Variability of hospital resources for acute care of COPD patients: the European COPD Audit

Introduction

There is an established body of literature that strongly suggests that larger and more specialised hospital centres provide better care than do smaller units [1, 2]. There are a number of reasons why this might be the case. For surgical procedures, a higher patient volume may facilitate the growth of greater expertise for the surgeon and also the whole surgical team. The hospital’s annual expenditure, the numbers of available doctors or nurse shift patterns are also factors that relate to generic clinical outcomes, suggesting that resources are also important. Recent evidence from the UK indicates that focused organisation of care, as exemplified by stroke, heart attack and trauma centres, where units are designed to care for patients with a specific presenting condition, also provides better patient outcomes [2–4].

Chronic obstructive pulmonary disease (COPD) is a highly prevalent condition, generating large numbers of admissions throughout Europe, with a high risk of short- and long-term all-cause mortality [5]. A single small study from the UK demonstrated that small district general hospitals had higher COPD patient mortality than did larger and university hospitals, and were less likely to provide optimum process of care. More detailed analysis showed this to be related to the numbers of available medical staff [6]. Similar wide variations in the provision of resources for the treatment of in-hospital COPD have been shown in Spain [7].

Although there are European and international guidelines on the management of COPD, there are no guidelines that recommend minimum resources or suggest how services should be organised to deliver optimum care. In this study, we explore the variation in the provision of resources to manage patients admitted with COPD exacerbation across 13 European countries, and the association between the size of the hospitals and the provision of resources, looking at the relationship between resources and clinical care provision. This article is the report from the organisation and resources survey, and will be followed by further detailed clinical analyses in due course.

Results

Of the 432 participating hospitals, five centres in the UK, one in Belgium and one in Slovakia did not complete the organisational survey, resulting in 425 (98.4%) recording information for the present analysis. The distribution of hospitals in the different participant countries and the proportion of each national population covered by those hospitals are given in figure 1. The number of beds varied between 40 and 3800; the 33rd percentile was 367 beds and the 66th percentile was 600 beds.

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Figure 1–

Distribution of participant hospitals and proportion of population screened. 185 814 623 (62.8%) patients were screened.

Discussion

The present study describes for the first time the resources available for healthcare provision to COPD patients admitted to hospital in 13 European countries. The results of the organisational information from the European COPD Audit show a great variability in different aspects between the different sizes of hospitals and between countries. Although large hospitals have more resources, this does not imply better access to services or a striking difference in adherence to guidelines. The present data provide a broad picture that may help healthcare managers to identify those areas of improvement needed in each location and brings an opportunity to set some minimum standards across Europe for providing clinical care to COPD patients.

The main strength of this study is the novel information it provides and a wide coverage in the catchment population screened, as well as the methodology of auditing different healthcare systems in different languages [8]. However, in order to interpret our results, a number of issues must be considered. This was a pilot study and, as such, did not include all European countries. Within each country, the participating hospitals volunteered, so there is no attempt at representative sampling. There is a lack of consistency across Europe in the titles and roles of staff, and in the definitions of key organisation and resource elements of the audit. For instance, the concept of a nurse specialist or a specialty triage system may not have the same meaning in different countries. To reduce this interpretation bias, some concepts were specifically defined, and there were explanatory tags in the web tool, to help researchers incorporate the requested information [8]. The different number of participating hospitals per country was another key factor. The number of hospitals per country ranged from one (Malta) to 125 (UK), largely related to the size of the country. The statistical effect is that the countries contributing smaller numbers of hospitals result in higher intercountry variation. In the same way, some correlations between hospital size and performance may be affected by the practice across all hospital sizes in one of the larger national contributors to the dataset. Despite these limitations, we believe that this dataset represents the largest available comparative survey of European hospitals treating COPD patients. While the results should be interpreted in the context of the limitations defined above, there is much valuable information to be analysed.

