cardiopulmonary disease.

There are a number of potential benefits of routine assessment of dyspnea in hospitalized patients. Implementation of a standardized approach to dyspnea measurement would result in more uniform assessment and documentation practices, and in turn greater awareness among members of the patient‐care team. Though not sufficient to improve care, measurement is necessary because physicians do not always recognize the severity of patients' dyspnea or may not recognize its presence. A retrospective study that assessed the prevalence of symptoms in 410 ambulatory patients showed that one‐quarter of patients had dyspnea, but only half of them told their doctor about it.[21] Two other studies of patients with cancer diagnoses found that 30%70% of patients had dyspnea, but the symptom was recognized in only half of them; even when recognized, dyspnea severity was frequently underrated by physicians.[21, 22] Importantly, underestimation appears to correlate with underutilization of symptomatic management of dyspnea.[8]

Although the results of our survey are encouraging, they highlight a number of potential barriers and misconceptions among hospitalists. For example, although dyspnea can be characterized only by the person experiencing it, only 42% of our survey respondents believed that patients are able to rate their dyspnea intensity on a scale. Some of these responses may be influenced by the fact that dyspnea scales are not currently available to patients under their care. Another explanation is that similar to the case for pain, some hospitalists may believe that patients will exaggerate dyspnea severity. Almost one‐third of the respondents stated that objective measures, such as respiratory rate or oxygen saturation, are more important than a patient's experience of dyspnea in guiding the treatment, and that dyspnea is a subjective symptom and not a vital sign itself. Hospitalists who appreciated the importance of dyspnea in clinical practice were more likely to support the implementation of a standardized dyspnea scale for dyspnea assessment.

Although the potential benefits of including routine measurement of dyspnea in standard hospital practice may seem obvious, evidence that implementing routine assessment improves patient care or outcomes is lacking. Even if hospitalists see the value of dyspnea assessment, asking nurses to collect and document additional information would represent a substantial change in hospital workflow. Finally, without specific protocols to guide care, it is unclear whether physicians will be able to use new information about dyspnea severity effectively. Future studies need to evaluate the impact of implementing routine dyspnea assessment on the management of patients with cardiopulmonary diseases including the use of evidence‐based interventions and reducing the use of less valuable care.

Most hospitalists agreed with the basic principles of dyspnea treatment in patients with advanced cardiopulmonary disease after the primary disease had been stabilized. Effective measures are available, and several guidelines endorse opioids in dyspnea management.[1, 4, 7] However, many clinicians are uncomfortable with this approach for dyspnea, and opioids remain underused. In our study, almost 90% of physicians recognized that concerns about respiratory depression limits opioids use as a treatment. A qualitative study that explored the physicians' perspective toward opioids showed that most physicians were reluctant to prescribe opioids for refractory dyspnea, describing a lack of related knowledge and experience, and fears related to the potential adverse effects. The findings of our study also outline the need to better educate residents and hospitalists on the assessment and management of dyspnea, including prescribing opioids for refractory dyspnea.[23]

CONCLUSIONS

The results of this survey suggest that most hospitalists believe that routine assessment of dyspnea severity would enhance their clinical decision making and improve patient care. Standardized assessment of dyspnea might result in better awareness of this symptom among providers, reduce undertreatment and mistreatment, and ultimately result in better outcomes for patients. However, implementation of the routine assessment of dyspnea would change current clinical practices and may have a significant effect on existing nursing and physician workflows. Additional research is needed to determine the feasibility and impact on outcomes of routine dyspnea assessment.

Dyspnea, defined as a subjective experience of breathing discomfort,[1] is the seventh most frequent reason adult patients present to the emergency room and the most frequent cause for emergency room visits in patients 65 years or older.[2] Moreover, dyspnea is experienced by 49% of patients hospitalized with a medical condition[3, 4, 5] and by 70% of patients who are seriously ill.[6]

Based on evidence that patients are not treated consistently and effectively for relief of their shortness of breath, the American College of Chest Physicians (ACCP) statement on dyspnea management in patients with advanced lung or heart disease recommended that patients should be asked to rate their dyspnea, and the rating should be routinely documented in the medical record to guide management.[7] Although clinicians may question the utility of routine assessment of dyspnea using a standardized scale, studies have found that the prevalence of dyspnea reported from chart review is much lower than when patients are directly interviewed.[8] This may be the result of underrecognition of dyspnea or poor documentation by physicians, or that patients may not communicate their symptoms unless the physician specifically asks. As is the case with pain, routine assessment of dyspnea severity could lead to improved clinical management and greater patient‐centered care. However, unlike in the case of pain, regulatory bodies, such as the Joint Commission for Accreditation of Healthcare Organization, do not require routine dyspnea assessment.[9]

Currently, there are more than 40,000 hospitalists in the United States, and the vast majority of hospitals with >200 beds have a hospitalist group.[10] Hospitalists care for over 60% of inpatients[11] and play a major role in the management of patients with acute cardiopulmonary diseases. If standardized approaches for the assessment and documentation of dyspnea are to be implemented, hospitalists would be a key stakeholder group for utilizing enhanced clinical information about dyspnea. Therefore, we evaluated attitudes and practices of hospitalists in regard to the assessment and management of dyspnea, including the potential benefits and challenges related to the implementation of standardized assessment. We hypothesized that hospitalists would believe that a dyspnea scale for assessment of severity could improve their management of patients with cardiovascular diseases. Further, we hypothesized that physicians who agreed with the general statement that dyspnea is an important clinical problem would be more likely to believe that routine dyspnea assessment would be valuable.

