51
|
Parekh TM, Bhatt SP, Westfall AO, Wells JM, Kirkpatrick D, Iyer AS, Mugavero M, Willig JH, Dransfield MT. Implications of DRG Classification in a Bundled Payment Initiative for COPD. AMERICAN JOURNAL OF ACCOUNTABLE CARE 2017; 5:12-18. [PMID: 29623307 PMCID: PMC5881946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Institutions participating in the Medicare Bundled Payments for Care Improvement (BPCI) initiative invest significantly in efforts to reduce readmissions and costs for patients who are included in the program. Eligibility for the BPCI initiative is determined by diagnosis-related group (DRG) classification. The implications of this methodology for chronic diseases are not known. We hypothesized that patients included in a BPCI initiative for chronic obstructive pulmonary disease (COPD) would have less severe illness and decreased hospital utilization compared with those excluded from the bundled payment initiative. STUDY DESIGN Retrospective observational study. METHODS We sought to determine the clinical characteristics and outcomes of Medicare patients admitted to the University of Alabama at Birmingham Hospital with acute exacerbations of COPD between 2012 and 2014 who were included and excluded in a BPCI initiative. Patients were included in the analysis if they were discharged with a COPD DRG or with a non-COPD DRG but with an International Classification of Diseases, Ninth Revision code for COPD exacerbation. RESULTS Six hundred and ninety-eight unique patients were discharged for an acute exacerbation of COPD; 239 (34.2%) were not classified into a COPD DRG and thus were excluded from the BPCI initiative. These patients were more likely to have intensive care unit (ICU) admissions (63.2% vs 4.4%, respectively; P <.001) and require noninvasive (46.9% vs 6.5%; P <.001) and invasive mechanical ventilation (41.4% vs 0.7%; P <.001) during their hospitalization than those in the initiative. They also had a longer ICU length of stay (5.2 vs 1.8 days; P = .011), longer hospital length of stay (10.3 days vs 3.9 days; P <.001), higher in-hospital mortality (14.6% vs 0.7%; P <.001), and greater hospitalization costs (median = $13,677 [interquartile range = $7489-$23,054] vs $4281 [$2718-$6537]; P <.001). CONCLUSIONS The use of DRGs to identify patients with COPD for inclusion in the BPCI initiative led to the exclusion of more than one-third of patients with acute exacerbations who had more severe illness and worse outcomes and who may benefit most from the additional interventions provided by the initiative.
Collapse
Affiliation(s)
- Trisha M Parekh
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Surya P Bhatt
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Andrew O Westfall
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - James M Wells
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Denay Kirkpatrick
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Anand S Iyer
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Michael Mugavero
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - James H Willig
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| | - Mark T Dransfield
- Department of Medicine (TMP, SPB, JMW, dK, ASI, MM, JHW, MTD), and Division of Pulmonary, Allergy, and Critical Care (TMP, SPB, JMW, dK, ASI, MTD), and Division of Infectious Diseases (MM, JHW), University of Alabama at Birmingham, Birmingham, AL; UAB Lung Health Center (TMP, SPB, JMW, dK, ASI, MTD), Birmingham, AL; Department of Biostatistics (AOW), and Department of Health Behavior (MM), University of Alabama School of Public Health, Birmingham, AL; Birmingham VA Medical Center (JMW, MTD), Birmingham, AL
| |
Collapse
|
52
|
Effectiveness of case management in the prevention of COPD re-admissions: a pilot study. BMC Res Notes 2017; 10:621. [PMID: 29178934 PMCID: PMC5702099 DOI: 10.1186/s13104-017-2946-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/17/2017] [Indexed: 11/17/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) exacerbations are associated with high disease burden and costs, especially in the case of hospitalizations. The overall number of hospital admissions due to exacerbations of COPD has increased. It is remarkable that re-admissions account for a substantial part of these hospitalizations. This pilot study investigates the use of case management to reduce re-admissions due to COPD. Methods COPD patients with more than one hospitalization per year due to an exacerbation were included. The participants (n = 10) were closely monitored and intensively coached for 20 weeks after hospitalization. The case manager provided care in a person-focused manner. The case manager informed and supported the patient, took action when relapse threatened, coordinated and connected primary and secondary care. Data of 12 months before and after start of the intervention were compared. Primary outcome was the difference in number of hospitalizations. Secondary outcomes were health-related quality of life (measured by the Clinical COPD Questionnaire, CCQ) and dyspnoea (measured by the MRC Dyspnoea Scale). Results The incidence rate of hospitalizations was found to be 2.25 times higher (95% confidence interval [CI] 1.3–3.9; P = 0.004) 12 months before compared with 12 months after the start of case management. COPD patients had a mean CCQ score of 3.3 (95% CI 2.8–3.8) before and 2.4 (95% CI 1.9–2.8) after 20 weeks of case management; a difference of 1.0 (95% CI 0.4–1.6; P = 0.001). The mean MRC scores showed no significant differences before (4.3; 95% CI 3.7–4.9) and after the case management period (3.9; 95% CI 3.2–4.6); a difference of 0.4 (95% CI − 0.1 to 0.9; P = 0.114). Conclusions This pilot study shows that the number of COPD hospital re-admissions decreased significantly after the introduction of a case manager. Moreover, there was an improvement in patient-reported health-related quality of life. Electronic supplementary material The online version of this article (10.1186/s13104-017-2946-5) contains supplementary material, which is available to authorized users.
Collapse
|
53
|
Boyle J, Speroff T, Worley K, Cao A, Goggins K, Dittus RS, Kripalani S. Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients. J Hosp Med 2017; 12:918-924. [PMID: 29091980 DOI: 10.12788/jhm.2841] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the association of health literacy with the number and type of transitional care needs (TCN) among patients being discharged to home. DESIGN, SETTING, PARTICIPANTS A cross-sectional analysis of patients admitted to an academic medical center. MEASUREMENTS Nurses administered the Brief Health Literacy Screen and documented TCNs along 10 domains: caregiver support, transportation, healthcare utilization, high-risk medical comorbidities, medication management, medical devices, functional status, mental health comorbidities, communication, and financial resources. RESULTS Among the 384 patients analyzed, 113 (29%) had inadequate health literacy. Patients with inadequate health literacy had needs in more TCN domains (mean = 5.29 vs 4.36; P < 0 .001). In unadjusted analysis, patients with inadequate health literacy were significantly more likely to have TCNs in 7 out of the 10 domains. In multivariate analyses, inadequate health literacy remained significantly associated with inadequate caregiver support (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.37-4.99) and transportation barriers (OR, 1.69; 95% CI, 1.04-2.76). CONCLUSIONS Among hospitalized patients, inadequate health literacy is prevalent and independently associated with other needs that place patients at a higher risk of adverse outcomes, such as hospital readmission. Screening for inadequate health literacy and associated needs may enable hospitals to address these barriers and improve postdischarge outcomes.
Collapse
Affiliation(s)
- Joseph Boyle
- School of Graduate Medical Education, University of Colorado, Aurora, Colorado, USA
| | - Theodore Speroff
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katherine Worley
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aize Cao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn Goggins
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert S Dittus
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
54
|
Mantero M, Rogliani P, Di Pasquale M, Polverino E, Crisafulli E, Guerrero M, Gramegna A, Cazzola M, Blasi F. Acute exacerbations of COPD: risk factors for failure and relapse. Int J Chron Obstruct Pulmon Dis 2017; 12:2687-2693. [PMID: 28932112 PMCID: PMC5598966 DOI: 10.2147/copd.s145253] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Acute exacerbations are a leading cause of worsening COPD in terms of lung function decline, quality of life, and survival. They also have a relevant economic burden on the health care system. Determining the risk factors for acute exacerbation and early relapse could be a crucial element for a better management of COPD patients. This review analyzes the current knowledge and underlines the main risk factors for recurrent acute exacerbations. Comprehensive evaluation of COPD patients during stable phase and exacerbation could contribute to prevent treatment failure and relapses.
