BRIEF REPORT chronic obStructive pulmonary disease, psychosocial factors
Emergency Department Return Visits in Chronic Obstructive Pulmonary Disease: The Importance of Psychosocial Factors Study objectives: Relapses are common after treatment of decompensated chronic obstructive pulmonary disease (COPD) in the emergency department. The purpose of this study was to identify psychosocial and pulmonary function variables that distinguish patients who relapse from those who do not. Design: Retrospective case analysis. A relapse was defined as an unscheduled return to the ED within two weeks of treatment. Setting: 475-bed Veterans Administration Medical Center. Type of participants: 33 male veterans with COPD who used the ED. M e a s u r e m e n t s : Demographic profile, a Likert-scaled questionnaire about illness beliefs, and physiologic data obtained by chart review. Main results: Patients who relapsed at least once (R patients) were more likely to be widowed, separated, or divorced than patients who did not relapse at any time (N patients) (52.4% vs 8.3%; P = .01i). R patients were more likely to have lost a first-order relative within three years (57.1% vs 8.3% P = .006). Stepwise logistic regression showed that the loss of a first-order relative, a negative attitude about prognosis, and a higher forced vital capacity distinguished R from N patients. Stepw.ise linear regression showed that six specific illness beliefs, distance of the home from the hospital, and baseline bronchodilator response correlated with the number of relapses (multiple r 2 = 0.82; P < .001). Conclusion: Social and psychological parameters are closely correlated with relapse in patients with decompensated COPD. [Stehr DE, Klein BJ, Murata GH: Emergency department return visits in chronic obstructive pulmonary disease: The importance of psychosocia] factors. Ann Emerg Med October 1991;20:1113-1116.]
Donald E Stehr, MD Benjamin J Klein, MD Glen H Murata, MD Albuquerque, New Mexico From Ambulatory Care and Psychology Services, Veterans Affairs Medical Center; and the University of New Mexico School of Medicine, Albuquerque. Received for publication December 26, 1990. Revision received April 30, 1991. Accepted for publication May 16, 1991. Presented in part at the Society of General Internal Medicine Annual Meeting in Washington, DC, April 1989. Address for reprints: Donald E Stehr, MD, Ambulatory Care Service (11AC), VA Medical Center, 2100 Ridgecrest Drive SE, Albuquerque, New Mexico 87108.
INTRODUCTION Return visits are c o m m o n after certain conditions are treated in an emergency department. 14 This problem has been attributed to failure of medical therapy, system failures, poor patient compliance, inadequate patient education, and psychological factors. In 1987, a quality assurance study at our institution showed that decompensated chronic obstructive pulmonary disease (COPD) was the leading cause of return visits to the ED within 48 hours. In a subsequent study of more than 1,600 consecutive visits for COPD, we found that 14% of patients accounted for 68% of relapses occurring with 14 days of the initial v i s i t s Except for minor differences in bronchodilator response, relapsers could not be differentiated from nonrelapsers by baseline pulmonary function tests (PFTs). The purpose of this study was to determine if certain psychosocial and physiologic factors were associated with relapse.