METHODS

RESULTS

Overall, 178 (69.8%) of 255 identified hospitalists completed the survey, and all 9 participating hospitals had a response rate greater than 50%. The median number of years in practice was 6 (range, 038 years). A majority (77.5%) of respondents agreed with the statement that dyspnea is 1 of the major symptoms of patients with cardiopulmonary disease, and that its treatment is central to the management of these patients (77.0%) (Figure 1).

Figure 1

DISCUSSION

In this survey of 178 most hospitalists from a diverse group of 9 US hospitals, we found that most indicate that severity of dyspnea has a profound influence on their clinical practice (including their decision whether to intensify treatments such as diuretics or bronchodilators, to pursue additional diagnostic testing, add opioids or other nonpharmacological treatments) and ultimately their decision regarding the timing of hospital discharge. More importantly, whereas less than half reported experience with standardized assessment of dyspnea severity, most stated that such data would be very useful in their practice.

Despite being a highly prevalent symptom in diverse patient populations, several studies have shown that documentation of dyspnea is sporadic and evaluation of dyspnea quality of care is not routinely performed.[13, 14, 15] Statements from a number of professional societies, including the ACCP, the American Thoracic Society and the Canadian Respiratory Society, recommend that dyspnea management should rely on patient reporting, and that dyspnea severity should be recorded.[1, 4, 7] Assessment is an essential step to guide interventions; however, simply asking about the presence or absence of dyspnea is insufficient.

Several rating scales have been validated and might be implementable in the acute care setting, including the Numerical Rating Scale and the Visual Assessment Scale.[16, 17, 18, 19, 20] Our survey shows that standardized documentation of dyspnea severity in clinical practice is uncommon. However, most hospitalists in our study believed that assessment of dyspnea, using a standardized scale, would positively impact their management of patients with cardiopulmonary disease.

There are a number of potential benefits of routine assessment of dyspnea in hospitalized patients. Implementation of a standardized approach to dyspnea measurement would result in more uniform assessment and documentation practices, and in turn greater awareness among members of the patient‐care team. Though not sufficient to improve care, measurement is necessary because physicians do not always recognize the severity of patients' dyspnea or may not recognize its presence. A retrospective study that assessed the prevalence of symptoms in 410 ambulatory patients showed that one‐quarter of patients had dyspnea, but only half of them told their doctor about it.[21] Two other studies of patients with cancer diagnoses found that 30%70% of patients had dyspnea, but the symptom was recognized in only half of them; even when recognized, dyspnea severity was frequently underrated by physicians.[21, 22] Importantly, underestimation appears to correlate with underutilization of symptomatic management of dyspnea.[8]

Although the results of our survey are encouraging, they highlight a number of potential barriers and misconceptions among hospitalists. For example, although dyspnea can be characterized only by the person experiencing it, only 42% of our survey respondents believed that patients are able to rate their dyspnea intensity on a scale. Some of these responses may be influenced by the fact that dyspnea scales are not currently available to patients under their care. Another explanation is that similar to the case for pain, some hospitalists may believe that patients will exaggerate dyspnea severity. Almost one‐third of the respondents stated that objective measures, such as respiratory rate or oxygen saturation, are more important than a patient's experience of dyspnea in guiding the treatment, and that dyspnea is a subjective symptom and not a vital sign itself. Hospitalists who appreciated the importance of dyspnea in clinical practice were more likely to support the implementation of a standardized dyspnea scale for dyspnea assessment.

Although the potential benefits of including routine measurement of dyspnea in standard hospital practice may seem obvious, evidence that implementing routine assessment improves patient care or outcomes is lacking. Even if hospitalists see the value of dyspnea assessment, asking nurses to collect and document additional information would represent a substantial change in hospital workflow. Finally, without specific protocols to guide care, it is unclear whether physicians will be able to use new information about dyspnea severity effectively. Future studies need to evaluate the impact of implementing routine dyspnea assessment on the management of patients with cardiopulmonary diseases including the use of evidence‐based interventions and reducing the use of less valuable care.

Most hospitalists agreed with the basic principles of dyspnea treatment in patients with advanced cardiopulmonary disease after the primary disease had been stabilized. Effective measures are available, and several guidelines endorse opioids in dyspnea management.[1, 4, 7] However, many clinicians are uncomfortable with this approach for dyspnea, and opioids remain underused. In our study, almost 90% of physicians recognized that concerns about respiratory depression limits opioids use as a treatment. A qualitative study that explored the physicians' perspective toward opioids showed that most physicians were reluctant to prescribe opioids for refractory dyspnea, describing a lack of related knowledge and experience, and fears related to the potential adverse effects. The findings of our study also outline the need to better educate residents and hospitalists on the assessment and management of dyspnea, including prescribing opioids for refractory dyspnea.[23]

CONCLUSIONS

The results of this survey suggest that most hospitalists believe that routine assessment of dyspnea severity would enhance their clinical decision making and improve patient care. Standardized assessment of dyspnea might result in better awareness of this symptom among providers, reduce undertreatment and mistreatment, and ultimately result in better outcomes for patients. However, implementation of the routine assessment of dyspnea would change current clinical practices and may have a significant effect on existing nursing and physician workflows. Additional research is needed to determine the feasibility and impact on outcomes of routine dyspnea assessment.

