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      Interventions at presentation and discharge for patients with acute exacerbation of chronic obstructive pulmonary disease to reduce unnecessary admissions and readmissions: A scoping review protocol

      research-article
      1 , , 1 , 1
      Nursing Open
      John Wiley and Sons Inc.
      AECOAD, AECOPD, COAD, COPD, nurses, nursing, scoping review

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          Abstract

          Aim

          This scoping review will gather existing evidence on specific interventions at presentation and discharge which aim to standardize care and/or reduce unnecessary admissions and/or readmissions to hospital for patients presenting with acute exacerbation of chronic obstructive pulmonary (airways) disease.

          Design

          Scoping review of relevant literature from January 2000–March 2019.

          Methods

          Database searches for primary evidence in peer‐reviewed journals will be conducted electronically using Web of Science, EMBASE (Elsevier) and PUBMED. Eligibility criteria will include hospital‐based interventions for presentations of acute exacerbation of chronic obstructive pulmonary disease with outcomes specific to standardizing care or reducing unnecessary admissions or readmissions. Abstract, full‐text screening and data extraction will be completed independently by a panel of expert reviewers.

          Results

          We aim to identify current interventions and improvement approaches in acute exacerbation of chronic obstructive pulmonary (airways) disease care that have an impact on admission and discharge processes or readmissions. Recommendations as a result of this review will aid the design and development of future improvement intervention.

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          Most cited references17

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          Global and regional estimates of COPD prevalence: Systematic review and meta–analysis

          Background The burden of chronic obstructive pulmonary disease (COPD) across many world regions is high. We aim to estimate COPD prevalence and number of disease cases for the years 1990 and 2010 across world regions based on the best available evidence in publicly accessible scientific databases. Methods We conducted a systematic search of Medline, EMBASE and Global Health for original, population–based studies providing spirometry–based prevalence rates of COPD across the world from January 1990 to December 2014. Random effects meta–analysis was conducted on extracted crude prevalence rates of COPD, with overall summaries of the meta–estimates (and confidence intervals) reported separately for World Health Organization (WHO) regions, the World Bank's income categories and settings (urban and rural). We developed a meta–regression epidemiological model that we used to estimate the prevalence of COPD in people aged 30 years or more. Findings Our search returned 37 472 publications. A total of 123 studies based on a spirometry–defined prevalence were retained for the review. From the meta–regression epidemiological model, we estimated about 227.3 million COPD cases in the year 1990 among people aged 30 years or more, corresponding to a global prevalence of 10.7% (95% confidence interval (CI) 7.3%–14.0%) in this age group. The number of COPD cases increased to 384 million in 2010, with a global prevalence of 11.7% (8.4%–15.0%). This increase of 68.9% was mainly driven by global demographic changes. Across WHO regions, the highest prevalence was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage increase in COPD cases between 1990 and 2010 was the highest in the Eastern Mediterranean region (118.7%), followed by the African region (102.1%), while the European region recorded the lowest increase (22.5%). In 1990, we estimated about 120.9 million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230 million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years or more was 14.3% (95% CI 13.3%–15.3%) compared to 7.6% (95% CI 7.0%–8.2%) in women. Conclusions Our findings suggest a high and growing prevalence of COPD, both globally and regionally. There is a paucity of studies in Africa, South East Asia and the Eastern Mediterranean region. There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD globally.
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            The unmet global burden of COPD