Collapse
Affiliation(s)
- Marco Mantero
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
| | - Paola Rogliani
- Respiratory Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marta Di Pasquale
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
| | - Eva Polverino
- Respiratory Disease Department, Servei de Pneumologia, Hospital Universitari Vall d'Hebron (HUVH), Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain
| | - Ernesto Crisafulli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Monica Guerrero
- Hospital d'Igualada, Consorci Socisanitari de l'Anoia, Barcelona, Spain
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
| | - Mario Cazzola
- Respiratory Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano.,Internal Medicine Department, Respiratory Unit and Regional Adult Cystic Fibrosis Center, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan
| |
Collapse
|
55
|
Lau CS, Siracuse BL, Chamberlain RS. Readmission After COPD Exacerbation Scale: determining 30-day readmission risk for COPD patients. Int J Chron Obstruct Pulmon Dis 2017; 12:1891-1902. [PMID: 28721034 PMCID: PMC5500510 DOI: 10.2147/copd.s136768] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND COPD affects over 13 million Americans, and accounts for over half a million hospitalizations annually. The Hospital Readmission Reduction Program, established by the Affordable Care Act requires the Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions for COPD as of 2015. This study sought to develop a predictive readmission scale to identify COPD patients at higher readmission risk. METHODS Demographic and clinical data on 339,389 patients from New York and California (derivation cohort) and 258,113 patients from Washington and Florida (validation cohort) were abstracted from the State Inpatient Database (2006-2011), and the Readmission After COPD Exacerbation (RACE) Scale was developed to predict 30-day readmission risk. RESULTS Thirty-day COPD readmission rates were 7.54% for the derivation cohort and 6.70% for the validation cohort. Factors including age 40-65 years (odds ratio [OR] 1.17; 95% CI, 1.12-1.21), male gender (OR 1.16; 95% CI, 1.13-1.19), African American (OR 1.11; 95% CI, 1.06-1.16), 1st income quartile (OR 1.10; 95% CI, 1.06-1.15), 2nd income quartile (OR 1.06; 95% CI, 1.02-1.10), Medicaid insured (OR 1.83; 95% CI, 1.73-1.93), Medicare insured (OR 1.45; 95% CI, 1.38-1.52), anemia (OR 1.05; 95% CI, 1.02-1.09), congestive heart failure (OR 1.06; 95% CI, 1.02-1.09), depression (OR 1.18; 95% CI, 1.14-1.23), drug abuse (OR 1.17; 95% CI, 1.09-1.25), and psychoses (OR 1.19; 95% CI, 1.13-1.25) were independently associated with increased readmission rates, P<0.01. When the devised RACE scale was applied to both cohorts together, it explained 92.3% of readmission variability. CONCLUSION The RACE Scale reliably predicts an individual patient's 30-day COPD readmission risk based on specific factors present at initial admission. By identifying these patients at high risk of readmission with the RACE Scale, patient-specific readmission-reduction strategies can be implemented to improve patient care as well as reduce readmissions and health care expenditures.
Collapse
Affiliation(s)
- Christine Sm Lau
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA.,Saint George's University School of Medicine, Grenada, West Indies
| | - Brianna L Siracuse
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Ronald S Chamberlain
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA.,Saint George's University School of Medicine, Grenada, West Indies.,Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA.,Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| |
Collapse
|
56
|
Liu M, Zhang Y, Li DD, Sun J. Transitional care interventions to reduce readmission in patients with chronic obstructive pulmonary disease: A meta-analysis of randomized controlled trials. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.cnre.2017.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
57
|
García-Sanz MT, Cánive-Gómez JC, Senín-Rial L, Aboal-Viñas J, Barreiro-García A, López-Val E, González-Barcala FJ. One-year and long-term mortality in patients hospitalized for chronic obstructive pulmonary disease. J Thorac Dis 2017; 9:636-645. [PMID: 28449471 DOI: 10.21037/jtd.2017.03.34] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Identifying potentially-modifiable predictors of mortality could help optimize COPD patient management. The aim of this study is to determine long-term mortality following hospitalization due to acute exacerbations of COPD (AECOPD), as well as AECOPD mortality predictors. METHODS We conducted a retrospective study by reviewing the medical records of all patients admitted with AECOPD in the University Hospital Complex of Santiago de Compostela in 2007 and 2008. In order to identify variables independently associated with mortality, we conducted a multivariate Cox proportional hazard regression analysis including those variables which proved to be significant in the univariate analysis. RESULTS Seven hundred and fifty seven patients were assessed. Patient mean age was 74.8 years and males accounted for 77% of all patients. Mean stay was 12.2 days. Three point six percent of all patients required intensive care. As for mortality rates, 1-year mortality was 26.2%, and 5-year mortality was 64.3%. In both scenarios, the most frequent causes of death were respiratory and cardiovascular disorders. Factors independently associated with mortality were older age, hospitalization by internal medicine (IMU), length of stay, the need for mechanical ventilation (MV) or noninvasive mechanical ventilation (NIV), early readmission, and history of atrial fibrillation (AF) and dementia. CONCLUSIONS In patients with COPD, age, exacerbation severity and comorbidity have long-term prognostic significance.
Collapse
Affiliation(s)
| | | | - Laura Senín-Rial
- Nursing Staff, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Jorge Aboal-Viñas
- Regional Department of Health, San Caetano s/n, Santiago de Compostela, Spain
| | | | - Eva López-Val
- Nursing Staff, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Francisco-Javier González-Barcala
- Medicine Department, University of Santiago de Compostela, Santiago de Compostela, Spain.,Spanish Biomedical Research Networking Centre-CIBERES, Santiago de Compostela, Spain.,Respiratory Medicine Department, University Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| |
Collapse
|
58
|
Bishwakarma R, Zhang W, Kuo YF, Sharma G. Long-acting bronchodilators with or without inhaled corticosteroids and 30-day readmission in patients hospitalized for COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:477-486. [PMID: 28203071 PMCID: PMC5293361 DOI: 10.2147/copd.s122354] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The ability of a long-acting muscarinic antagonist (LAMA) and long-acting beta 2 agonists (LABAs; long-acting bronchodilators, LABDs) with or without inhaled corticosteroids (ICSs) to reduce early readmission in hospitalized patients with COPD is unknown. METHODS We studied a 5% sample of Medicare beneficiaries enrolled in Medicare parts A, B and D and hospitalized for COPD in 2011. We examined prescriptions filled for LABDs with or without ICSs (LABDs±ICSs) within 90 days prior to and 30 days after hospitalization. Primary outcome was the 30-day readmission rate between "users" and "nonusers" of LABDs±ICSs. Propensity score matching and sensitivity analysis were performed by limiting analysis to patients hospitalized for acute exacerbation of COPD (AECOPD). Among 6,066 patients hospitalized for COPD, 3,747 (61.8%) used LABDs±ICSs during the specified period. The "user" and "nonuser" groups had similar rates of all-cause emergency room (ER) visits and readmissions within 30 days of discharge date (22.4% vs 20.7%, P-value 0.11; 18.0% vs 17.8%, P-value 0.85, respectively). However, the "users" had higher rates of COPD-related ER visits (5.3% vs 3.4%, P-value 0.0006), higher adjusted odds ratio (aOR) 1.47 (95% CI, 1.11-1.93) and readmission (7.8% vs 5.0%, P-value <0.0001 and aOR 1.48 [95% CI, 1.18-1.86]) than "nonusers". After propensity score matching, the aOR of COPD-related ER visits was 1.45 (95% CI, 1.07-1.96) and that of readmission was 1.34 (95% CI, 1.04-1.73). The results were similar when restricted to patients hospitalized for AECOPD. CONCLUSION Use of LABDs±ICSs did not reduce 30-day readmissions in patients hospitalized for COPD.