Dyspnea, defined as a subjective experience of breathing discomfort,[1] is the seventh most frequent reason adult patients present to the emergency room and the most frequent cause for emergency room visits in patients 65 years or older.[2] Moreover, dyspnea is experienced by 49% of patients hospitalized with a medical condition[3, 4, 5] and by 70% of patients who are seriously ill.[6]

Based on evidence that patients are not treated consistently and effectively for relief of their shortness of breath, the American College of Chest Physicians (ACCP) statement on dyspnea management in patients with advanced lung or heart disease recommended that patients should be asked to rate their dyspnea, and the rating should be routinely documented in the medical record to guide management.[7] Although clinicians may question the utility of routine assessment of dyspnea using a standardized scale, studies have found that the prevalence of dyspnea reported from chart review is much lower than when patients are directly interviewed.[8] This may be the result of underrecognition of dyspnea or poor documentation by physicians, or that patients may not communicate their symptoms unless the physician specifically asks. As is the case with pain, routine assessment of dyspnea severity could lead to improved clinical management and greater patient‐centered care. However, unlike in the case of pain, regulatory bodies, such as the Joint Commission for Accreditation of Healthcare Organization, do not require routine dyspnea assessment.[9]

Currently, there are more than 40,000 hospitalists in the United States, and the vast majority of hospitals with >200 beds have a hospitalist group.[10] Hospitalists care for over 60% of inpatients[11] and play a major role in the management of patients with acute cardiopulmonary diseases. If standardized approaches for the assessment and documentation of dyspnea are to be implemented, hospitalists would be a key stakeholder group for utilizing enhanced clinical information about dyspnea. Therefore, we evaluated attitudes and practices of hospitalists in regard to the assessment and management of dyspnea, including the potential benefits and challenges related to the implementation of standardized assessment. We hypothesized that hospitalists would believe that a dyspnea scale for assessment of severity could improve their management of patients with cardiovascular diseases. Further, we hypothesized that physicians who agreed with the general statement that dyspnea is an important clinical problem would be more likely to believe that routine dyspnea assessment would be valuable.

METHODS

RESULTS

Overall, 178 (69.8%) of 255 identified hospitalists completed the survey, and all 9 participating hospitals had a response rate greater than 50%. The median number of years in practice was 6 (range, 038 years). A majority (77.5%) of respondents agreed with the statement that dyspnea is 1 of the major symptoms of patients with cardiopulmonary disease, and that its treatment is central to the management of these patients (77.0%) (Figure 1).

Figure 1

DISCUSSION

In this survey of 178 most hospitalists from a diverse group of 9 US hospitals, we found that most indicate that severity of dyspnea has a profound influence on their clinical practice (including their decision whether to intensify treatments such as diuretics or bronchodilators, to pursue additional diagnostic testing, add opioids or other nonpharmacological treatments) and ultimately their decision regarding the timing of hospital discharge. More importantly, whereas less than half reported experience with standardized assessment of dyspnea severity, most stated that such data would be very useful in their practice.

Despite being a highly prevalent symptom in diverse patient populations, several studies have shown that documentation of dyspnea is sporadic and evaluation of dyspnea quality of care is not routinely performed.[13, 14, 15] Statements from a number of professional societies, including the ACCP, the American Thoracic Society and the Canadian Respiratory Society, recommend that dyspnea management should rely on patient reporting, and that dyspnea severity should be recorded.[1, 4, 7] Assessment is an essential step to guide interventions; however, simply asking about the presence or absence of dyspnea is insufficient.

Several rating scales have been validated and might be implementable in the acute care setting, including the Numerical Rating Scale and the Visual Assessment Scale.[16, 17, 18, 19, 20] Our survey shows that standardized documentation of dyspnea severity in clinical practice is uncommon. However, most hospitalists in our study believed that assessment of dyspnea, using a standardized scale, would positively impact their management of patients with cardiopulmonary disease.

There are a number of potential benefits of routine assessment of dyspnea in hospitalized patients. Implementation of a standardized approach to dyspnea measurement would result in more uniform assessment and documentation practices, and in turn greater awareness among members of the patient‐care team. Though not sufficient to improve care, measurement is necessary because physicians do not always recognize the severity of patients' dyspnea or may not recognize its presence. A retrospective study that assessed the prevalence of symptoms in 410 ambulatory patients showed that one‐quarter of patients had dyspnea, but only half of them told their doctor about it.[21] Two other studies of patients with cancer diagnoses found that 30%70% of patients had dyspnea, but the symptom was recognized in only half of them; even when recognized, dyspnea severity was frequently underrated by physicians.[21, 22] Importantly, underestimation appears to correlate with underutilization of symptomatic management of dyspnea.[8]

