Quality Indicators for the Care of Chronic Obstructive PulmonaryDisease in Vulnerable Elders
Quality Indicators for the Care of Chronic Obstructive Pulmonary Disease in Vulnerable Elders
Eric Kleerup, MD
Key words: chronic obstructive pulmonary disease;smoking cessation; vulnerable elderly; quality indicators;oxygen therapy; bronchodilators; corticosteroids
Chronic obstructive pulmonary disease (COPD) pro-duces persistent respiratory symptoms of cough,sputum production, wheezing, and, in later stages, dyspnea,poor exercise tolerance, and symptoms and signs ofright-sided heart failure. The Global Initiative for ChronicObstructive Lung Disease, (GOLD)1defines COPD as:A disease state characterized by airflow limitation that is not fullyreversible. The airflow limitation is usually both progressive andassociated with an abnormal inflammatory response of the lungsto noxious particles or gases.1Small-airway disease (obstructive bronchiolitis) andparenchymal destruction (emphysema) result in airflowlimitation perceived as dyspnea. Parenchymal destructionalso reduces the surface area for gas exchange, contributingto exercise limitation late in disease. Many, although notall, patients with COPD have chronic bronchitis (mucoushypersecretion), a condition defined as the presence ofcough and sputum production for at least 3 months in eachof 2 consecutive years. A predominance of CD81 cells,macrophages, and neutrophils characterize inflammation inCOPD. In contrast, CD41 (helper) cells and eosinophilspredominate in asthmatic airways.Although COPD begins soon after the onset of smoking(a habit that typically begins in the teenage years), primarilyolder persons experience the effects of its morbidity andmortality. Symptomatic COPD affects more than 5% to 8%of the adult population. In 2000, 9.6% of those aged 65 to74 and 10.6% of those aged 75 and older had self-reportedphysician-diagnosed lifetime emphysema or chronic bron-chitis.2Approximately 3.2 million Americans aged 65 andolder have COPD.3In 2000, the annual COPD death ratewas 43.1 per 100,000 population for those aged 55 to 64,171.2 for those aged 65 to 74, and 449.7 for those aged 75and older.2Chronic lower respiratory diseases are thefourth leading cause of death in women (269.4) andthe third leading cause in men (353.4) in the United Statesfor people aged 65 and older.4COPD is increasing in prev-alence and incident mortality worldwide.1,5Between 1980and 2000, the overall death rate for COPD increased 67%.COPD as a primary diagnosis resulted in 4.2 millionphysician office and hospital outpatient visits and 5.5 mil-lion emergency department visits for patients aged 65 andolder in 2000. The estimated annual rate of hospitalizationfor COPD is higher for people aged 65 and older thanfor younger patients. COPD also affects quality of life formany people. Eight percent of COPD patients self-reportactivity limitationFtwice the rate of those withoutCOPD.2COPD is projected to be the fifth leading causeof disability-adjusted life years lost worldwide by 2020.Finally, decreased pulmonary function is an independentrisk factor for coronary heart disease.6METHODSArticles were identified through reference mining and fromthe author’s files on COPD in older persons. A total of 111articles were considered in this review, and 13 guidelineswere identified using a Web search. Three additional articleswere included after peer review.RESULTSOf the 13 potential quality indicators, 10 were judged validaccording to the expert panel process, and one newindicator was developed (see the quality indicators on pag-es S464–S487 of this supplement); three indicators wererejected. The literature summaries that support each of theindicators judged to be valid in the expert panel process aredescribed.Evaluate Respiratory Symptoms1. IF a vulnerable elder (VE) presents with noncardiacexertional dyspnea, chronic cough ( 6 months), wheeze
Address correspondence to Eric Kleerup, MD, 10833 Le Conte Ave., CHS37-131, Los Angeles, CA 90095-1690. E-mail: ekleerup@mednet.ucla.edu
DOI: 10.1111/j.1532-5415.2007.01332.x
From the Division of Pulmonary, Critical Care Medicine and Hospitalists,David Geffen School of Medicine at the University of California, Los Angeles,California.
JAGS 55:S270–S276, 2007
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2007.01332.x/epdf