Larger hospitals tend to have greater resources than do smaller ones. In some cases, this also allows better provision of services. However, both the availability of services to patients and the adherence to management recommendations are no better among large hospitals than it is among smaller ones. It may be that for the majority of COPD patients, smaller hospitals provide equally good care as larger ones. Providing care in a local setting, which is integrated to local services, may be an advantage in many cases. Larger hospitals with higher numbers of specialists may offer advantages to a minority of patients who need tertiary care interventions, but these audit data suggest that there is little difference in the care quality offered on average. This suggests that either greater resources are matched to greater workload, or that resources are not organised in an efficient manner. Indeed, table 3 suggests that although larger hospitals have more staff, the ratio of staff to beds is lower than in smaller hospitals. Such a situation may mitigate against specialists caring for every COPD patient admitted, but should still provide opportunities for better organisation of specialist care. For example, a specialty on-call rota or the staffing of a respiratory ward.

If we view these findings from the perspective of the patient, the variability is likely to cause some concern. The European Union has benefitted large populations by the introduction of Europe-wide standards, yet there are no standards for the provision of a hospital service. This raises the question of what the minimum acceptable standards should be to provide safe, high-quality care for patients. The findings of this audit present an opportunity for the medical profession and others dedicated to the provision of high-quality care to patients across Europe to initiate a process of defining minimum standards for units providing services to such patients.

There is particular concern where strongly evidence-based services are not available across a wider range of hospitals and countries. The evidence about the efficacy and cost-effectiveness of intermediate-care units is strong [10], but the provision of these types of units was low in the majority of countries. It is interesting that quite a number of centres declared not to have the capacity to treat all eligible patients throughout the year for invasive and noninvasive ventilation. It is well known that COPD exacerbations cluster in time, with an increase in colder months [11] and in certain geographical areas [12]. This variability provides an organisational challenge, as the available ventilators and staff may also need to change during the year, but it is a challenge that is not met in over a fifth of hospitals (table 4). The use of home mechanical ventilation was not in the scope of the present study and has been evaluated in a previous European survey [13].

Pulmonary rehabilitation improves survival in those patients who survive a hospital admission due to COPD [14] as well as a number of other clinically relevant outcomes, either after or during the admission [15]. Nonetheless, despite this demonstrated effect, the provision of rehabilitation is far from optimal in Europe. In this context, where resources are scarce, the implementation of home- or community-based rehabilitation programmes may be a more cost-effective solution that is demonstrated to be effective in providing rehabilitation programmes in the community setting [16]. Another, more simple approach would be promoting daily physical exercise in the community, known to have positive impact on health status [17].

Early supported discharge programmes are also known to be safe and effective, reducing time in hospital without an adverse impact on mortality, but were also not frequently used. In a recent randomised controlled trial, an early supported discharge programme with community nurses resulted in a feasible alternative to traditional hospital admission [18].

Palliative care services included a broad group of services for either in-hospital or out-patient palliative care. Severe acute exacerbations of COPD are associated with deterioration in lung function and represent one of the most important adverse prognostic factors [19]. Frequently, the management of COPD exacerbations requires urgent medical care and hospitalisation. Unfortunately, several patients with acute exacerbations of COPD die during the hospital admission [20] or within the months following hospital discharge [21]. Symptom management is one of the most important aspects of end-of-life care, because COPD symptoms often worsen in the final days. In this context, the availability of palliative care units offers the opportunity to meet the needs of patients and their carers towards the end of life [22].

Staff provision has recently been described to have an impact on the outcomes of admitted patients [3]; however, the relationship between hospital staffing and access to resources or adjustment to guidelines has not been described. The present data document the number of professionals and trainees available in the participant units. In this regard a European regulation to define the staff provision for a specific service is lacking and needed.

In summary, the present study describes the resources available and the organisation of care provided by individual hospitals and units in 13 European countries in relation to COPD admissions. This study has shown huge variation in both the resourcing and the organisation of care amongst European hospitals caring for acute COPD admissions. This variability applies both between countries and within countries. Further prospective audits, mapping patient outcomes to resource provision and service organisation may inform the development of pan-European recommendations. This information will help managers and policy makers to evaluate the provision of resources in their own country, to adapt these to the necessities of COPD patients admitted to hospital, and to result in improving this care and avoiding inequalities in European health systems.