Although the results of our survey are encouraging, they highlight a number of potential barriers and misconceptions among hospitalists. For example, although dyspnea can be characterized only by the person experiencing it, only 42% of our survey respondents believed that patients are able to rate their dyspnea intensity on a scale. Some of these responses may be influenced by the fact that dyspnea scales are not currently available to patients under their care. Another explanation is that similar to the case for pain, some hospitalists may believe that patients will exaggerate dyspnea severity. Almost one‐third of the respondents stated that objective measures, such as respiratory rate or oxygen saturation, are more important than a patient's experience of dyspnea in guiding the treatment, and that dyspnea is a subjective symptom and not a vital sign itself. Hospitalists who appreciated the importance of dyspnea in clinical practice were more likely to support the implementation of a standardized dyspnea scale for dyspnea assessment.

Although the potential benefits of including routine measurement of dyspnea in standard hospital practice may seem obvious, evidence that implementing routine assessment improves patient care or outcomes is lacking. Even if hospitalists see the value of dyspnea assessment, asking nurses to collect and document additional information would represent a substantial change in hospital workflow. Finally, without specific protocols to guide care, it is unclear whether physicians will be able to use new information about dyspnea severity effectively. Future studies need to evaluate the impact of implementing routine dyspnea assessment on the management of patients with cardiopulmonary diseases including the use of evidence‐based interventions and reducing the use of less valuable care.

Most hospitalists agreed with the basic principles of dyspnea treatment in patients with advanced cardiopulmonary disease after the primary disease had been stabilized. Effective measures are available, and several guidelines endorse opioids in dyspnea management.[1, 4, 7] However, many clinicians are uncomfortable with this approach for dyspnea, and opioids remain underused. In our study, almost 90% of physicians recognized that concerns about respiratory depression limits opioids use as a treatment. A qualitative study that explored the physicians' perspective toward opioids showed that most physicians were reluctant to prescribe opioids for refractory dyspnea, describing a lack of related knowledge and experience, and fears related to the potential adverse effects. The findings of our study also outline the need to better educate residents and hospitalists on the assessment and management of dyspnea, including prescribing opioids for refractory dyspnea.[23]

CONCLUSIONS

The results of this survey suggest that most hospitalists believe that routine assessment of dyspnea severity would enhance their clinical decision making and improve patient care. Standardized assessment of dyspnea might result in better awareness of this symptom among providers, reduce undertreatment and mistreatment, and ultimately result in better outcomes for patients. However, implementation of the routine assessment of dyspnea would change current clinical practices and may have a significant effect on existing nursing and physician workflows. Additional research is needed to determine the feasibility and impact on outcomes of routine dyspnea assessment.

Chronic obstructive pulmonary disease (COPD) affects as many as 24 million individuals in the United States, is responsible for more than 700,000 annual hospital admissions, and is currently the nation's third leading cause of death, accounting for nearly $49.9 billion in medical spending in 2010.[1, 2] Reported in‐hospital mortality rates for patients hospitalized for exacerbations of COPD range from 2% to 5%.[3, 4, 5, 6, 7] Information about 30‐day mortality rates following hospitalization for COPD is more limited; however, international studies suggest that rates range from 3% to 9%,[8, 9] and 90‐day mortality rates exceed 15%.[10]

Despite this significant clinical and economic impact, there have been no large‐scale, sustained efforts to measure the quality or outcomes of hospital care for patients with COPD in the United States. What little is known about the treatment of patients with COPD suggests widespread opportunities to increase adherence to guideline‐recommended therapies, to reduce the use of ineffective treatments and tests, and to address variation in care across institutions.[5, 11, 12]

Public reporting of hospital performance is a key strategy for improving the quality and safety of hospital care, both in the United States and internationally.[13] Since 2007, the Centers for Medicare and Medicaid Services (CMS) has reported hospital mortality rates on the Hospital Compare Web site, and COPD is 1 of the conditions highlighted in the Affordable Care Act for future consideration.[14] Such initiatives rely on validated, risk‐adjusted performance measures for comparisons across institutions and to enable outcomes to be tracked over time. We present the development, validation, and results of a model intended for public reporting of risk‐standardized mortality rates for patients hospitalized with exacerbations of COPD that has been endorsed by the National Quality Forum.[15]

METHODS

RESULTS

Model Derivation

After exclusions were applied, the development sample included 150,035 admissions in 2008 at 4537 US hospitals (Figure 1). Factors that were most strongly associated with the risk of mortality included metastatic cancer (odds ratio [OR] 2.34), protein calorie malnutrition (OR 2.18), nonmetastatic cancers of the lung and upper digestive tract, (OR 1.80) cardiorespiratory failure and shock (OR 1.60), and congestive heart failure (OR 1.34) (Table 2).

Figure 1

Hospital Risk‐Standardized Mortality Rates

The mean unadjusted hospital 30‐day mortality rate was 8.6% and ranged from 0% to 100% (Figure 2a). Risk‐standardized mortality rates varied across hospitals (Figure 2b). The mean risk‐standardized mortality rate was 8.6% and ranged from 5.9% to 13.5%. The odds of mortality at a hospital 1 standard deviation above average was 1.20 times that of a hospital 1 standard deviation below average.

