Determinants of between‐hospital variations in outcomes for patients admitted with COPD exacerbations: findings from a nationwide clinical audit ( AUDIPOC ) in Spain

Abstract

SummaryBackgroundPrevious studies have demonstrated significant variability in the processes of care and outcomes of chronic obstructive pulmonary disease (COPD) exacerbations. The AUDIPOC is a Spanish nationwide clinical audit that identified large between‐hospital variations in care and clinical outcomes. Here, we test the hypothesis that these variations can be attributed to either patient characteristics, hospital characteristics and/or the so‐called hospital‐clustering effect, which indicates that patients with similar characteristics may experience different processes of care and outcomes depending on the hospital to which they are admitted.MethodsA clinical audit of 5178 COPD patients consecutively admitted to 129 Spanish public hospitals was performed, with a 90‐day follow‐up. Multilevel regression analysis was conducted to model the probability of patients experiencing adverse outcomes. For each outcome, an empty model (with no independent variables) was fitted to assess the clustering effect, followed by a model adjusted for the patient‐ and hospital‐level covariables. The hospital‐clustering effect was estimated using the intracluster correlation coefficient (ICC); the cluster heterogeneity was estimated with the median odds ratio (MOR), and the coefficients of predictors were estimated with the odds ratio (OR).ResultsIn the empty models, the ICC (MOR) for inpatient mortality and the follow‐up mortality and readmission were 0.10 (1.80), 0.08 (1.65) and 0.01 (1.24), respectively. In the adjusted models, the variables that most represented the patients’ clinical conditions and interventions were identified as outcome predictors and further reduced the hospital variations. By contrast, the resource factors were primarily unrelated with outcomes.ConclusionsThis study demonstrates a noteworthy reduction in the observed crude between‐hospital variation in outcomes after accounting for the hospital‐cluster effect and the variables representing patient's clinical conditions. This emphasises the predictor importance of the patients’ clinical conditions and interventions, and understates the impacts of hospital resources and organisational factors.

Variability in adherence to clinical practice guidelines and recommendations in COPD outpatients: a multi-level, cross-sectional analysis of the EPOCONSUL study

“…A greater number of medical and nursing staff was identified as a protective factor for intra-hospital mortality. In AUDIPOC Spain [12, 20], the large hospital COPD volume and the number of COPD patients admitted to the hospital the year prior to admission was identified as a predictor of a favourable outcome.…”

Clinical Audits in Outpatient Clinics for Chronic Obstructive Pulmonary Disease: Methodological Considerations and Workflow

“…Categorical data were compared using the χ 2 test. The variables associated with exacerbations and mortality during the 1-year follow-up were identified using hierarchical multilevel multivariate logistic regression analysis, as previously described [ 23 ]. The alpha error was set at 0.05.…”

“…Recently, a European Clinical COPD Audit has been carried out through 13 European countries [ 14 , 15 ]. The results of these in-hospital audits have provided valuable information on the clinical care provided to patients admitted to medical wards because of COPD exacerbations [ 15 ], as well as the available resources [ 16 ] and the interrelationships between health resources and clinical practice [ 17 ]. Unfortunately, clinical audits of COPD in an outpatient setting are scarce [ 18 ] and no general methodological guidelines are currently available.…”

Peer‐pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals

“…1,2 Large variations in healthcare delivery could in fact lead to worse patient outcomes and to unfavourable economic consequences. 3,4 Traditionally, unwarranted variations were analysed to explore the magnitude of underuse, 5,6 however, in recent years, mainly in western countries, a widespread, pervasive and latent phenomenon represented by overuse of medical treatments has come to light. 7,8 Unnecessary care is not only an economic waste; it could lead to significant harmful consequences for patients.…”