Action plans to reduce hospitalizations for chronic obstructive pulmonary disease exacerbations: focus on oral corticosteroids.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is associated with a huge burden of suffering and healthcare expenditures. Patients hospitalized due to COPD have increased risk of death. Starting in 2015, reimbursements by the Centers for Medicaid Medicare Services will be significantly reduced to hospitals with excess 30 day readmissions for COPD. Oral corticosteroid (OCS) therapy is established in improving outcomes in COPD patients treated in the emergency department and hospital. The objective of this article is to review the evidence evaluating home OCS treatment of COPD exacerbations as part of a comprehensive self-management action plan.

METHODS: We reviewed the English literature via PubMed, Embase, and Scopus using the search terms: chronic obstructive pulmonary disease exacerbations AND: oral corticosteroids, prednisone, prednisolone, methylprednisolone, treatment, self-management, disease management, written action plans. When pertinent articles were found, we reviewed the relevant articles cited.

FINDINGS: Two randomized trials enrolling 933 patients provide evidence of reduced rates of hospitalization by using comprehensive COPD action plans, including OCS therapy. Three trials with 790 patients enrolled did not reveal reduced rates of hospitalization. Among all five trials together, there were no differences in deaths (76 in the intervention groups [home action plans]; 81 in the usual care groups). Additional studies not assessing hospitalizations have found home use of OCSs increases time to the next exacerbation and decreases recovery time.

CONCLUSION: Further randomized trials are needed to establish that home use of OCS therapy, as part of a comprehensive action plan, reduces the rate of hospitalizations. Such action plans should include structured patient education, early initiation of OCSs, oral antibiotics, and frequent telephone reinforcement and support from case management.