Comportamiento del efecto clúster hospital y los factores asociados a la mortalidad a largo plazo, después de un ingreso por exacerbación en epoc

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina Preventiva y Salud Pública y Microbiología. Fecha de lectura: 23-09-2020INTRODUCCIÓN: Resultado del análisis exhaustivo de cohortes multicéntricas, históricas y periódicas de casos, usando aproximaciones multivariables multinivel, hemos abordado el tema de la variabilidad de los datos y encontrado, la presencia de un claro efecto clúster de hospital, que reduce drásticamente la variabilidad de los desenlaces encontrados (duración del ingreso, mortalidad y reingresos a 90 días(1)) en los datos crudos. Reconociendo la advertencia de Juan Merlo en su trabajo (1-3), referida a que la OR promedio es solo una aproximación inexacta y quizá no represente completamente la variabilidad geográfica real en áreas sanitarias, postulamos como hipótesis que el efecto clúster hospital, se mantiene a largo plazo sobre la mortalidad y que este efecto, en parte, se debe a factores asociados al contexto territorial y ambiental del Área de Salud, como la calidad del aire respirado. METODOLOGIA Con el objetivo de demostrar el efecto diferencial del clúster hospital, particularmente en relación con la mortalidad a largo plazo, en el paciente con EPOC, se plantea un estudio descriptivo observacional, con seguimiento prospectivo de mortalidad a largo plazo, para una cohorte de pacientes con EPOC, identificados durante un ingreso hospitalario por exacerbación de su enfermedad. La Tabla de datos contiene información disociada y mortalidad a largo plazo de 10.449 casos procedentes de 142 hospitales públicos españoles, a la que se han asociado datos agregados por localidad, de los registros diarios de emisiones obtenidos entre 2008 y 2011 (Período de reclutamiento de la cohorte) por las diferentes estaciones. La mortalidad a corto plazo (a 90 días del ingreso), fue informada por los responsables locales de investigación de la red de hospitales participantes, y contrastada con la información obtenida de los registros oficiales del índice nacional de defunciones (INDEF) desde octubre de 2008 a diciembre de 2015. Todas las variables fueron evaluadas respecto de la significancia (valor P) en la diferencia de su distribución por mortalidad intrahospitalaria, a 90 días, al año y a los 5 años, usando como estadísticos el chi-cuadrado de independencia y log-Rank test. Se construyó un modelo de supervivencia de riesgos proporcionales (Cox), y un modelo en regresión logística de mortalidad, calculando los coeficientes estandarizados y la curva ROC. RESULTADOS La media de seguimiento fue de 304·5 días posteriores al ingreso hospitalario, con un máximo de 7 años. Casi la mitad de la mortalidad total de la cohorte se produjo dentro de los 90 días posteriores al ingreso hospitalario a partir del cual fueron reclutados. La ponderación del efecto de cada uno de las variables finalmente retenidas por los modelos explicativos, a través de los coeficientes estandarizados obtenidos en la regresión, enfatiza el peso del perfil clínico grave (dimensión paciente), seguido de cerca por la exposición de micro partículas (dimensión local territorio) y las características del hospital (dimensión local hospital). El modelo obtenido logró discriminar la mortalidad a largo plazo, con un área de 0·71 y un IC 95% entre 0·69-0·72. CONCLUSIONES: Además de los determinantes clínicos de enfermedad, otros factores del contexto espacio/temporal externo al individuo, sumados a las condiciones de salud y atención sanitaria recibida, afectan la supervivencia/mortalidad a largo plazo y configuran lo que hemos llamado en nuestros trabajos previos efecto clúster hospitalEste trabajo ha sido financiado principalmente por fondos destinados al Grupo de investigación de la Red temática Enfermedades Respiratorias del Consorcio CIBER M. P, en el Hospital Universitario 12 de Octubre. También obtuvo financiación de ayudas a los proyectos FIS número PS 09/01763, PS 09/01787 y PS 09/00629 (Instituto de Salud Carlos III, Secretaría de Estado de Investigación, Desarrollo e Innovación y FEDER/FSE

Understanding variation in length of hospital stay for COPD exacerbation: European COPD audit