Collapse
Affiliation(s)
- Raju Bishwakarma
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine
| | - Wei Zhang
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine
| | - Yong-Fang Kuo
- Office of Biostatistics
- Sealy Center of Aging, University of Texas Medical Branch, Galveston, TX, USA
| | - Gulshan Sharma
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine
- Sealy Center of Aging, University of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
59
|
Prognostic factors after hospitalization for COPD exacerbation. Rev Mal Respir 2017; 34:1-18. [DOI: 10.1016/j.rmr.2016.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/26/2016] [Indexed: 11/21/2022]
|
60
|
Wise RA, Acevedo RA, Anzueto AR, Hanania NA, Martinez FJ, Ohar JA, Tashkin DP. Guiding Principles for the Use of Nebulized Long-Acting Beta2-Agonists in Patients with COPD: An Expert Panel Consensus. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 4:7-20. [PMID: 28848907 DOI: 10.15326/jcopdf.4.1.2016.0141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Determining which patients with COPD may benefit from a nebulized long-acting beta2-agonist (LABA) is a challenge in current practice. In the absence of strong clinical guidelines addressing this issue, an expert panel convened to develop guiding principles for the use of nebulized LABA therapy in patients with COPD. This article summarizes these guiding principles and other practical issues discussed during a roundtable meeting.
Collapse
Affiliation(s)
- Robert A Wise
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Antonio R Anzueto
- University of Texas Health Science Center, and South Texas Veterans Health Care System, San Antonio, Texas
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Jill A Ohar
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Donald P Tashkin
- David Geffen School of Medicine at the University of California, Los Angeles
| |
Collapse
|
61
|
Jacob J, Tost J, Miró Ò, Herrero P, Martín-Sánchez FJ, Llorens P. Impact of chronic obstructive pulmonary disease on clinical course after an episode of acute heart failure. EAHFE-COPD study. Int J Cardiol 2016; 227:450-456. [PMID: 27838130 DOI: 10.1016/j.ijcard.2016.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To study if the coexistence of chronic obstructive pulmonary disease (COPD) in patients diagnosed with acute heart failure (AHF) at the emergency department (ED) has an impact on short- and long-term outcomes. METHOD The EAHFE-COPD study included patients who attended in 34 Spanish EDs for AHF. We compared patients with AHF plus COPD with patients with AHF in whom COPD was neither diagnosed nor excluded by functional respiratory tests (FRT). Outcome analysis included all-cause mortality, prolonged hospitalization, and ED revisit. Crude results were adjusted by differences between patients with and without COPD. RESULTS We included 8099 patients with AHF, 2069 having COPD (25.6%; AHF-COPD-known). Compared with AHF-COPD-unknown, AHF-COPD-known differed in 20 variables. After adjusting for differences between the two groups, AHF-COPD-known patients showed no significant differences in 30-day mortality (OR=0.89; 95% CI=0.71-1.11), prolonged hospitalization in general wards (OR=1.04; 95% CI=0.89-1.22) or SSU (OR=1.38; 95% CI=0.97-1.97), and 1-year mortality (HR: 1.02; 95% CI=0.89-1.17), but showed a higher 30-day revisit rate (OR=1.32; 95% CI=1.13-1.54). CONCLUSIONS In patients attending the ED for AHF, the coexistence of COPD is only associated with an increased risk of short-term ED revisit, but not prolonged hospitalization and short- or long-term mortality.
Collapse
Affiliation(s)
- Javier Jacob
- Servicio de Urgencias, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Josep Tost
- Servicio de Urgencias, Consorci Sanitari de Terrassa, Terrassa, Barcelona, Spain
| | - Òscar Miró
- Área de Urgencias, Hospital Clínic, Barcelona, Spain; Grupo de investigación "Urgencias: procesos y patologías", IDIBAPS, Barcelona, Spain
| | - Pablo Herrero
- Servicio de Urgencias, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Francisco Javier Martín-Sánchez
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Pere Llorens
- Servicio de Urgencias-UCE y UHD, Hospital General Universitario de Alicante, Alicante, Spain
| | | |
Collapse
|
62
|
Micek ST, Samant M, Bailey T, Chen Y, Lu C, Heard K, Kollef MH. Real-time automated clinical deterioration alerts predict thirty-day hospital readmission. J Hosp Med 2016; 11:768-772. [PMID: 27256009 PMCID: PMC5309927 DOI: 10.1002/jhm.2617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/05/2016] [Accepted: 04/19/2016] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Clinical deterioration alerts (CDAs) are increasingly employed to identify deteriorating patients. METHODS We performed a retrospective study to determine whether CDAs predict 30-day readmission. Patients admitted to 8 general medicine units were assessed for all-cause 30-day readmission. RESULTS Among 3015 patients, 567 (18.8%) were readmitted within 30 days. Patients triggering a CDA (n = 1141; 34.4%) were more likely to have a 30-day readmission (23.6% vs 15.9%; P < 0.001). Logistic regression identified triggering of a CDA to be independently associated with 30-day readmission (odds ratio [OR]: 1.40; 95% confidence interval [CI]: 1.26-1.55; P = 0.001). Other predictors were: an emergency department visit in the previous 6 months (OR: 1.23; 95% CI:, 1.20-1.26; P < 0.001), increasing age (OR: 1.01; 95% CI: 1.01-1.02; P = 0.003), presence of connective tissue disease (OR: 1.63; 95% CI: 1.34-1.98; P = 0.012), diabetes mellitus with end-organ complications (OR: 1.23; 95% CI: 1.13-1.33; P = 0.010), chronic renal disease (OR: 1.16; 95% CI: 1.08-1.24; P = 0.034), cirrhosis (OR: 1.25; 95% CI: 1.17-1.33; P < 0.001), and metastatic cancer (OR: 1.12; 95% CI: 1.08-1.17; P = 0.002). Addition of the CDA to the other predictors added only modest incremental value for the prediction of hospital readmission. CONCLUSIONS Readily identifiable clinical variables can be identified that predict 30-day readmission. It may be important to include these variables in existing prediction tools if pay for performance and across-institution comparisons are to be "fair" to institutions that care for more seriously ill patients. Journal of Hospital Medicine 2016;11:768-772. © 2016 Society of Hospital Medicine.
Collapse
Affiliation(s)
- Scott T Micek
- Department of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, Missouri
| | - Maanasi Samant
- Department of Internal Medicine, Washington University, St. Louis, Missouri
| | - Thomas Bailey
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Yixin Chen
- School of Engineering and Applied Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Chenyang Lu
- School of Engineering and Applied Sciences, Washington University in St. Louis, St. Louis, Missouri
| | - Kevin Heard
- Center for Clinical Excellence, BJC HealthCare, St. Louis, Missouri
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri.
| |
Collapse
|
63
|
Wang H, Johnson C, Robinson RD, Nejtek VA, Schrader CD, Leuck J, Umejiego J, Trop A, Delaney KA, Zenarosa NR. Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions. BMC Health Serv Res 2016; 16:564. [PMID: 27724889 PMCID: PMC5057382 DOI: 10.1186/s12913-016-1814-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 10/01/2016] [Indexed: 11/24/2022] Open
Abstract
Background Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission. Methods Hospital readmission data were reviewed retrospectively from September 2012 through June 2015. Patient demographics and clinical variables including insurance type, homeless status, substance abuse, psychiatric problems, length of stay, SOI, ROM, ICD-10 diagnoses and medications prescribed at discharge, and prescription ratio at discharge (number of medications prescribed divided by number of ICD-10 diagnoses) were analyzed using logistic regression. Relationships among SOI, type of hospital visits, time between hospital visits, and readmissions were also investigated. Results A total of 6011 readmissions occurred from 55,532 index admissions. The adjusted odds ratios of SOI and ROM predicting readmissions were 1.31 (SOI: 95 % CI 1.25–1.38) and 1.09 (ROM: 95 % CI 1.05–1.14) separately. Ninety percent (5381/6011) of patients were readmitted from the Emergency Department (ED) or Urgent Care Center (UCC). Average time interval from index discharge date to ED/UCC visit was 9 days in both the no readmission and readmission groups (p > 0.05). Similar hospital readmission rates were noted during the first 10 days from index discharge regardless of whether post-index discharge patient clinic visits occurred when time-to-event analysis was performed. Conclusions SOI and ROM significantly predict hospital readmission risk in general. Most readmissions occurred among patients presenting for ED/UCC visits after index discharge. Simply providing early post-discharge follow-up clinic visits does not seem to prevent hospital readmissions.