            Chronic respiratory diseases receive little attention and funding in comparison with other major causes of global morbidity and mortality [1]. Chronic obstructive pulmonary disease (COPD) is a major public health problem. COPD is the end result of a susceptible lung being exposed to sufficient environmental stimulus. Caused principally by tobacco smoking and household air pollution (HAP), COPD is a silent killer in low- and middle-income countries (LMICs): an estimated 328 million people have COPD worldwide [2], and in 15 years, COPD is expected to become the leading cause of death [3]. The relentless decline in lung function that characterises COPD is associated with progressive symptoms and functional impairment, with susceptibility to respiratory infections called ‘exacerbations’. Exacerbations are responsible for much of the morbidity and mortality. COPD has a significant impact on quality of life for those living with the condition, and on local economies for those affected, those caring for the affected and health services. A population literally struggling for breath is, in consequence, unproductive. The majority of cases of chronic lung disease are preventable. Exposure reduction initiatives must focus on tobacco control, and cook-stove interventions: either cleaner fuel (ideally), or better ventilation (at the least). Awareness campaigns and health programmes have the potential to revolutionise the diagnosis and management of COPD and COPD exacerbations, improving quality of life and health service cost and burden. LMICs face unique challenges in managing COPD, including sub-optimal and diverse primary care systems which present challenges with diagnosis and management, especially during exacerbations. A better understanding of how to prevent, diagnose and manage COPD in both rural and urban settings would make a real difference in countries of need. Two important aspects to consider when addressing the global economic burden of COPD are that of underdiagnosis and comorbidities [4]. Firstly, COPD remains underdiagnosed in many jurisdictions [5]. Studies included in reviews focusing on the global economic burden of COPD are all based on diagnosed COPD, and a simple multiplication of these values by the number of COPD patients to calculate the overall economic burden of COPD will underestimate the contribution of undiagnosed COPD [5]. Secondly, COPD is known to be associated with a significant number of comorbid conditions, and estimating costs that are directly attributable to COPD fails to consider the burden of such comorbidities [4]. Adjusting for comorbidities by calculating excess costs with an appropriate comparison group can provide a better opportunity, but even this results in an underestimation of the costs of the comorbidities [6–8]. Global COPD statistics More than 90% of COPD-related deaths occur in LMICs [3]. According to the Global Burden of Disease (GBD), COPD is already the third leading cause of death worldwide, something that WHO had not predicted to occur until 2030 [9]. The economic impact of COPD among LMICs is expected to increase to £1.7 trillion by 2030 [10]. In 15 years, COPD is expected to become the leading cause of death worldwide [3]. Air pollution and HAP Air pollution is the biggest environmental cause of death worldwide, with HAP accounting for about 3.5–4 million deaths every year [11]. Extensive literature supports a causal association between HAP and chronic lung diseases [12], respiratory infections and respiratory tract cancers. One-third of the world's population, some three billion people use fuel derived from organic material (biomass) or solid fuel including coal, wood and charcoal as an energy source to heat and light their homes, and to cook. Respiratory morbidity relates to products of incomplete combustion such as carbon monoxide, and to particulate matter (PM). PM include both organic and inorganic particles, and represents the sum of all solid and liquid particles suspended in the air, many of which are hazardous. PM10 is the most widely used indicator of the health hazard of indoor air pollution. The EU and the US Environmental Protection Agency have set standards for annual mean PM10 levels in outdoor air at 40  and 50 µg/m3, respectively [13]. When burning solid fuels, peak levels of PM10 in biomass-using homes can be as high as 10 000 µg/m3, 200 times more than the standard in high-income countries. PM2.5 are finer particles which penetrate deep into the lung and have the greatest health-damaging potential. Pollutants are particularly damaging and of concern to children growing up in homes with HAP, the effect on the developing lung results in lung function that does not reach maximum potential. Household air pollution statistics Air pollution is the biggest environmental cause of death worldwide [14]. Three billion people worldwide are exposed to toxic amounts of HAP every day [11]. HAP accounts for up to four million deaths annually [11]. Smoking Tobacco is a legal drug which is currently responsible for the deaths of an estimated six million people across the world each year, with many of these deaths occurring prematurely [15]. Tobacco smoking is associated with morbidity and mortality from non-communicable respiratory diseases (NCDs), including about 600 000 people who are estimated to die every year from the effects of second-hand smoke [15]. The poor tend to smoke the most. Globally, 84% of smokers live in developing and transitional economy countries [16]. Tobacco smoke potentiates the detrimental effects of biomass smoke exposure. The WHO stated that in 2015, over 1.1 billion people smoked tobacco, males smoked tobacco more than females, and although it is declining worldwide and in many countries, the prevalence of tobacco smoking appears to be increasing in the Eastern Mediterranean and Africa [17]. Tobacco and smoking statistics Due to the incomplete combustion of formaldehyde and DEET, one mosquito coil burning for 8 h releases the same amount of PM2.5 as 100 cigarettes [18]. A 1 h hookah session with shisha tobacco is equivalent to smoking over 100 cigarettes [19]. Those who have never smoked tobacco can still get COPD – think ‘biomass COPD’. COPD: under-recognition and inequity There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD. TB, HIV/AIDS and malaria all compete for headlines and funds; COPD is rarely the headline. There is global under-recognition of COPD. This needs to change and we welcome recent initiatives highlighting unmet needs in NCDs. The United Nations (UN) declaration of NCDs, and the World Health Assembly in 2012, endorsed a new health goal (the ‘25 by 25 goal’), which focuses on the reduction of premature deaths from COPD and other NCDs by 25% by the year 2025 [20]. Many NCDs occur together in the context of multi-morbidity, yet despite this initiative, COPD remains a growing but neglected global epidemic. It is under-recognised, under-diagnosed and under-treated resulting in millions of people continuing to suffer from this preventable and treatable condition. The lower an individual's socio-economic position, the higher their risk of poor health: women and children living in severe poverty have the greatest exposures to HAP [21]. In the poorest countries, cooking with solid fuels can be the equivalent of smoking two packs of cigarettes a day [22]. A 1-year old would have accumulated a two pack year smoking history having never seen tobacco. Inaction to mitigate COPD therefore exacerbates health inequalities. Climbing the ‘energy ladder’ occurs gradually as most LMIC households use a combination of fuels. The poorest, at the bottom of the ladder, use crop waste or dung which is the most harmful when undergoing incomplete combustion. Those at the top of the ladder use electricity or natural gas. Increasing prosperity and development has a direct positive correlation with increasing use of cleaner and more efficient fuels for cooking [23]. The unmet global burden of COPD is a silent killer in LMICs. In conclusion, we suggest that given the high and rising global burden of COPD, a revolution in the diagnosis and management of COPD and exacerbations of COPD in LMICs must be an urgent priority. Summary An estimated 328 million people have COPD worldwide [3]. In 15 years, COPD is expected to become the leading cause of death worldwide [3]. Three billion people worldwide are exposed to toxic amounts of HAP every day and HAP accounts for 3.5–4 million deaths annually [11]. Those who have never smoked tobacco can still get COPD – think ‘biomass COPD’.
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              Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit.