Chronic obstructive pulmonary disease (COPD) care across Europe has high heterogeneity with respect to cost and the services available. Variations in length of stay (LOS) may be attributed to patient characteristics, resource and organisational characteristics, and/or the so-called hospital cluster effect. The European COPD Audit in 13 countries included data from 16 018 hospitalised patients. The recorded variables included information on patient and disease characteristics, and resources available. Variables associated with LOS were evaluated by a multivariate, multilevel analysis. Mean±sd LOS was 8.7±8.3 days (median 7 days, interquartile range 4–11 days). Crude variability between countries was reduced after accounting for clinical factors and the clustering effect. The main factors associated with LOS being longer than the median were related to disease or exacerbation severity, including GOLD class IV (OR 1.77) and use of mechanical ventilation (OR 2.15). Few individual resource variables were associated with LOS after accounting for the hospital cluster effect. This study emphasises the importance of the patients' clinical severity at presentation in predicting LOS. Identifying patients at risk of a long hospital stay at admission and providing targeted interventions offers the potential to reduce LOS for these individuals. The complex interactions between factors and systems were more important that any single resource or organisational factor in determining differences in LOS between hospitals or countries

Predictors of one-year mortality after hospitalization for an exacerbation of COPD

Abstract Background Hospitalization for a severe exacerbation of COPD (eCOPD) is an important event in the natural history of COPD. Identifying factors related to mortality 1 year after hospitalization could help determine interventions to reduce mortality. Methods In a prospective, observational, multicentre study, we evaluated data from two cohorts: the Spanish audit of hospital COPD exacerbation care (our derivation sample) and the Spanish cohort of the European audit of COPD exacerbation care (our validation sample). The endpoint was all-cause mortality. Mortality was determined by local research managers of the participating hospitals and matched the official national index records in Spain. Results In the multivariate analysis, factors independently related to an increase in mortality were older age, cardio-cerebro-vascular and/or dementia comorbidities, PaCO2 > 55 mmHg measured at emergency department arrival, hospitalizations for COPD exacerbations in the previous year, and hospital characteristics. The area under the receiver-operating curve for this model was 0.75 in the derivation cohort and 0.76 in the validation cohort. Conclusion One-year mortality following the index hospitalization for an exacerbation of COPD was related to clinical characteristics of the patient and of the index event, previous events of similar severity, and characteristics of the hospital where the patient was treated

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

Results from an Audit Feedback Strategy for Chronic Obstructive Pulmonary Disease In-Hospital Care: A Joint Analysis from the AUDIPOC and European COPD Audit Studies

<div><p>Background</p><p>Clinical audits have emerged as a potential tool to summarize the clinical performance of healthcare over a specified period of time. However, the effectiveness of audit and feedback has shown inconsistent results and the impact of audit and feedback on clinical performance has not been evaluated for COPD exacerbations. In the present study, we analyzed the results of two consecutive nationwide clinical audits performed in Spain to evaluate both the in-hospital clinical care provided and the feedback strategy.</p><p>Methods</p><p>The present study is an analysis of two clinical audits performed in Spain that evaluated the clinical care provided to COPD patients who were admitted to the hospital for a COPD exacerbation. The first audit was performed from November–December 2008. The feedback strategy consisted of personalized reports for each participant center, the presentation and discussion of the results at regional, national and international meetings and the creation of health-care quality standards for COPD. The second audit was part of a European study during January and February 2011. The impact of the feedback strategy was evaluated in term of clinical care provided and in-hospital survival.</p><p>Results</p><p>A total of 94 centers participated in the two audits, recruiting 8,143 admissions (audit 1<b>∶</b>3,493 and audit 2<b>∶</b>4,650). The initially provided clinical care was reasonably acceptable even though there was considerable variability. Several diagnostic and therapeutic procedures improved in the second audit. Although the differences were significant, the degree of improvement was small to moderate. We found no impact on in-hospital mortality.</p><p>Conclusions</p><p>The present study describes COPD hospital care in Spanish hospitals and evaluates the impact of peer-benchmarked, individually written and group-oral feedback strategy on the clinical outcomes for treating COPD exacerbations. It describes small to moderate improvements in the clinical care provided to COPD patients with no impact on in-hospital mortality.</p></div

Characteristics of the patients included in each audit.

<p>Data are expressed as the mean (standard deviation) or absolute (relative) frequencies. NS: not significant. FEV₁: forced expiratory volume in one second.</p><p>*Calculated using the unpaired Student’s <i>t</i>-test or chi-square test.</p><p>Characteristics of the patients included in each audit.</p

Kaplan-Meier curves comparing the in-hospital survival between the audits.

<p>The grey line represents the first audit. The black line represents the second audit.</p

Diagnostic procedures performed during admission in each audit.

<p>Data are expressed as the mean (standard deviation) or absolute (relative) frequencies. NS: not significant. PaO₂: partial pressure of oxygen in arterial blood. PaCO₂: partial pressure of carbon dioxide in arterial blood.</p><p>*Calculated using the unpaired Student’s <i>t</i>-test or chi-square test.</p><p>Diagnostic procedures performed during admission in each audit.</p