Collapse
Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA.
| | - Carol Johnson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Vicki A Nejtek
- Institute for Health Aging, Center for Alzheimer's and Neurodegenerative Disease Research, University of North Texas Health Science Center, 3500 Camp Bowie Blvd., Fort Worth, TX, 76107, USA
| | - Chet D Schrader
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - JoAnna Leuck
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Johnbosco Umejiego
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Allison Trop
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Kathleen A Delaney
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| |
Collapse
|
64
|
Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD Readmissions: Addressing COPD in the Era of Value-based Health Care. Chest 2016; 150:916-926. [PMID: 27167208 PMCID: PMC5812767 DOI: 10.1016/j.chest.2016.05.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/19/2016] [Accepted: 05/01/2016] [Indexed: 11/17/2022] Open
Abstract
Of those patients hospitalized for an exacerbation of COPD, one in five will require rehospitalization within 30 days. Many developed countries are now implementing policies to increase care quality while controlling costs for COPD, known as value-based health care. In the United States, COPD is part of Medicare's Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals for excess 30-day, all-cause readmissions after a hospitalization for an acute exacerbation of COPD, despite minimal evidence to guide hospitals on how to reduce readmissions. This review outlines challenges for improving overall COPD care quality and specifically for the HRRP. These challenges include heterogeneity in the literature for how COPD and readmissions are defined, difficulty finding the target population during hospitalizations, and a lack of literature to guide evidence-based programs for COPD readmissions as defined by the HRRP in the hospital setting. It then identifies risk factors for early readmissions after acute exacerbation of COPD and discusses tested and emerging strategies to reduce these readmissions. Finally, we evaluate the current HRRP and future policy changes and their effect on the goal to deliver value-based COPD care. COPD remains a chronic disease with a high prevalence that has finally garnered the attention of health systems and policy makers, but we still have a long way to go to truly deliver value-based care to patients.
Collapse
Affiliation(s)
- Tina Shah
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago, Chicago, IL
| | - Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
| |
Collapse
|
65
|
Gulcev M, Reilly C, Griffin TJ, Broeckling CD, Sandri BJ, Witthuhn BA, Hodgson SW, Woodruff PG, Wendt CH. Tryptophan catabolism in acute exacerbations of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2016; 11:2435-2446. [PMID: 27729784 PMCID: PMC5047709 DOI: 10.2147/copd.s107844] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Introduction Exacerbations are a leading cause of morbidity in COPD. The objective of this study was to identify metabolomic biomarkers of acute exacerbations of COPD (AECOPD). Methods We measured metabolites via mass spectrometry (MS) in plasma drawn within 24 hours of admission to the hospital for 33 patients with an AECOPD (day 0) and 30 days later and for 65 matched controls. Individual metabolites were measured via selective reaction monitoring with mass spectrometry. We used a mixed-effect model to compare metabolite levels in cases compared to controls and a paired t-test to test for differences between days 0 and 30 in the AECOPD group. Results We identified 377 analytes at a false discovery rate of 5% that differed between cases (day 0) and controls, and 31 analytes that differed in the AECOPD cases between day 0 and day 30 (false discovery rate: 5%). Tryptophan was decreased at day 0 of AECOPD compared to controls corresponding to an increase in indoleamine 2,3-dioxygenase activity. Conclusion Patients with AECOPD have a unique metabolomic signature that includes a decrease in tryptophan levels consistent with an increase in indoleamine 2,3-dioxygenase activity.
Collapse
Affiliation(s)
| | - Cavan Reilly
- Division of Biostatistics, School of Public Health
| | - Timothy J Griffin
- Department of Biochemistry, Molecular Biology and Biophysics, University of Minnesota, Minneapolis, MN, USA
| | - Corey D Broeckling
- Department of Computer Science, Colorado State University, Fort Collins, CO, USA
| | | | - Bruce A Witthuhn
- Department of Biochemistry, Molecular Biology and Biophysics, University of Minnesota, Minneapolis, MN, USA
| | | | - Prescott G Woodruff
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine and the CVRI, University of California, San Francisco, CA, USA
| | - Chris H Wendt
- Department of Medicine; Department of Medicine, Minneapolis VA Medical Center, Minneapolis, MN, USA
| |
Collapse
|
66
|
Abstract
In recent years, thousands of publications on chronic obstructive pulmonary disease (COPD) and its related biology have entered the world literature, reflecting the increasing scientific and medical interest in this devastating condition. This article is a selective review of several important emerging themes that offer the hope of creating new classes of COPD medicines. Whereas basic science is parsing molecular pathways in COPD, its comorbidities, and asthma COPD overlap syndrome (ACOS) with unprecedented sophistication, clinical translation is disappointingly slow. The article therefore also considers solutions to current difficulties that are impeding progress in translating insights from basic science into clinically useful treatments.
Collapse
Affiliation(s)
- Gary P Anderson
- Lung Health Research Centre, Faculty of Medicine, University of Melbourne, Parkville, VIC, Australia; Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
67
|
Evaluation of Chronic Obstructive Pulmonary Disease (COPD) and reduced ejection fraction heart failure (HFrEF) discharge medication prescribing: Is drug therapy concordant with national guidelines associated with a reduction in 30-day readmissions? Respir Med 2016; 119:135-140. [PMID: 27692135 DOI: 10.1016/j.rmed.2016.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 09/04/2016] [Accepted: 09/06/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Approximately 1 in 5 hospitalized COPD patients are readmitted within 30 days of discharge. CHF coexists in more than 20% of patients with COPD, and is associated with early readmission for COPD. Reducing 30-day hospital readmissions for COPD is of intense current interest. METHODOLOGY A retrospective chart review was performed to identify patients discharged with COPD exacerbation and HFrEF. The primary objective was to evaluate if discharge medication prescribing following guidelines for both COPD and HFrEF correlates with reduced 30-day readmission rates. RESULTS The study included 281 admissions with 39.1% prescribed appropriate discharge medications for both COPD and HFrEF; 30-day readmission rate was 24.5% for these patients compared to 31.1% that were not prescribed appropriate medications (p = 0.24). Beta blockers, ACE inhibitors or ARBS, and aldosterone antagonists were under-prescribed, but this did not significantly associate with increased readmission (p = 0.51, p = 0.23 or 0.99, and p = 0.18, respectively). Those prescribed hydralazine or nitrates were more likely to readmit (both p = 0.01). Diabetes and hyperlipidemia were associated with increased readmission (p = 0.01 and 0.05). CONCLUSIONS This study did not show a significant difference in 30-day readmission rate based on appropriate discharge medications for both COPD and HFrEF. The comorbidities diabetes and hyperlipidemia and prescription of hydralazine or nitrates were significantly associated with increased readmission rate. Larger patient populations may be needed to assess if guideline based discharge medication prescribing is associated with reduced 30-day readmissions for COPD.