Figure 2

DISCUSSION

We present a hospital‐level risk‐standardized mortality measure for patients admitted with COPD based on administrative claims data that are intended for public reporting and that have achieved endorsement by the National Quality Forum, a voluntary consensus standards‐setting organization. Across more than 4500 US hospitals, the mean 30‐day risk‐standardized mortality rate in 2008 was 8.6%, and we observed considerable variation across institutions, despite adjustment for case mix, suggesting that improvement by lower‐performing institutions may be an achievable goal.

Although improving the delivery of evidence‐based care processes and outcomes of patients with acute myocardial infarction, heart failure, and pneumonia has been the focus of national quality improvement efforts for more than a decade, COPD has largely been overlooked.[23] Within this context, this analysis represents the first attempt to systematically measure, at the hospital level, 30‐day all‐cause mortality for patients admitted to US hospitals for exacerbation of COPD. The model we have developed and validated is intended to be used to compare the performance of hospitals while controlling for differences in the pretreatment risk of mortality of patients and accounting for the clustering of patients within hospitals, and will facilitate surveillance of hospital‐level risk‐adjusted outcomes over time.

In contrast to process‐based measures of quality, such as the percentage of patients with pneumonia who receive appropriate antibiotic therapy, performance measures based on patient outcomes provide a more comprehensive view of care and are more consistent with patients' goals.[24] Additionally, it is well established that hospital performance on individual and composite process measures explains only a small amount of the observed variation in patient outcomes between institutions.[25] In this regard, outcome measures incorporate important, but difficult to measure aspects of care, such as diagnostic accuracy and timing, communication and teamwork, the recognition and response to complications, care coordination at the time of transfers between levels of care, and care settings. Nevertheless, when used for making inferences about the quality of hospital care, individual measures such as the risk‐standardized hospital mortality rate should be interpreted in the context of other performance measures, including readmission, patient experience, and costs of care.

A number of prior investigators have described the outcomes of care for patients hospitalized with exacerbations of COPD, including identifying risk factors for mortality. Patil et al. carried out an analysis of the 1996 Nationwide Inpatient Sample and described an overall in‐hospital mortality rate of 2.5% among patients with COPD, and reported that a multivariable model containing sociodemographic characteristics about the patient and comorbidities had an area under the ROC curve of 0.70.[3] In contrast, this hospital‐level measure includes patients with a principal diagnosis of respiratory failure and focuses on 30‐day rather than inpatient mortality, accounting for the nearly 3‐fold higher mortality rate we observed. In a more recent study that used clinical from a large multistate database, Tabak et al. developed a prediction model for inpatient mortality for patients with COPD that contained only 4 factors: age, blood urea nitrogen, mental status, and pulse, and achieved an area under the ROC curve of 0.72.[4] The simplicity of such a model and its reliance on clinical measurements makes it particularly well suited for bedside application by clinicians, but less valuable for large‐scale public reporting programs that rely on administrative data. In the only other study identified that focused on the assessment of hospital mortality rates, Agabiti et al. analyzed the outcomes of 12,756 patients hospitalized for exacerbations of COPD, using similar ICD‐9‐CM diagnostic criteria as in this study, at 21 hospitals in Rome, Italy.[26] They reported an average crude 30‐day mortality rate of 3.8% among a group of 5 benchmark hospitals and an average mortality of 7.5% (range, 5.2%17.2%) among the remaining institutions.

To put the variation we observed in mortality rates into a broader context, the relative difference in the risk‐standardized hospital mortality rates across the 10th to 90th percentiles of hospital performance was 25% for acute myocardial infarction and 39% for heart failure, whereas rates varied 30% for COPD, from 7.6% to 9.9%.[27] Model discrimination in COPD (C statistic, 0.72) was also similar to that reported for models used for public reporting of hospital mortality in acute myocardial infarction (C statistic, 0.71) and pneumonia (C statistic, 0.72).

This study has a number of important strengths. First, the model was developed from a large sample of recent Medicare claims, achieved good discrimination, and was validated in samples not limited to Medicare beneficiaries. Second, by including patients with a principal diagnosis of COPD, as well as those with a principal diagnosis of acute respiratory failure when accompanied by a secondary diagnosis of COPD with acute exacerbation, this model can be used to assess hospital performance across the full spectrum of disease severity. This broad set of ICD‐9‐CM codes used to define the cohort also ensures that efforts to measure hospital performance will be less influenced by differences in documentation and coding practices across hospitals relating to the diagnosis or sequencing of acute respiratory failure diagnoses. Moreover, the inclusion of patients with respiratory failure is important because these patients have the greatest risk of mortality, and are those in whom efforts to improve the quality and safety of care may have the greatest impact. Third, rather than relying solely on information documented during the index admission, we used ambulatory and inpatient claims from the full year prior to the index admission to identify comorbidities and to distinguish them from potential complications of care. Finally, we did not include factors such as hospital characteristics (eg, number of beds, teaching status) in the model. Although they might have improved overall predictive ability, the goal of the hospital mortality measure is to enable comparisons of mortality rates among hospitals while controlling for differences in patient characteristics. To the extent that factors such as size or teaching status might be independently associated with hospital outcomes, it would be inappropriate to adjust away their effects, because mortality risk should not be influenced by hospital characteristics other than through their effects on quality.

