Improving adherence for management of acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND: Clinical practice guidelines recommend 40-60 mg of prednisone equivalent for 10-14 days for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the amount of corticosteroid prescribed varies widely in clinical practice. Using the electronic health record, we implemented an evidence-based order set to standardize treatment of patients hospitalized with acute exacerbations of COPD. METHODS: This is a pre- and post-intervention study on patients hospitalized between January 1, 2009 and September 30, 2012 with primary discharge diagnosis of COPD (International Classifi cation of Diseases, 9^th Revision code: 491.xx, 492.xx, and 496) and receipt of at least one dose of corticosteroid at our tertiary care hospital. Data on baseline demographics, dose of corticosteroid in prednisone equivalent administered during the first 48 hours and during the entire hospitalizations were collected from the electronic health record. Evidence-based guidelines were used to build and implement acute exacerbations of COPD management electronic ordersets in our electronic health record, Epic (Verona, WI). We divided the study into 2 time periods (January 1, 2009 through February 28, 2011 as pre- [n = 203] and March 1, 2011 through September 30, 2012 as post-intervention periods [n = 217]). The primary outcome measure was corticosteroid dose administered in the first 48 hours. Secondary outcome measures were corticosteroid dosage during the entire hospitalization, length of stay, hospital follow-up rates, and 30-day readmission rates. RESULTS: A total of 420 patients with acute exacerbations of COPD were included in the study. In the post-intervention period, the median amount of corticosteroid used in the first 48 hours was significantly reduced (306.2 mg vs 156.25 mg, P < .0001), as was that used during the entire hospitalization (352.5 mg vs 175 mg, P < .0001). There was no difference in hospital follow-up rates, length of stay, or 30-day readmission rates between the 2 periods. CONCLUSIONS: Evidence-based electronic ordersets improve compliance with clinical practice guidelines and reduce the total dose of corticosteroid administered in patients hospitalized with acute exacerbations of COPD.