MATERIALS A N D METHODS The Albuquerque VA Medical Center is a 475-bed facility serving veterans in New Mexico and west Texas. The ED is staffed by a large number of faculty and house officers from the University of New Mexico. Patients who present with decompensated COPD are triaged to the ED for evaluation and therapy. All decisions regarding treatment or hospital admission are made by the attending physician on duty and are not based on protocols. Patients who respond to therapy are instructed to return to the ED if
Annals of Emergency Medicine
RETURN VISITS Stehr, Klein & Murata
Physical exercise is dangerous for my breathing. CompletelyDISAGREE1__ 2__ 3__ 4__ 5__ 6 AGREEcompletely
s y m p t o m s recur. Visits to the ED are recorded in a log b o o k t h a t c o n t a i n s i n f o r m a t i o n about the p a t i e n t ' s chief c o m p l a i n t , clinical findings, diagnosis, and treatment. This log was reviewed for all visits for d e c o m p e n s a t e d COPD over a period of 29 months. Visits were included in this study if the chief comp l a i n t was s h o r t n e s s of breath; the p a t i e n t w a s g i v e n t h e d i a g n o s i s of COPD, chronic bronchitis, or emphysema by the physician on duty; and the p a t i e n t had at least one set of baseline PFTs w i t h i n three years of entry. Cases c o m p l i c a t e d b y p n e u monia, pneumothorax, pulmonary embolism, left ventricular failure, or a pleural effusion were excluded. A r e l a p s e w a s d e f i n e d as a n u n scheduled return to the ED for dyspnea w i t h i n 14 days. At the conclusion of the observation period, each subject was classified by one of the authors as relapser or nonrelapser. A patient was considered a relapser if he relapsed at least once during t h e o b s e r v a t i o n period. PFTs were reviewed for each subject. If m o r e t h a n one set was available, the study with the highest prebronchodilator one-second forced expiratory v o l u m e [FEV1) was analyzed. B r o n c h o d i l a t o r r e s p o n s e w a s expressed as the response index given by the following expression:
My treatmentfor my breathingproblemsis successful. CompletelyDISAGREE1__ 2__ 3__ 4__ 5__ 6 AGREEcompletely
P o s t b r o n c h o d i l a t o r FEV 1 - p r e b r o n c h o d i l a t o r FEV I P r e d i c t e d FEV 1 -
p r e b r o n c h o d i l a t o r FEV I
I n f o r m a t i o n was e x t r a c t e d from the medical record on the number of ED visits made by the patient, n u m b e r of doses of n e b u l i z e d b r o n c h o d i l a t o r s used during each visit, and proportion of visits in w h i c h the p a t i e n t was given parenteral ~-agonists, IV corticosteroids, a m i n o p h y l l i n e , antibiotics, and prednisone. Interviews were conducted over the next seven months. Patients were eligible for interview if they had a regularly scheduled appointment with the general medical or p u l m o n a r y clinic during this interval. Patients were approached for an interview in the order that they reported for these previously scheduled visits. Those consenting to the study were given a semistructured interview by one of the investigators who was blinded to the patient's relapse category. Likert-scaled responses 94/1114
were obtained to a 28-item questionnaire (Figure) developed by one of the investigators, who is a clinical psychologist. The questionnaire included items previously shown to predict abn o r m a l i l l n e s s b e h a v i o r in p a t i e n t s with COPD. 6-8 Continuous variables are expressed as mean _+ SD. Group differences in the p r o p o r t i o n of n o m i n a l variables were examined by X2 analysis. Differences in continuous variables were exa m i n e d by Student's t test. P ~ .05 was considered significant. Stepwise logistic regression was used to determ i n e the factors that distinguished relapsers from nonrelapsers. Step selections were based on a s y m p t o t i c covariance estimates with an c~ of 0.10 to enter and 0.15 to remove. Stepwise linear regression was used to examine the relationship between the number of relapses and psychosocial and PFT variables. For the latter analysis, an of 0.15 was used to enter and remove terms. All computations were done on a m i c r o c o m p u t e r equipped w i t h two c o m m e r c i a l statistical packages (SYST A T and B M D P } .
RESULTS One h u n d r e d one p a t i e n t s w i t h a recent visit for decompensated C O P D were eligible for this study. Forty-six of these p a t i e n t s were selected at r a n d o m for an i n t e r v i e w ; ten refused, two were illiterate, and one had dementia. T h e r e m a i n i n g t h i r t y - t h r e e subjects were interviewed. Mean age was 65.8 -+ 8.6 years, and all s u b j e c t s were m e n . M e a n FEV 1 was 50.3 _+ 20.4% predicted, and forced vital cap a c i t y (FVC) was 64.8 _+ 19.3% predicted. T w e n t y - o n e relapsers experie n c e d o n e or m o r e r e l a p s e s d u r i n g this period, w h i l e 12 nonrelapsers did not. Prebronchodilator and postbronchodilator FEV u FVC, and FEV Ito-FVC ratio were similar for the two groups. N o d i f f e r e n c e s w e r e f o u n d b e t w e e n relapsers and n o n r e l a p s e r s for the n u m b e r of doses of nebulized bronchodilators given per visit or the proportion of visits in w h i c h patenAnnals of Emergency Medicine