              Studies report high in-hospital and post-discharge mortality of chronic obstructive pulmonary disease (COPD) exacerbations varying depending upon patient characteristics, hospital resources and treatment standards. This study aimed to investigate the patient, resource and organisational factors associated with in-hospital and 90-day post-discharge mortality and readmission of COPD exacerbations within the European COPD Audit. The audit collected data of COPD exacerbation admissions from 13 European countries.On admission, only 49.7% of COPD patients had spirometry results available and only 81.6% had blood gases taken. Using logistic regression analysis, the risk associated with in-hospital and post-discharge mortality was higher age, presence of acidotic respiratory failure, subsequent need for ventilatory support and presence of comorbidity. In addition, the 90-day risk of COPD readmission was associated with previous admissions. Only the number of respiratory specialists per 1000 beds, a variable related to hospital resources, decreased the risk of post-discharge mortality.The European COPD Audit identifies risk factors associated with in-hospital and post-discharge mortality and COPD readmission. Addressing the deficiencies in acute COPD care such as making spirometry available and measuring blood gases and providing noninvasive ventilation more regularly would provide opportunities to improve COPD outcomes.
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                Author and article information

                Contributors
                rachelmacdonell@rcpi.ie
                Journal
                Nurs Open
                Nurs Open
                10.1002/(ISSN)2054-1058
                NOP2
                Nursing Open
                John Wiley and Sons Inc. (Hoboken )
                2054-1058
                03 December 2019
                March 2020
                : 7
                : 2 ( doiID: 10.1002/nop2.v7.2 )
                : 669-673
                Affiliations
                [ 1 ] Royal College of Physicians of Ireland Dublin Ireland
                Author notes
                [*] [* ] Correspondence

                Rachel MacDonell, Royal College of Physicians of Ireland, Dublin, Ireland.

                Email: rachelmacdonell@ 123456rcpi.ie

                Author information
                https://orcid.org/0000-0003-3467-302X
                Article
                NOP2423
                10.1002/nop2.423
                7024625
                d342e04a-347e-4241-80c2-cd09e83f4b5f
                © 2019 The Authors. Nursing Open published by John Wiley & Sons Ltd

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                : 14 October 2019
                : 05 November 2019
                : 05 November 2019
                Page count
                Figures: 0, Tables: 0, Pages: 5, Words: 3742
                Funding
                Funded by: Heath Service Executive Ireland
                Categories
                Study Protocol
                Study Protocol
                Custom metadata
                2.0
                March 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.5 mode:remove_FC converted:16.02.2020

                aecoad,aecopd,coad,copd,nurses,nursing,scoping review
                aecoad, aecopd, coad, copd, nurses, nursing, scoping review

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