Collapse
|
68
|
Simmering JE, Polgreen LA, Comellas AP, Cavanaugh JE, Polgreen PM. Identifying Patients With COPD at High Risk of Readmission. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 3:729-738. [PMID: 28848899 DOI: 10.15326/jcopdf.3.4.2016.0136] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Readmission within 30 days of a COPD hospitalization is a common measure of performance for COPD care. However, most studies of COPD readmission risk have been constrained to a single data source, private payer claims, or Medicare claims data, making it difficult to generalize results from these studies to other populations. The purpose of this study was to examine the risk for readmission within 30 days from time of discharge in patients with COPD using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database for California for the years 2005-2011. This statewide dataset allows us to consider all readmissions for COPD regardless of age or payer status. Methods: The total dataset included 28,265,070 visits among 17,918,374 patients over 480 hospitals. We identified patients with a hospitalization, a primary diagnosis related to COPD, age 40 or older, and discharged alive. We found 286,313 hospitalizations that matched this definition and included information on covariates such as comorbidities, age, and insurance status. To characterize the joint associations of these covariates with readmission within 30 days, we used a generalized linear model. Results: Patients aged 40-64 are more likely to be readmitted to the hospital within 30 days of a COPD-related hospitalization than patients 65 and older. This effect persists after adjustment for patient severity, comorbidities, payer, and demographics. Our model featured an interaction of age with insurance type. We found that younger patients (aged 40-64) on public insurance have the highest readmission rates: 14.77% for Medicare and 16.27% for Medicaid. However, younger patients with private insurance have the lowest readmission rates at 8.25%. Additional significant covariates included whether or not the patient left against medical advice, and diagnoses of congestive heart failure and diabetes. In addition, we found that although admissions for COPD were highest in the winter, this is not true for COPD readmissions, which peak in summer. Also, inpatient mortality for patients admitted for COPD decreased from approximately 3% to 1.25% over the study period. Conclusion: Our results demonstrate that many of the risk factors for readmission may be dependent on the data source used. Furthermore, many of the strongest predictors are clearly related to the patients themselves. This observation may help explain why prior programs to reduce readmissions have had limited success.
Collapse
Affiliation(s)
- Jacob E Simmering
- University of Iowa, Department of Pharmacy Practice and Science, Iowa City
| | - Linnea A Polgreen
- University of Iowa, Department of Pharmacy Practice and Science, Iowa City
| | | | | | | |
Collapse
|
69
|
Maneechotesuwan K, Kasetsinsombat K, Wongkajornsilp A, Barnes PJ. Simvastatin up-regulates adenosine deaminase and suppresses osteopontin expression in COPD patients through an IL-13-dependent mechanism. Respir Res 2016; 17:104. [PMID: 27557561 PMCID: PMC4997725 DOI: 10.1186/s12931-016-0424-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/20/2016] [Indexed: 01/23/2023] Open
Abstract
Background Adenosine deaminase (ADA) and osteopontin (OPN) may play opposing roles in the pathogenesis of COPD. Deficiency of ADA results in enhanced adenosine signaling which up-regulates OPN expression. Although statins suppress OPN in cancer cells, little is known about their effects on ADA and OPN in COPD patients. Methods We extended a previous randomized double-blind placebo crossover study to investigate the effects of simvastatin (20 mg/day) on sputum ADA and OPN expression and explored the underlying signaling pathways involved by conducting in vitro experiments with cigarette smoke extract (CSE)-treated monocyte-derived macrophages (MDM) from COPD patients and healthy subjects. Results Simvastatin decreased sputum IL-13, OPN and CD73, while increasing ADA expression, irrespective of inhaled corticosteroid treatment and smoking status in parallel to increased inosine levels. The degree of simvastatin-restored ADA activity was significantly correlated with the magnitude of changes in pre-bronchodilator FEV1. Mechanistic exploration showed that CSE enhanced the expression of IL-13, which induced an increase in OPN and inhibited ADA mRNA accumulation in MDM from COPD patients but not healthy subjects through a STAT6-dependent mechanism. Simvastatin treatment inhibited IL-13 transcription in a dose-dependent manner, and therefore diminished the IL-13-induced increase in OPN and restored IL-13-suppressed ADA. There was no effect of simvastatin on adenosine receptors in CSE-stimulated MDM, indicating that its effects were on the adenosine pathway. Conclusion Simvastatin reversed IL-13-suppressed ADA activity that leads to the down-regulation of adenosine signaling and therefore inhibits OPN expression through the direct inhibition of IL-13-activated STAT6 pathway. Inhibition of IL-13 may reverse the imbalance between ADA and OPN in COPD and therefore may prevent COPD progression. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0424-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kittipong Maneechotesuwan
- Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkok, 10700, Thailand.
| | - Kanda Kasetsinsombat
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Adisak Wongkajornsilp
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peter J Barnes
- Airway Section, National Heart and Lung Institute, Imperial College, London, UK
| |
Collapse
|
70
|
Chronic Obstructive Pulmonary Disease Rehospitalization. A Big Problem that Now Needs Solutions. Ann Am Thorac Soc 2016; 12:1741-2. [PMID: 26653184 DOI: 10.1513/annalsats.201510-687ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
71
|
Soltani A, Reid D, Wills K, Walters EH. Prospective outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease presenting to hospital: a generalisable clinical audit. Intern Med J 2016; 45:925-33. [PMID: 26010582 DOI: 10.1111/imj.12816] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 05/11/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM To determine predictors of short- and long-term outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) (AECOPD) presenting to hospital. METHODS A prospective clinical audit of AECOPD attendances to the only public acute general hospital in Southern Tasmania, Australia. Out of 416 attendances with AECOPD to the emergency department (ED) between November 2006 and July 2008, 150 patients with 218 attendances were followed to March 2009. Predictors of hospital admission from ED, in-hospital death, length of hospital stay, post-discharge mortality and re-attendance rate for AECOPD were the main outcomes. RESULTS There were no clear differences between patients admitted to hospital and those sent home from ED. Predictors of in-hospital death were initial physiologic parameters, that is, arterial pH, PaCO2 , oxygen saturation and blood pressure. Longer hospital stay was associated with older age, current smoking, hyperglycaemia, lower blood pressure and lower oxygen saturation. Risk of mortality after discharge was associated with a history of myocardial infarction, nursing home residence and severity of COPD. Re-attendance rate was associated with osteoporosis, younger age and severity of COPD. CONCLUSIONS Further investigation into the process of decision making about which AECOPD patients are admitted from the ED is required. Short-term outcomes, in-hospital death and length of hospital stay are mainly predicted by severity of the acute exacerbation and patient demographics. Although severity of COPD was a predictor of long-term outcomes, the main predictors of these were presence of co-morbidities.
Collapse
Affiliation(s)
- A Soltani
- NHMRC Centre of Research Excellence for Chronic Respiratory Disease, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - D Reid
- NHMRC Centre of Research Excellence for Chronic Respiratory Disease, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia.,Queensland Institute of Medical Research, Brisbane, Queensland, Australia
| | - K Wills
- NHMRC Centre of Research Excellence for Chronic Respiratory Disease, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - E H Walters
- NHMRC Centre of Research Excellence for Chronic Respiratory Disease, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| |
Collapse
|
72
|
Abstract
PURPOSE OF REVIEW This article examines factors associated with readmission for chronic obstructive pulmonary disease and interventions that may decrease readmissions. RECENT FINDINGS The literature on this topic is relatively sparse. Drug therapy revolves around appropriate use of bronchodilators, antibiotics, and steroids. Patient education and participation and a multidisciplinary approach to the transition out of hospital can lead to decreased rehospitalizations. Patients who cannot participate in self-care may do better in skilled nursing facilities. SUMMARY We must optimize in-hospital care and see that patients receive a continuum of care upon discharge. We must also recognize that some patients have received optimal care and yet continue to suffer with end-stage disease on an ongoing basis; palliative medications such as long-acting narcotics and end-of-life discussions need to be considered in patients unable to survive for long outside of hospital.
