Chronic Obstructive Pulmonary Disease Exacerbations: The Killing Weekends

Alexandros G. Mathioudakis MD1, Victoria Chatzimavridou-Grigoriadou MS2, Georgios A. Mathioudakis MD, PhD2.
1 Medical Department, Southport and Ormskirk NHS Trust, 2 Respiratory Department, General Hospital of Nikaia St. Panteleimon

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Cite as: Mathioudakis AG, Chatzimavridou-Grigoriadou V, Mathioudakis GA. Chronic Obstructive Pulmonary Disease Exacerbations: The Killing Weekends. Alveolus 2013; 1(1):9-12

 

The weekend effect and generally the off-hour effect have been studied thoroughly during the last couple of years. Both terms refer to the hypothesis that during the weekends/nights, the hospital staff which lacks in numbers, expertise and sometimes experience could possibly pose a burden on the acutely ill patients[1]. Recent cohort studies show increased mortality in weekend admissions for trauma[2-4], stroke[5-6], atrial fibrillation[7], gastrointestinal bleeding[8,9], pulmonary embolism[10], myocardial infarction[11] and COPD[12,13]. Another interesting study show an increased rate of errors in the clinical management of hospitalised patients during the weekend[14].

COPD exacerbations are among the leading causes of morbidity and mortality, while their hospital management is responsible for more than half of the costs of treating respiratory diseases in both Europe and the USA[15]. This data resulted in a quest for the identification of all the potential risk factors for COPD exacerbations and their mortality. The hospital admission during weekends emerged as a significant risk factor associated with increased mortality, by several extensive cohorts[12, 13, 16, 17(N/S)]. However, the causes of this association have not been adequately investigated yet.

Although the weekend effect would be the obvious answer, van den Borst and Wesseling, in their very interesting letter to the editor[18], points that the weekend variation could be secondary to the reluctance of the COPD patients to visit hospital during the weekend. This implies that only the most severe exacerbations would reach the hospital during the weekend, while the rest would either be treated empirically or wait until Monday. The significantly decreased admissions of COPD exacerbations during Saturday and Sunday compared to the weekdays, showed by Barba et al[12], supports this assumption. The significantly increased rates of respiratory failure in the weekend admissions are also supportive.

We should not forget that COPD patients are chronic patients, informed and experienced regarding their disease. Many of them have antibiotics, oxygen and nebulisers in their homes and are able to cope with most of their exacerbations by themselves. They usually can wait until Monday to go to the hospital, in contrary to the patients with trauma, MI, GI bleeding or stroke.

On the other hand, the significant decrease in the mortality of patients admitted with COPD exacerbations during the weekend, after opening a MAU in their hospital, noted by Brims et al[13], supports the weekend effect. As a result, we could hypothesize that both parameters are implicated in the increased mortality of the weekend COPD exacerbation admissions.

The anticipated next step would have been to stratify the admitted patients according to the severity of the exacerbation. Unfortunately, systemic review shows that there is no recognised, reliable severity index. Several indices have been proposed, including CURB-65[19], CAT (COPD Assessment test)[20], MRCD (Medical Research Council Dyspnoea Scale) and eMRCD (extended MRCD)[21], the BODE index[22], demographics and comorbidities[23], spirometry changes, sputum neutrophilia[24], CRP[25], pro-BNP and troponins[26,27]. As a result, we are planning to initiate a clinical study, to evaluate all these indices and their predictive values for increased severity and mortality of a COPD exacerbation. Since this is anticipated to be an extensive study and an extensive design and population will be needed, we would accept suggestions for co-operation from other departments with pleasure.

Table 1. Medical Research Council Dyspnoea Scale.

 

References:

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Conflicts of Interest: None