t e r a l f3-agonists, IV c o r t i c o s t e r o i d s , aminophylline, prednisone, or antibiotics were used. Univariate analysis showed that relapsers were more l i k e l y t h a n nonrelapsers to be either widowed, separated, or divorced (52.4% vs 8.3%, P = .011). R e l a p s e r s also w e r e m o r e likely to have experienced the loss of a first-order relative within three y e a r s of t h e i n t e r v i e w (57.1% vs 8.3%, P - .006). N o differences were found for age; distance of the h o m e from the hospital; p r o p o r t i o n living alone; m a r i t a l satisfaction; i n c o m e level; p r o p o r t i o n e x p e r i e n c i n g t h e death of a friend; n u m b e r of years of education, e m p l o y m e n t , r e t i r e m e n t , or p r o p o r t i o n u n d e r g o i n g a f a m i l y disruption. S t e p w i s e l o g i s t i c r e g r e s s i o n was used to identify patient factors that distinguished relapsers from nonrelapsers. Sixteen social factors, the 28 r e s p o n s e s to t h e q u e s t i o n n a i r e , and six PFT variables were tested in the model. The following were identified as c h a r a c t e r i s t i c of relapsers: loss of a first-order relative, a negative response to the s t a t e m e n t " M y t r e a t m e n t for m y breathing problems will keep m e functioning well in the future," and a higher FVC. Stepwise linear regression was used to examine the relationship between the n u m b e r of relapses and the following: age; distance of the h o m e from the hospital; i n c o m e ; n u m b e r of years of education, e m p l o y m e n t , and retirement; the 28 responses to the questionnaire; and six PFT variables. T h e n u m b e r of relapses was highly correlated w i t h the distance of the h o m e from the hospital, baseline response index, and the six attitudes and beliefs ( m u l t i p l e r 2 = .82, P < .001). Fewer relapses occurred for patients who lived further from the hospital. The n u m b e r of relapses was p o s i t i v e l y c o r r e l a t e d w i t h response index (Table).
DISCUSSION D e c o m p e n s a t e d C O P D is one of t h e m o s t c o m m o n causes of r e t u r n 20:10 October 1991
R E T U R N VISITS Stehr, Klein & M u r a t a
TABLE. Factors correlated with the ~umber of relapses on stepwise linear regression Variable Distance from the hospital Bronchodilator response (response index) "1 often have problems breathing during conversations." "Breathing problems sometimes start when I am doing little or nothing [resting]." "My breathing problems are relieved by rest." "My breathing problems will take much effort from myself in the future."
± .01 ± .04
"When I have severe breathing problems, the best thing to do is come to the hospital immediately."
"When I come to the ED for my breathing problems, I usually feel much better after receiving treatment."
Multiple r 2 .82.
visits to an ED. Despite the magnitude of this problem, little is known about the patients who relapse after treatment. The purpose of this study was to determine if relapsers could be distinguished from nonrelapsers on the basis of pulmonary function testing and psychosocial profiling. Univariate analysis showed that there were no differences between relapsers and nonrelapsers in the number of doses of n e b u l i z e d bronchodilators given per visit or the frequency with which parenteral ~-agonists, IV corticosteroids, aminophylline, antibiotics, or prednisone were used. This observation suggested that patient factors were more important than treatment factors as a cause of relapse. We used two multiv a r i a t e m e t h o d s to d e t e r m i n e whether psychosocial and PFT variables were important determinants of relapse. We found that relapsers were more likely to have experienced the loss of a f i r s t - o r d e r r e l a t i v e , be m o r e pessimistic about their prognosis, and have a higher FVC than nonrelapsers. Furthermore, the number of relapses was highly correlated with the distance of the home from the hospital, six specific illness beliefs (Table J, and bronchodilator response. These observations suggest that psychosocial factors play an important role in how patients respond to treatment. Psychological intervention and improved social support could result in a significant change in the behavior of these patients. Several p r e c a u t i o n s s h o u l d be taken when interpreting our findings. This study was confined to elderly, male veterans who may differ sub20:10 O c t o b e r 1991