Collapse
|
73
|
Zhou H, Della PR, Roberts P, Goh L, Dhaliwal SS. Utility of models to predict 28-day or 30-day unplanned hospital readmissions: an updated systematic review. BMJ Open 2016; 6:e011060. [PMID: 27354072 PMCID: PMC4932323 DOI: 10.1136/bmjopen-2016-011060] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To update previous systematic review of predictive models for 28-day or 30-day unplanned hospital readmissions. DESIGN Systematic review. SETTING/DATA SOURCE CINAHL, Embase, MEDLINE from 2011 to 2015. PARTICIPANTS All studies of 28-day and 30-day readmission predictive model. OUTCOME MEASURES Characteristics of the included studies, performance of the identified predictive models and key predictive variables included in the models. RESULTS Of 7310 records, a total of 60 studies with 73 unique predictive models met the inclusion criteria. The utilisation outcome of the models included all-cause readmissions, cardiovascular disease including pneumonia, medical conditions, surgical conditions and mental health condition-related readmissions. Overall, a wide-range C-statistic was reported in 56/60 studies (0.21-0.88). 11 of 13 predictive models for medical condition-related readmissions were found to have consistent moderate discrimination ability (C-statistic ≥0.7). Only two models were designed for the potentially preventable/avoidable readmissions and had C-statistic >0.8. The variables 'comorbidities', 'length of stay' and 'previous admissions' were frequently cited across 73 models. The variables 'laboratory tests' and 'medication' had more weight in the models for cardiovascular disease and medical condition-related readmissions. CONCLUSIONS The predictive models which focused on general medical condition-related unplanned hospital readmissions reported moderate discriminative ability. Two models for potentially preventable/avoidable readmissions showed high discriminative ability. This updated systematic review, however, found inconsistent performance across the included unique 73 risk predictive models. It is critical to define clearly the utilisation outcomes and the type of accessible data source before the selection of the predictive model. Rigorous validation of the predictive models with moderate-to-high discriminative ability is essential, especially for the two models for the potentially preventable/avoidable readmissions. Given the limited available evidence, the development of a predictive model specifically for paediatric 28-day all-cause, unplanned hospital readmissions is a high priority.
Collapse
Affiliation(s)
- Huaqiong Zhou
- Clinical Nurse, General Surgical Ward, Princess Margaret Hospital for Children, Perth, Western Australia, Australia School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Phillip R Della
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Pamela Roberts
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Louise Goh
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Satvinder S Dhaliwal
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
74
|
|
75
|
Han MK, Martinez CH, Au DH, Bourbeau J, Boyd CM, Branson R, Criner GJ, Kalhan R, Kallstrom TJ, King A, Krishnan JA, Lareau SC, Lee TA, Lindell K, Mannino DM, Martinez FJ, Meldrum C, Press VG, Thomashow B, Tycon L, Sullivan JL, Walsh J, Wilson KC, Wright J, Yawn B, Zueger PM, Bhatt SP, Dransfield MT. Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective. THE LANCET RESPIRATORY MEDICINE 2016; 4:473-526. [PMID: 27185520 DOI: 10.1016/s2213-2600(16)00094-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 12/21/2022]
Abstract
The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.
Collapse
Affiliation(s)
- MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Carlos H Martinez
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - David H Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, and VA Puget Sound Health Care System, US Department of Veteran Affairs, Seattle, WA, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Jean Bourbeau
- McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard Branson
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital & Health Sciences System, University of Illinois, Chicago, IL, USA
| | - Suzanne C Lareau
- University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL, USA
| | | | - David M Mannino
- Department of Preventive Medicine and Environmental Health, University of Kentucky, Lexington, KY, USA
| | - Fernando J Martinez
- Department of Internal Medicine, Weill Cornell School of Medicine, New York, NY, USA
| | - Catherine Meldrum
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Byron Thomashow
- Division of Pulmonary, Critical Care and Sleep Medicine, Columbia University Medical Center, New York, NY, USA
| | - Laura Tycon
- Palliative and Supportive Institute, Pittsburgh, PA, USA
| | | | | | - Kevin C Wilson
- Boston University School of Medicine, Boston, MA, USA; American Thoracic Society, New York, NY, USA
| | - Jean Wright
- Carolinas HealthCare System, Charlotte, NC, USA
| | - Barbara Yawn
- Family and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Patrick M Zueger
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
| |
Collapse
|
76
|
Howard ML, Vincent AH. Statin Effects on Exacerbation Rates, Mortality, and Inflammatory Markers in Patients with Chronic Obstructive Pulmonary Disease: A Review of Prospective Studies. Pharmacotherapy 2016; 36:536-47. [PMID: 26990316 DOI: 10.1002/phar.1740] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a debilitating, irreversible disease with currently available therapies targeting symptom control and exacerbation reduction. A need for alternative disease-modifying therapies remains, specifically those that may have antiinflammatory and immunomodulatory properties that impact the pathophysiologic components of COPD. Statin drugs, the current gold standard for the treatment of dyslipidemia and prevention of cardiovascular disease (CVD), contain properties that affect the inflammatory disease processes seen in COPD. Several retrospective studies have demonstrated that statins may have a benefit in the reduction of morbidity and mortality in patients with COPD. This has led to prospective trials evaluating the impact of statins on various COPD-related outcomes. This article reviews the current body of prospective evidence for use of statins in patients with COPD. A search of the PubMed/Medline database of English-language articles was conducted from 1964 through November 2015; references of relevant articles were also reviewed for qualifying studies. Prospective studies of all types relating to statin use in patients with COPD were included if they had COPD- or respiratory-related outcomes; ultimately, eight studies were identified for this review. Statin effects on exacerbation rates, mortality, and inflammatory markers in patients with COPD are discussed. Strong prospective evidence does not currently exist to suggest that statins provide a clinical benefit in patients with COPD who do not have other CVD risk factors. Benefits from statins that have been illustrated are likely explained by their impact on underlying CVD risk factors rather than the COPD disease process. An opportunity exists for unanswered questions to be addressed in future studies.
