Self Timothy H, Patterson Shanise J, Headley Arthur S, Finch Christopher K
University of Tennessee Health Science Center, Methodist University Hospital , Memphis, TN , USA.
Curr Med Res Opin. 2014 Dec;30(12):2607-15. doi: 10.1185/03007995.2014.934795. Epub 2014 Jun 30.
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.
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.
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.
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.
慢性阻塞性肺疾病（COPD）带来了巨大的痛苦负担和医疗支出。因COPD住院的患者死亡风险增加。从2015年开始，医疗保险和医疗补助服务中心将大幅减少对COPD 30天再入院率过高的医院的报销。口服糖皮质激素（OCS）疗法已被证实可改善在急诊科和医院接受治疗的COPD患者的预后。本文的目的是回顾评估将家庭OCS治疗COPD急性加重作为综合自我管理行动计划一部分的证据。
我们通过PubMed、Embase和Scopus检索英文文献，检索词为：慢性阻塞性肺疾病急性加重 以及：口服糖皮质激素、泼尼松、泼尼松龙、甲泼尼龙、治疗、自我管理、疾病管理、书面行动计划。当找到相关文章时，我们会查阅所引用的相关文章。
两项纳入933例患者的随机试验提供了证据，表明使用包括OCS疗法在内的综合COPD行动计划可降低住院率。三项纳入790例患者的试验未显示住院率降低。在所有五项试验中，干预组（家庭行动计划）有76例死亡，常规护理组有81例死亡，两组死亡率无差异。其他未评估住院情况的研究发现，在家使用OCS可延长至下次急性加重的时间并缩短恢复时间。
需要进一步的随机试验来确定，作为综合行动计划的一部分，在家使用OCS疗法可降低住院率。此类行动计划应包括结构化的患者教育、OCS的早期使用、口服抗生素以及病例管理的频繁电话强化和支持。
