Success Story

New Decision Tool for COPD Better Identifies At-Risk Patients, Could Save System $115 Million

Researchers at The Ottawa Hospital have developed a new clinical decision tool to assist ED physicians in better identifying at-risk patients with COPD. An economic analysis has shown that this could save Ontario’s health care system $115 million over three years.

A team at The Ottawa Hospital, led by physician and Senior Scientist Dr. Ian Stiell, has generated a series of decision rules to help Emergency Department (ED) physicians in their critical decision-making processes – case in point, the Ottawa Ankle Rules and Canadian C-Spine Rules.

This time, Stiell and his group have introduced a new clinical decision tool to assist ED doctors identify at-risk patients with chronic obstructive pulmonary disease (COPD) presenting in hospital emergency rooms.

“Identification of high-risk characteristics by physicians has the potential to significantly improve patient safety by helping to ensure that patients most at risk for poor outcomes be admitted,” explains Stiell – himself, an emergency physician.

Good for patients, it’s also good for the system. An economic analysis by the Centre for exceLlence in Economic Analysis Research (CLEAR), located at HUB Research Solutions of St. Michael’s Hospital, has shown that this new decision rule could save Ontario’s health care system $115 million over three years.

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COPD, an umbrella term for a number of diseases including chronic bronchitis and emphysema, is a chronic disease caused largely by smoking and characterized by shortness of breath, cough and sputum production. It progresses slowly over many years. As it advances, shortness of breath limits the activity levels of individuals and reduces their quality of life. It can also lead to premature death.

COPD affects approximately 11% of the Canadian over the age of 35, but it is a leading cause of hospital admission among older people, and it is the leading cause of chronic disease hospitalization.

In 2009, approximately 697,551 Ontarians presented with COPD. The number of corresponding hospitalizations due to COPD over a three year period (2009-2012) was 32,889. It has been reported that 35% of COPD patients discharged from Canadian academic hospital EDs return within 30 days because of worsening respiratory symptoms.

Patients with COPD pose a unique challenge for ED physicians; it’s difficult to determine who should be admitted. Many of them respond well to treatment in the ED and do not need to be admitted. However, after being discharged from the hospital, some of these patients have serious adverse events, or can even die. If they do return to the hospital, they are often admitted.

ED doctors do their best to avoid both unnecessary admissions and unsafe discharge decisions. That’s exactly where Stiell’s new decision rule comes in.

Gives ED Docs Much-Needed Evidence-Based Guidance

Up until now, ED physicians didn’t have evidence-based guidance to help identify risk factors for adverse events in patients with COPD who presented in EDs. Stiell and his team aimed to remedy this conundrum and undertook a key study.

His group at The Ottawa Hospital conducted a prospective cohort study in six large Canadian academic EDs. Patients with COPD were assessed and then followed for serious adverse events ‒ namely, death, intubation, admission to a monitored unit or new visit to the ED requiring admission.

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Dr. Ian Stiell, The Ottawa Hospital and University of Ottawa. Photograph courtesy of the Ottawa Hospital Research Institute.

The study enrolled 945 patients of whom 354, or 37%, were admitted to hospital. Of 74 patients with a subsequent serious adverse event, 36 had not been admitted after the initial ED visit.

Stiell discovered that characteristics associated with short-term adverse effects can be determined using simple diagnostic procedures, a key consideration in creating the Ottawa COPD Risk Scale to gauge patient attributes for risk. He wanted any hospital to be able to use the COPD Risk Scale, which is made up of 10 clinical and laboratory predictors shown to be strongly associated with the development of serious adverse events.

Using this, patients who most need hospital admission will be better identified. This means fewer return visits to the ED for patients in potentially avoidable distress, had they been admitted upon first presenting. In addition, those who can be safely discharged will be sent home from the ED, resulting in a significant reduction of admissions.

The Ottawa Hospital expects that the use of this new tool will reduce the number of unnecessary hospitalizations from 49% (in current practice) to 10% (using the decision tool).

CLEAR Finds COPD Decision Rule Saves System $115 Million Over Three Years

As part of the Council of Academic Hospitals of Ontario (CAHO)’s Research Impact Stories project, CLEAR conducted an economic analysis on the COPD decision rule, the COPD Risk Scale. The analysis showed that “the reduction in unnecessary hospitalizations due to the introduction of the decision tool can potentially be 12,761 visits over three years, corresponding to approximately $115 million in savings to the health care system.”

Stiell’s study was supported by the Canadian Institutes of Health Research (CIHR), via investments allotted between 2010 to present, totaling $852,287.

The findings of the study were published in the esteemed Canadian Medical Association Journal (CMAJ) on April 1, 2014. To read this article, “Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study,” go here: http://1.usa.gov/1IEuaME.