Quality Indicators for the Care of Chronic Obstructive Pulmonary Disease in Vulnerable Elders

Published in: Journal of the American Geriatrics Society, v. 55, no. S2, Oct. 2007, p. S270-S276

Posted on RAND.org on December 31, 2006

by Eric C. Kleerup

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Chronic obstructive pulmonary disease (COPD) produces persistent respiratory symptoms of cough, sputum production, wheezing, and, in later stages, dyspnea, poor exercise tolerance, and symptoms and signs of right-sided heart failure. The Global Initiative for Chronic Obstructive Lung Disease, (GOLD) defines COPD as: A disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Small-airway disease (obstructive bronchiolitis) and parenchymal destruction (emphysema) result in airflow limitation perceived as dyspnea. Parenchymal destruction also reduces the surface area for gas exchange, contributing to exercise limitation late in disease. Many, although not all, patients with COPD have chronic bronchitis (mucous hypersecretion), a condition defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years. A predominance of CD8+ cells, macrophages, and neutrophils characterize inflammation in COPD. In contrast, CD4+ (helper) cells and eosinophils predominate in asthmatic airways. Although COPD begins soon after the onset of smoking (a habit that typically begins in the teenage years), primarily older persons experience the effects of its morbidity and mortality. Symptomatic COPD affects more than5%to 8% of the adult population. In 2000, 9.6% of those aged 65 to 74 and 10.6% of those aged 75 and older had self-reported physician-diagnosed lifetime emphysema or chronic bronchitis. Approximately 3.2 million Americans aged 65 and older have COPD.3 In 2000, the annual COPD death rate was 43.1 per 100,000 population for those aged 55 to 64, 171.2 for those aged 65 to 74, and 449.7 for those aged 75 and older. Chronic lower respiratory diseases are the fourth leading cause of death in women (269.4) and the third leading cause in men (353.4) in the United States for people aged 65 and older. COPD is increasing in prevalence and incident mortality worldwide. Between 1980 and 2000, the overall death rate for COPD increased 67%. COPD as a primary diagnosis resulted in 4.2 million physician office and hospital outpatient visits and 5.5 million emergency department visits for patients aged 65 and older in 2000. The estimated annual rate of hospitalization for COPD is higher for people aged 65 and older than for younger patients. COPD also affects quality of life for many people. Eight percent of COPD patients self-report activity limitation-twice the rate of those without COPD. COPD is projected to be the fifth leading cause of disability-adjusted life years lost worldwide by 2020. Finally, decreased pulmonary function is an independent risk factor for coronary heart disease. METHODS: Articles were identified through reference mining and from the author's files on COPD in older persons. A total of 111 articles were considered in this review, and 13 guidelines were identified using a Web search. Three additional articles were included after peer review. RESULTS: Of the 13 potential quality indicators, 10 were judged valid according to the expert panel process, and one new indicator was developed; three indicators were rejected. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.

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