stantially from other patients with COPD. A significant number of subjects refused to take part in the study. Finally, selection of patients was done on the basis of appointments kept after patients were classified. The results could therefore be biased toward patients who had a nonterminal illness and were willing to establish a long-term relationship with providers at our institution. We used multivariate analysis because this approach has significant advantages over univariate methods for studies involving multiple comparisons between two gronps. 9 Multivariate analysis avoided the inflated Type II error that was possible when several pairwise comparisons were made between relapsers and nonrelapsers. Furthermore, this approach corrected for confounding variables when the effect of any one factor was analyzed. For instance, univariate analysis showed that distances of the home from the hospital were similar for relapsers and nonrelapsers. However, this variable was incorporated into the multiple linear regression model for the number of relapses. The effect of distance became apparent only when other factors were controlled. Validation of our findings should be done by applying these models to an independent data set. A l t h o u g h there were i m p o r t a n t psychological differences between relapsers and nonrelapsers, the reasons for these differences are unknown. It is possible that relapsers were more likely to seek medical care because of depression, alcoholism, substance abuse, post-traumatic stress disorder, medical illnesses unrelated to COPD, or economic hardship. Future studies Annals of Emergency Medicine
should be done to determine the role of these factors in the pessimistic outlook of our relapse group. Although we could not find similar studies for comparison, these results are consistent with previous reports regarding illness behavior in COPD. Burns and Howell compared two groups of 31 patients each; one of the groups was thought to show disproportionate breathlessness. 6 Psychological testing showed depression, anxiety, hysteria, obsessional traits, excessive health consciousness, and psychogenic stress to be more common in the more symptomatic group. Rutter studied 83 patients who were assigned to three different management programs. 7 Although there was no significant difference in medical outcomes, multiple regression analysis revealed that a negative attitude about returning to work; self-evaluation as hard, rugged, and active; and evaluation of one's work as heavy and fast accounted for 75% of the variance in weeks off work. Physiological factors showed no significant correlation. Morgan and associates studied 50 patients whose functional disability was measured by a standardized 12minute walking test. 8 Stepwise multiple regression revealed that FVC accounted for only 4% of the variance in walking distance, whereas perceived exertion accounted for 27%. Even more striking was the finding that five attitudes and beliefs about themselves, their illness, and their response to treatment accounted for 48% of the variance. In an interventional study, Agle and associates studied 21 veterans with COPD who were given an intensive four-week inpatient rehabilitation program and followed for one yearA ° In 18 of the patients, significant functional improvement occurred that correlated with psychological changes but not with physical changes. The 21 patients accounted for 30 pulmonary admissions in the year before the intervention but only five admissions during the follow-up year. CONCLUSION We found that psychosocial factors were important in distinguishing patients with decompensated chronic obstructive pulmonary disease who relapse from those who do not. If confirmed by other studies, a more comprehensive treatment approach 1115/95
RETURN VISITS Stehr, Klein & Murata
appears to be indicated. Providing psychological support or enrollment in a pulmonary rehabilitation program might prove to be more effective than changing the drug regimen in a relapse patient. REFERENCES 1. Pierce JM, Kellerman AL, Oster C: "Bounces": An analysis of short-term return visits to a public hospital emergency department. Ann Emerg Med 1990;19: 752-757.
2. Keith ED, Bocka JJ, Kobernick MS, et al: Emergency department revisits. Ann Emerg Med 1989;18:964-968.
7. Rutter BM: The prognostic significance of psychological factors in the management of chronic bronchitis. Psycho] Med 1979;9:63-70.
3. Lerman B, Kobemick MS: Return visits to the emergency department. J Emerg Med 1987;5:359-362.
8. Morgan AD, Peck DF, Buchanan DR, et al: Effect of attitudes and beliefs on exercise tolerance in chronic bronchitis. Br Med J 1983;286:171 173.
4. Jaeoby LE, Jones SL: Factors associated with ED use by "repeater" and "nonrepeater" patients, fEN 1982~8: 243-247.
9. Cupples LA, Heeren T, Schatzkin A, et ai: Multiple testing of hypotheses in comparing two groups. Ann Intern Med 1984;100:122-129.
5. Murata GH, Gorby MS, Chick TW, et al: Use of emergency medical services by patients with decompensated obstructive lung disease. Ann Emerg Med 1989;18: 501-506.
10. Agle DP, Baum GL, Chester EH, et al: Multidiscipline t r e a t m e n t of chronic p u l m o n a r y insufficiency: 1. Psychologic aspects of rehabilitation. Psychosore Med 1973;35:41-49.
6. Burns BH, Howell JBL: Disproportionately severe breathlessness in chronic bronchitis. Q [ Med 1969;38: 277-294.
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