These results should be viewed in light of several limitations. First, we used ICD‐9‐CM codes derived from claims files to define the patient populations included in the measure rather than collecting clinical or physiologic information prospectively or through manual review of medical records, such as the forced expiratory volume in 1 second or whether the patient required long‐term oxygen therapy. Nevertheless, we included a broad set of potential diagnosis codes to capture the full spectrum of COPD exacerbations and to minimize differences in coding across hospitals. Second, because the risk‐adjustment included diagnoses coded in the year prior to the index admission, it is potentially subject to bias due to regional differences in medical care utilization that are not driven by underlying differences in patient illness.[28] Third, using administrative claims data, we observed some paradoxical associations in the model that are difficult to explain on clinical grounds, such as a protective effect of substance and alcohol abuse or prior episodes of respiratory failure. Fourth, although we excluded patients from the analysis who were enrolled in hospice prior to, or on the day of, the index admission, we did not exclude those who choose to withdraw support, transition to comfort measures only, or enrolled in hospice care during a hospitalization. We do not seek to penalize hospitals for being sensitive to the preferences of patients at the end of life. At the same time, it is equally important that the measure is capable of detecting the outcomes of suboptimal care that may in some instances lead a patient or their family to withdraw support or choose hospice. Finally, we did not have the opportunity to validate the model against a clinical registry of patients with COPD, because such data do not currently exist. Nevertheless, the use of claims as a surrogate for chart data for risk adjustment has been validated for several conditions, including acute myocardial infarction, heart failure, and pneumonia.[29, 30]

CONCLUSIONS

Risk‐standardized 30‐day mortality rates for Medicare beneficiaries with COPD vary across hospitals in the US. Calculating and reporting hospital outcomes using validated performance measures may catalyze quality improvement activities and lead to better outcomes. Additional research would be helpful to confirm that hospitals with lower mortality rates achieve care that meets the goals of patients and their families better than at hospitals with higher mortality rates.

Disclosures

Peter K. Lindenauer, MD, MSc, is the guarantor of this article, taking responsibility for the integrity of the work as a whole, from inception to published article, and takes responsibility for the content of the manuscript, including the data and data analysis. All authors have made substantial contributions to the conception and design, or acquisition of data, or analysis and interpretation of data; have drafted the submitted article or revised it critically for important intellectual content; and have provided final approval of the version to be published. Preparation of this manuscript was completed under Contract Number: HHSM‐5002008‐0025I/HHSM‐500‐T0001, Modification No. 000007, Option Year 2 Measure Instrument Development and Support (MIDS). Sponsors did not contribute to the development of the research or manuscript. Dr. Au reports being an unpaid research consultant for Bosch Inc. He receives research funding from the NIH, Department of Veterans Affairs, AHRQ, and Gilead Sciences. The views of the this manuscript represent the authors and do not necessarily represent those of the Department of Veterans Affairs. Drs. Drye and Bernheim report receiving contract funding from CMS to develop and maintain quality measures.

Chronic obstructive pulmonary disease (COPD) affects as many as 24 million individuals in the United States, is responsible for more than 700,000 annual hospital admissions, and is currently the nation's third leading cause of death, accounting for nearly $49.9 billion in medical spending in 2010.[1, 2] Reported in‐hospital mortality rates for patients hospitalized for exacerbations of COPD range from 2% to 5%.[3, 4, 5, 6, 7] Information about 30‐day mortality rates following hospitalization for COPD is more limited; however, international studies suggest that rates range from 3% to 9%,[8, 9] and 90‐day mortality rates exceed 15%.[10]

Despite this significant clinical and economic impact, there have been no large‐scale, sustained efforts to measure the quality or outcomes of hospital care for patients with COPD in the United States. What little is known about the treatment of patients with COPD suggests widespread opportunities to increase adherence to guideline‐recommended therapies, to reduce the use of ineffective treatments and tests, and to address variation in care across institutions.[5, 11, 12]

Public reporting of hospital performance is a key strategy for improving the quality and safety of hospital care, both in the United States and internationally.[13] Since 2007, the Centers for Medicare and Medicaid Services (CMS) has reported hospital mortality rates on the Hospital Compare Web site, and COPD is 1 of the conditions highlighted in the Affordable Care Act for future consideration.[14] Such initiatives rely on validated, risk‐adjusted performance measures for comparisons across institutions and to enable outcomes to be tracked over time. We present the development, validation, and results of a model intended for public reporting of risk‐standardized mortality rates for patients hospitalized with exacerbations of COPD that has been endorsed by the National Quality Forum.[15]

METHODS

RESULTS

Model Derivation

After exclusions were applied, the development sample included 150,035 admissions in 2008 at 4537 US hospitals (Figure 1). Factors that were most strongly associated with the risk of mortality included metastatic cancer (odds ratio [OR] 2.34), protein calorie malnutrition (OR 2.18), nonmetastatic cancers of the lung and upper digestive tract, (OR 1.80) cardiorespiratory failure and shock (OR 1.60), and congestive heart failure (OR 1.34) (Table 2).