Collapse
Affiliation(s)
- Meredith L Howard
- Department of Pharmacotherapy, University of North Texas System College of Pharmacy, Fort Worth, TX
| | - Ashley H Vincent
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN.,Department of Pharmacy, Methodist Hospital, Indiana University Health, Indianapolis, IN
| |
Collapse
|
77
|
Jacobs MR, Rastogi A, Criner GJ. Hospitalizations and ED Visits in COPD: A Collision of Socioeconomic Realities with Chronic Comorbid Medical Illnesses. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 3:509-511. [PMID: 28848875 DOI: 10.15326/jcopdf.3.2.2016.0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Michael R Jacobs
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.,Department of Pharmacy Practice, School of Pharmacy, Temple University, Philadelphia, Pennsylvania
| | - Abhinav Rastogi
- Pulmonary Service Line and Project Management Office, Temple University Hospital, Philadelphia, Pennsylvania
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| |
Collapse
|
78
|
Guerrero M, Crisafulli E, Liapikou A, Huerta A, Gabarrús A, Chetta A, Soler N, Torres A. Readmission for Acute Exacerbation within 30 Days of Discharge Is Associated with a Subsequent Progressive Increase in Mortality Risk in COPD Patients: A Long-Term Observational Study. PLoS One 2016; 11:e0150737. [PMID: 26943928 PMCID: PMC4778849 DOI: 10.1371/journal.pone.0150737] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/18/2016] [Indexed: 01/10/2023] Open
Abstract
Background and Objective Twenty per cent of chronic obstructive pulmonary disease (COPD) patients are readmitted for acute exacerbation (AECOPD) within 30 days of discharge. The prognostic significance of early readmission is not fully understood. The objective of our study was to estimate the mortality risk associated with readmission for acute exacerbation within 30 days of discharge in COPD patients. Methods The cohort (n = 378) was divided into patients readmitted (n = 68) and not readmitted (n = 310) within 30 days of discharge. Clinical, laboratory, microbiological, and severity data were evaluated at admission and during hospital stay, and mortality data were recorded at four time points during follow-up: 30 days, 6 months, 1 year and 3 years. Results Patients readmitted within 30 days had poorer lung function, worse dyspnea perception and higher clinical severity. Two or more prior AECOPD (HR, 2.47; 95% CI, 1.51–4.05) was the only variable independently associated with 30-day readmission. The mortality risk during the follow-up period showed a progressive increase in patients readmitted within 30 days in comparison to patients not readmitted; moreover, 30-day readmission was an independent risk factor for mortality at 1 year (HR, 2.48; 95% CI, 1.10–5.59). In patients readmitted within 30 days, the estimated absolute increase in the mortality risk was 4% at 30 days (number needed to harm NNH, 25), 17% at 6-months (NNH, 6), 19% at 1-year (NNH, 6) and 24% at 3 years (NNH, 5). Conclusion In conclusion a readmission for AECOPD within 30 days is associated with a progressive increased long-term risk of death.
Collapse
Affiliation(s)
- Mónica Guerrero
- Respiratory Department, Clinic Institute of Respiratory (ICR), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques Agusti Pi i Sunyer (IDIBAPS) - CIBERES - University of Barcelona (UB), Barcelona, Spain
| | - Ernesto Crisafulli
- Department of Clinical and Experimental Medicine, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | | | - Arturo Huerta
- Respiratory Department, Clinic Institute of Respiratory (ICR), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques Agusti Pi i Sunyer (IDIBAPS) - CIBERES - University of Barcelona (UB), Barcelona, Spain
| | - Albert Gabarrús
- Respiratory Department, Clinic Institute of Respiratory (ICR), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques Agusti Pi i Sunyer (IDIBAPS) - CIBERES - University of Barcelona (UB), Barcelona, Spain
| | - Alfredo Chetta
- Department of Clinical and Experimental Medicine, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Nestor Soler
- Respiratory Department, Clinic Institute of Respiratory (ICR), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques Agusti Pi i Sunyer (IDIBAPS) - CIBERES - University of Barcelona (UB), Barcelona, Spain
| | - Antoni Torres
- Respiratory Department, Clinic Institute of Respiratory (ICR), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques Agusti Pi i Sunyer (IDIBAPS) - CIBERES - University of Barcelona (UB), Barcelona, Spain
- * E-mail:
| |
Collapse
|
79
|
Singh G, Zhang W, Kuo YF, Sharma G. Association of Psychological Disorders With 30-Day Readmission Rates in Patients With COPD. Chest 2016. [PMID: 26204260 DOI: 10.1378/chest.15-0449] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is a growing understanding of the prevalence and impact of psychological disorders on COPD. However, the role of these disorders in early readmission is unclear. METHODS We analyzed data from 5% fee-for-service Medicare beneficiaries diagnosed with COPD (International Classification of Diseases, Ninth Revision code, 491.xx, 492.xx, 493.xx, and 496.xx) between 2001 and 2011 who were hospitalized with a primary discharge diagnosis of COPD or a primary discharge diagnosis of respiratory failure (518.xx and 799.1) with secondary diagnosis of COPD. We hypothesized that such psychological disorders as depression, anxiety, psychosis, alcohol abuse, and drug abuse are independently associated with an increased risk of 30-day readmission in patients hospitalized for COPD. RESULTS Between 2001 and 2011, 135,498 hospitalizations occurred for COPD in 80,088 fee-for-service Medicare beneficiaries. Of these, 30,218 (22.30%) patients had one or more psychological disorders. In multivariate analyses, odds of 30-day readmission were higher in patients with COPD who had depression (OR, 1.34; 95% CI, 1.29-1.39), anxiety (OR, 1.43; 95% CI, 1.37-1.50), psychosis (OR, 1.18; 95% CI, 1.10-1.27), alcohol abuse (OR, 1.30; 95% CI, 1.15-1.47), and drug abuse (OR, 1.29; 95% CI, 1.11-1.50) compared with those who did not have these disorders. These psychological disorders increased amount of variation in 30-day readmission attributed to patient characteristics by 37%. CONCLUSIONS Psychological disorders like depression, anxiety, psychosis, alcohol abuse, and drug abuse are independently associated with higher all-cause 30-day readmission rates for Medicare beneficiaries with COPD.
Collapse
Affiliation(s)
- Gurinder Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX.
| | - Wei Zhang
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Yong-Fang Kuo
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX; Sealy Center of Aging, University of Texas Medical Branch, Galveston, TX
| | - Gulshan Sharma
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center of Aging, University of Texas Medical Branch, Galveston, TX
| |
Collapse
|
80
|
Adamson SL, Burns J, Camp PG, Sin DD, van Eeden SF. Impact of individualized care on readmissions after a hospitalization for acute exacerbation of COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:61-71. [PMID: 26792986 PMCID: PMC4708191 DOI: 10.2147/copd.s93322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) increase COPD morbidity and mortality and impose a great burden on health care systems. Early readmission following a hospitalization for AECOPD remains an important clinical problem. We examined how individualized comprehensive care influences readmissions following an index hospital admission for AECOPD. METHODS We retrospectively reviewed data of patients admitted for AECOPD to two inner-city teaching hospitals to determine the impact of a comprehensive and individualized care management strategy on readmissions for AECOPD. The control group consisted of 271 patients whose index AECOPD occurred the year before the comprehensive program, and the experimental group consisted of 191 patients who received the comprehensive care. The primary outcome measure was the total number of readmissions in 30- and 90-day postindex hospitalizations. Secondary outcome measures included the length of time between the index admission and first readmission and all-cause mortality. RESULTS The two groups were similar in terms of age, sex, forced expiratory volume in 1 second, body mass index (BMI), pack-years, and the number and types of comorbidities. Comprehensive care significantly reduced 90-day readmission rates in females (P=0.0205, corrected for age, BMI, number of comorbidities, substance abuse, and mental illness) but not in males or in the whole group (P>0.05). The average times between index admission and first readmission were not different between the two groups. Post hoc multivariate analysis showed that substance abuse (P<0.01) increased 30- and 90-day readmissions (corrected for age, sex, BMI, number of comorbidities, and mental illness). The 90-day all-cause in-hospital mortality rates were significantly less in the care package group (2.67% versus 7.97%, P=0.0268). CONCLUSION Comprehensive individualized care for subjects admitted to hospital for AECOPD did not reduce 30- and 90-day readmission rates but did reduce 90-day total mortality. Interestingly, it reduced 90-day readmission rate in females. We speculate that an individualized care package could impact COPD morbidity and mortality after an acute exacerbation.
