Are We Good as GOLD? – perhaps, maybe
COPD exacerbations are ubiquitous in all our hospitals as a cause of admissions, and they represent one of our most common DRG’s. Our locale has many patients with this condition, and although there are no conclusive data that we have more than the rest of the country, that is certainly the local impression. With a history of lots of manufacturing in the area, pollen, high historical smoking rates, air pollution and the composite health of our populace there are several theories as to why we have so many patients with COPD, and thus so many exacerbations.
With all this experience, this is one condition we in which our care should clearly excel, and in many ways that is definitely the case. We have excellent pulmonary consultants to support us and all admitting physicians appear to be very comfortable with the fundamentals of evaluation and management. And our patients feel better when they leave after a successful hospitalization for treatment of COPD.
But there is a mysterious underside to our expertise, and that is mortality. Data analytics tell us that our mortality rates are higher than expected in our COPD patients – the opposite of what we would anticipate from our personal experiences. These data are very complex and they definitely include patient severity and complexity in the calculations. So if we are “under-coding” or not listing fully all the serious medial comorbidities of these patients they will appear relatively healthy to the data analysts and thus have a lower expected mortality compared to someone with the same condition who looks “sicker” on paper. This may play some role, but we cannot be sure. The accuracy of the national sample we are being compared with is also unclear, so perhaps the data are imprecise. This may be a factor but we can’t tell. But the bottom line is that the data do not show any exemplary results with respect to our mortality rates that we can be proud of. And the issue is not just an intellectual exercise. CMS (Medicare’s parent organization) is looking specifically at every hospital’s COPD mortality rate to evaluate quality of care. Any hospital or system that appears to have higher than expected mortality rates will not only get a public spanking but will pay dearly – Medicare will slash their reimbursement for years until they see changes. Medicare considers this a quality measure that they can quantify and use as a barometer for overall quality of care for everything else.
What about our treatment of these patients – is it as good as GOLD? It should be with all our experience. In this case GOLD (Global Initiative for Chronic Obstructive Lung Disease) is the industry white paper that sets the standards that are recognized internationally for COPD. It is a weighty document, heavily researched, and features prominent international pulmonary specialists who review and evaluate all the evidence in compiling these recommendations. It is regularly updated so there are no dusty old recommendations that linger long after the state of the art has changed. At every conference I attend, including the ACP annual Internal Medicine educational meetings, speakers always reference the GOLD guidelines for any discussions about inpatient or outpatient COPD evaluation, prevention, and treatment. It’s boss in the world of pulmonary medicine.
One area where we differ from the GOLD recommendations is how we use steroids. GOLD mentions that steroids should be considered for patients who are hospitalized for COPD; that oral administration is equivalent to IV; that 5 days is the optimal duration of therapy; and that the optimal dosage is prednisone 40 mg per day or equivalent. It notes – supported by several additional studies that have been published – that higher doses and longer durations do not improve outcomes and in several measures the outcomes are worse when more or longer steroid doses are given. This is in notable contrast to a frequent practice in our area, where higher steroid doses are given, usually given much longer, and the IV route seems to be preferred for our inpatients most if not all the time. This is not a phenomenon of one hospital but is ubiquitous at our 5 sites and likely throughout the region since local practices typically transcend the community. We seem to be very treating our patients in this respect very differently than the GOLD guidelines advise.
What about our current bible – UpToDate? It looks like it is doing a fan dance with the recommendations. It states that IV is no better than oral, but many clinicians “typically use” the IV route. It reaffirms the GOLD recommendation of 5 days of treatment but then goes on to say that 5-14 days is “reasonable”. It cites the GOLD recommendations that 40mg of prednisone or equivalent is optimal, but then equivocates to say that the optimal steroid dose is unknown. It does clearly caution against high steroid doses without quantifying them.
So what can we conclude? Do we have reason to suspect that high steroid doses have some connection with mortality rates? We do not, even as we know the effect of steroids on infections, vascular disease, glucose metabolism, thrombosis, muscle strength and the other factors that make it plausible there could be a causal association. We know that studies show higher mortality rather than lower with higher steroid dosing but the difference is small and it can’t be extrapolated to a local experience and infer causality. Likewise, we don’t even see clear synchrony between GOLD and UpToDate, although the latter reflects one writer’s opinion rather than a subspecialty consensus – but it remains our most widely used reference. When I have discussed this issue with some of our pulmonary specialists, they do not seem eager to use the GOLD guidelines with respect to steroid dosing more ubiquitously. I have never ascertained exactly why, but there is a sense of concern that if someone is hospitalized, more steroids would logically be efficacious given the nature of the condition, and the concern about the acuity of patients suggests being as aggressive as possible – and more steroids can be viewed as more aggressive in some ways.
So what can we do? Clearly we cannot hide from the issue of COPD mortality. It is on our front burner, as CMS will be rating us on our mortality rates and the results will be publically displayed for all to see. And if we take a hit to our operating budget because of this, everyone will feel the effects. It behooves us to look carefully at our COD patients, study carefully the evidence, and make sure we plan treatment courses for our patients that reflect a measured and thoughtful review of all the available literature. We have to refrain from falling back on custom and habit when we have reason to reconsider the approaches we have used in the past. Each of us must be thoughtful and reasoned in how we determine our treatment plans for our patients, and look at the best evidence.
There may be some GOLD out there – maybe it’s time to mine it more consistently and effectively.
References:
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2018 Report. http://www.goldcopd.org
Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA 2013; 309:2223
Walters JA, Tan DJ, White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2018; 3:CD006897
Kiser TH, Allen RR, Valuck RJ, et al. Outcomes associated with corticosteroid dosage in critically ill patients with acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2014; 189:1052
Lindenauer PK, Pekow PS, Lahti MC, et al. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA 2010; 303:2359