Figure 1

Hospital Risk‐Standardized Mortality Rates

The mean unadjusted hospital 30‐day mortality rate was 8.6% and ranged from 0% to 100% (Figure 2a). Risk‐standardized mortality rates varied across hospitals (Figure 2b). The mean risk‐standardized mortality rate was 8.6% and ranged from 5.9% to 13.5%. The odds of mortality at a hospital 1 standard deviation above average was 1.20 times that of a hospital 1 standard deviation below average.

Figure 2

DISCUSSION

We present a hospital‐level risk‐standardized mortality measure for patients admitted with COPD based on administrative claims data that are intended for public reporting and that have achieved endorsement by the National Quality Forum, a voluntary consensus standards‐setting organization. Across more than 4500 US hospitals, the mean 30‐day risk‐standardized mortality rate in 2008 was 8.6%, and we observed considerable variation across institutions, despite adjustment for case mix, suggesting that improvement by lower‐performing institutions may be an achievable goal.

Although improving the delivery of evidence‐based care processes and outcomes of patients with acute myocardial infarction, heart failure, and pneumonia has been the focus of national quality improvement efforts for more than a decade, COPD has largely been overlooked.[23] Within this context, this analysis represents the first attempt to systematically measure, at the hospital level, 30‐day all‐cause mortality for patients admitted to US hospitals for exacerbation of COPD. The model we have developed and validated is intended to be used to compare the performance of hospitals while controlling for differences in the pretreatment risk of mortality of patients and accounting for the clustering of patients within hospitals, and will facilitate surveillance of hospital‐level risk‐adjusted outcomes over time.

In contrast to process‐based measures of quality, such as the percentage of patients with pneumonia who receive appropriate antibiotic therapy, performance measures based on patient outcomes provide a more comprehensive view of care and are more consistent with patients' goals.[24] Additionally, it is well established that hospital performance on individual and composite process measures explains only a small amount of the observed variation in patient outcomes between institutions.[25] In this regard, outcome measures incorporate important, but difficult to measure aspects of care, such as diagnostic accuracy and timing, communication and teamwork, the recognition and response to complications, care coordination at the time of transfers between levels of care, and care settings. Nevertheless, when used for making inferences about the quality of hospital care, individual measures such as the risk‐standardized hospital mortality rate should be interpreted in the context of other performance measures, including readmission, patient experience, and costs of care.

A number of prior investigators have described the outcomes of care for patients hospitalized with exacerbations of COPD, including identifying risk factors for mortality. Patil et al. carried out an analysis of the 1996 Nationwide Inpatient Sample and described an overall in‐hospital mortality rate of 2.5% among patients with COPD, and reported that a multivariable model containing sociodemographic characteristics about the patient and comorbidities had an area under the ROC curve of 0.70.[3] In contrast, this hospital‐level measure includes patients with a principal diagnosis of respiratory failure and focuses on 30‐day rather than inpatient mortality, accounting for the nearly 3‐fold higher mortality rate we observed. In a more recent study that used clinical from a large multistate database, Tabak et al. developed a prediction model for inpatient mortality for patients with COPD that contained only 4 factors: age, blood urea nitrogen, mental status, and pulse, and achieved an area under the ROC curve of 0.72.[4] The simplicity of such a model and its reliance on clinical measurements makes it particularly well suited for bedside application by clinicians, but less valuable for large‐scale public reporting programs that rely on administrative data. In the only other study identified that focused on the assessment of hospital mortality rates, Agabiti et al. analyzed the outcomes of 12,756 patients hospitalized for exacerbations of COPD, using similar ICD‐9‐CM diagnostic criteria as in this study, at 21 hospitals in Rome, Italy.[26] They reported an average crude 30‐day mortality rate of 3.8% among a group of 5 benchmark hospitals and an average mortality of 7.5% (range, 5.2%17.2%) among the remaining institutions.

To put the variation we observed in mortality rates into a broader context, the relative difference in the risk‐standardized hospital mortality rates across the 10th to 90th percentiles of hospital performance was 25% for acute myocardial infarction and 39% for heart failure, whereas rates varied 30% for COPD, from 7.6% to 9.9%.[27] Model discrimination in COPD (C statistic, 0.72) was also similar to that reported for models used for public reporting of hospital mortality in acute myocardial infarction (C statistic, 0.71) and pneumonia (C statistic, 0.72).

This study has a number of important strengths. First, the model was developed from a large sample of recent Medicare claims, achieved good discrimination, and was validated in samples not limited to Medicare beneficiaries. Second, by including patients with a principal diagnosis of COPD, as well as those with a principal diagnosis of acute respiratory failure when accompanied by a secondary diagnosis of COPD with acute exacerbation, this model can be used to assess hospital performance across the full spectrum of disease severity. This broad set of ICD‐9‐CM codes used to define the cohort also ensures that efforts to measure hospital performance will be less influenced by differences in documentation and coding practices across hospitals relating to the diagnosis or sequencing of acute respiratory failure diagnoses. Moreover, the inclusion of patients with respiratory failure is important because these patients have the greatest risk of mortality, and are those in whom efforts to improve the quality and safety of care may have the greatest impact. Third, rather than relying solely on information documented during the index admission, we used ambulatory and inpatient claims from the full year prior to the index admission to identify comorbidities and to distinguish them from potential complications of care. Finally, we did not include factors such as hospital characteristics (eg, number of beds, teaching status) in the model. Although they might have improved overall predictive ability, the goal of the hospital mortality measure is to enable comparisons of mortality rates among hospitals while controlling for differences in patient characteristics. To the extent that factors such as size or teaching status might be independently associated with hospital outcomes, it would be inappropriate to adjust away their effects, because mortality risk should not be influenced by hospital characteristics other than through their effects on quality.

These results should be viewed in light of several limitations. First, we used ICD‐9‐CM codes derived from claims files to define the patient populations included in the measure rather than collecting clinical or physiologic information prospectively or through manual review of medical records, such as the forced expiratory volume in 1 second or whether the patient required long‐term oxygen therapy. Nevertheless, we included a broad set of potential diagnosis codes to capture the full spectrum of COPD exacerbations and to minimize differences in coding across hospitals. Second, because the risk‐adjustment included diagnoses coded in the year prior to the index admission, it is potentially subject to bias due to regional differences in medical care utilization that are not driven by underlying differences in patient illness.[28] Third, using administrative claims data, we observed some paradoxical associations in the model that are difficult to explain on clinical grounds, such as a protective effect of substance and alcohol abuse or prior episodes of respiratory failure. Fourth, although we excluded patients from the analysis who were enrolled in hospice prior to, or on the day of, the index admission, we did not exclude those who choose to withdraw support, transition to comfort measures only, or enrolled in hospice care during a hospitalization. We do not seek to penalize hospitals for being sensitive to the preferences of patients at the end of life. At the same time, it is equally important that the measure is capable of detecting the outcomes of suboptimal care that may in some instances lead a patient or their family to withdraw support or choose hospice. Finally, we did not have the opportunity to validate the model against a clinical registry of patients with COPD, because such data do not currently exist. Nevertheless, the use of claims as a surrogate for chart data for risk adjustment has been validated for several conditions, including acute myocardial infarction, heart failure, and pneumonia.[29, 30]

CONCLUSIONS

Risk‐standardized 30‐day mortality rates for Medicare beneficiaries with COPD vary across hospitals in the US. Calculating and reporting hospital outcomes using validated performance measures may catalyze quality improvement activities and lead to better outcomes. Additional research would be helpful to confirm that hospitals with lower mortality rates achieve care that meets the goals of patients and their families better than at hospitals with higher mortality rates.

Disclosures

Peter K. Lindenauer, MD, MSc, is the guarantor of this article, taking responsibility for the integrity of the work as a whole, from inception to published article, and takes responsibility for the content of the manuscript, including the data and data analysis. All authors have made substantial contributions to the conception and design, or acquisition of data, or analysis and interpretation of data; have drafted the submitted article or revised it critically for important intellectual content; and have provided final approval of the version to be published. Preparation of this manuscript was completed under Contract Number: HHSM‐5002008‐0025I/HHSM‐500‐T0001, Modification No. 000007, Option Year 2 Measure Instrument Development and Support (MIDS). Sponsors did not contribute to the development of the research or manuscript. Dr. Au reports being an unpaid research consultant for Bosch Inc. He receives research funding from the NIH, Department of Veterans Affairs, AHRQ, and Gilead Sciences. The views of the this manuscript represent the authors and do not necessarily represent those of the Department of Veterans Affairs. Drs. Drye and Bernheim report receiving contract funding from CMS to develop and maintain quality measures.

Chronic obstructive pulmonary disease (COPD) affects as many as 24 million individuals in the United States, is responsible for more than 700,000 annual hospital admissions, and is currently the nation's third leading cause of death, accounting for nearly $49.9 billion in medical spending in 2010.[1, 2] Reported in‐hospital mortality rates for patients hospitalized for exacerbations of COPD range from 2% to 5%.[3, 4, 5, 6, 7] Information about 30‐day mortality rates following hospitalization for COPD is more limited; however, international studies suggest that rates range from 3% to 9%,[8, 9] and 90‐day mortality rates exceed 15%.[10]

Despite this significant clinical and economic impact, there have been no large‐scale, sustained efforts to measure the quality or outcomes of hospital care for patients with COPD in the United States. What little is known about the treatment of patients with COPD suggests widespread opportunities to increase adherence to guideline‐recommended therapies, to reduce the use of ineffective treatments and tests, and to address variation in care across institutions.[5, 11, 12]

Public reporting of hospital performance is a key strategy for improving the quality and safety of hospital care, both in the United States and internationally.[13] Since 2007, the Centers for Medicare and Medicaid Services (CMS) has reported hospital mortality rates on the Hospital Compare Web site, and COPD is 1 of the conditions highlighted in the Affordable Care Act for future consideration.[14] Such initiatives rely on validated, risk‐adjusted performance measures for comparisons across institutions and to enable outcomes to be tracked over time. We present the development, validation, and results of a model intended for public reporting of risk‐standardized mortality rates for patients hospitalized with exacerbations of COPD that has been endorsed by the National Quality Forum.[15]

METHODS