Collapse
Affiliation(s)
- Simon L Adamson
- The Centre for Heart Lung Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jane Burns
- The Centre for Heart Lung Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Pat G Camp
- The Centre for Heart Lung Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Don D Sin
- The Centre for Heart Lung Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
- Division of Respirology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Stephan F van Eeden
- The Centre for Heart Lung Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
- Division of Respirology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
81
|
Moy ML, Gould MK, Liu ILA, Lee JS, Nguyen HQ. Physical activity assessed in routine care predicts mortality after a COPD hospitalisation. ERJ Open Res 2016; 2:00062-2015. [PMID: 27730174 PMCID: PMC5005157 DOI: 10.1183/23120541.00062-2015] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 01/23/2016] [Indexed: 11/05/2022] Open
Abstract
The independent relationship between physical inactivity and risk of death after an index chronic obstructive pulmonary disease (COPD) hospitalisation is unknown. We conducted a retrospective cohort study in a large integrated healthcare system. Patients were included if they were hospitalised for COPD between January 1, 2011 and December 31, 2011. All-cause mortality in the 12 months after discharge was the primary outcome. Physical activity, expressed as self-reported minutes of moderate to vigorous physical activity (MVPA), was routinely assessed at outpatient visits prior to hospitalisation. 1727 (73%) patients were inactive (0 min of MVPA per week), 412 (17%) were insufficiently active (1-149 min of MVPA per week) and 231 (10%) were active (≥150 min of MVPA per week). Adjusted Cox regression models assessed risk of death across the MVPA categories. Among 2370 patients (55% females and mean age 73±11 years), there were 464 (20%) deaths. Patients who were insufficiently active or active had a 28% (adjusted HR 0.72 (95% CI 0.54-0.97), p=0.03) and 47% (adjusted HR 0.53 (95% CI 0.34-0.84), p<0.01) lower risk of death, respectively, in the 12 months following an index COPD hospitalisation compared to inactive patients. Any level of MVPA is associated with lower risk of all-cause mortality after a COPD hospitalisation. Routine assessment of physical activity in clinical care would identify persons at high risk for dying after COPD hospitalisation.
Collapse
Affiliation(s)
- Marilyn L. Moy
- VA Boston Healthcare System, Pulmonary and Critical Care Section, Harvard Medical School, Boston, MA, USA
| | - Michael K. Gould
- Dept of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - In-Lu Amy Liu
- Dept of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Janet S. Lee
- Dept of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Huong Q. Nguyen
- Dept of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| |
Collapse
|
82
|
Ruparel M, López-Campos JL, Castro-Acosta A, Hartl S, Pozo-Rodriguez F, Roberts CM. Understanding variation in length of hospital stay for COPD exacerbation: European COPD audit. ERJ Open Res 2016; 2:00034-2015. [PMID: 27730166 PMCID: PMC5005149 DOI: 10.1183/23120541.00034-2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 01/18/2016] [Indexed: 11/05/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) care across Europe has high heterogeneity with respect to cost and the services available. Variations in length of stay (LOS) may be attributed to patient characteristics, resource and organisational characteristics, and/or the so-called hospital cluster effect. The European COPD Audit in 13 countries included data from 16 018 hospitalised patients. The recorded variables included information on patient and disease characteristics, and resources available. Variables associated with LOS were evaluated by a multivariate, multilevel analysis. Mean±sd LOS was 8.7±8.3 days (median 7 days, interquartile range 4-11 days). Crude variability between countries was reduced after accounting for clinical factors and the clustering effect. The main factors associated with LOS being longer than the median were related to disease or exacerbation severity, including GOLD class IV (OR 1.77) and use of mechanical ventilation (OR 2.15). Few individual resource variables were associated with LOS after accounting for the hospital cluster effect. This study emphasises the importance of the patients' clinical severity at presentation in predicting LOS. Identifying patients at risk of a long hospital stay at admission and providing targeted interventions offers the potential to reduce LOS for these individuals. The complex interactions between factors and systems were more important that any single resource or organisational factor in determining differences in LOS between hospitals or countries.
Collapse
Affiliation(s)
| | - Jose Luis López-Campos
- Unidad Medico-Quirúrgica de Enfermedades Respiratorias/Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Ady Castro-Acosta
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación, Hospital 12 de Octubre, Madrid, Spain
| | - Sylvia Hartl
- Ludwig Boltzmann Institute of COPD and Respiratory Epidemiology, Otto Wagner Hospital, Vienna, Austria
| | - Francisco Pozo-Rodriguez
- Centre for Biomedical Research on Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación, Hospital 12 de Octubre, Madrid, Spain
| | - C. Michael Roberts
- Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| |
Collapse
|
83
|
Iwaoka M, Tsuji T. Twelve Weeks of Successful Smoking Cessation Therapy with Varenicline Reduces Spirometric Lung Age. Intern Med 2016; 55:2387-92. [PMID: 27580538 DOI: 10.2169/internalmedicine.55.6844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective We evaluated the short-term effects of smoking cessation therapy with varenicline on the lung function. Methods In this study, 81 subjects received 12 weeks of smoking cessation therapy with varenicline. No changes were made to any previously prescribed medications. A physical examination, blood sampling, and spirometry were performed at the first and last visit. Spirometric lung ages were calculated by a formula based on height and the forced expiratory volume in 1 second. The success group comprised 62 subjects who attained 4-week continuous abstinence confirmed by exhaled carbon monoxide testing; whereas the failure group comprised 19 subjects who did not attain this result. However, the number of cigarettes consumed per day was reduced in all subjects of the failure group. Results The spirometric lung ages significantly improved over the 12-week period in the success group (69.8±24.7 vs. 66.9±24.1, p<0.01); however, spirometric lung ages significantly deteriorated in the failure group (70.5±25.5 vs. 73.7±26.9, p<0.01). The effect sizes (Cohen's d) of spirometric lung age in the success and failure groups were 0.37 and 0.81, respectively. The post-hoc statistical power of the spirometric lung age in the success and failure groups was 0.83 and 0.91, respectively. According to a multiple regression analysis, success in smoking cessation exhibited an independent association with the difference in spirometric lung age between the last visit and baseline (p<0.01). Conclusion These findings suggest that successful smoking cessation therapy with varenicline improves the spirometric lung age in the short term.
Collapse
|
84
|
de Miguel-Díez J, Jiménez-García R, Hernández-Barrera V, Carrasco-Garrido P, Puente Maestu L, Ramírez García L, López de Andrés A. Readmissions following an initial hospitalization by COPD exacerbation in Spain from 2006 to 2012. Respirology 2015; 21:489-96. [DOI: 10.1111/resp.12705] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/02/2015] [Accepted: 09/15/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Javier de Miguel-Díez
- Pneumology Department, Hospital General Universitario Gregorio Marañón; Universidad Complutense de Madrid; Madrid Spain
| | - Rodrigo Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences; Universidad Rey Juan Carlos; Madrid Spain
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences; Universidad Rey Juan Carlos; Madrid Spain
| | - Pilar Carrasco-Garrido
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences; Universidad Rey Juan Carlos; Madrid Spain
| | - Luis Puente Maestu
- Pneumology Department, Hospital General Universitario Gregorio Marañón; Universidad Complutense de Madrid; Madrid Spain
| | - Laura Ramírez García
- Pneumology Department, Hospital General Universitario Gregorio Marañón; Universidad Complutense de Madrid; Madrid Spain
| | - Ana López de Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Department of Health Sciences; Universidad Rey Juan Carlos; Madrid Spain
| |
Collapse
|
85
|
Genao L, Durheim MT, Mi X, Todd JL, Whitson HE, Curtis LH. Early and Long-term Outcomes of Older Adults after Acute Care Encounters for Chronic Obstructive Pulmonary Disease Exacerbation. Ann Am Thorac Soc 2015; 12:1805-12. [PMID: 26394180 PMCID: PMC4722826 DOI: 10.1513/annalsats.201504-250oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/22/2015] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Older patients are at high risk of death and rehospitalization after hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD). Emergency department visits comprise a substantial portion of acute care encounters in this patient population. The risks of mortality and repeat acute care encounters, including both hospital readmission and repeat emergency department visits, after AE-COPD among older adults are not well understood. OBJECTIVES To examine early and long-term rates of death and repeat acute care encounters after hospitalization or emergency department visit for AE-COPD in Medicare fee-for-service beneficiaries and to identify patient characteristics, including medical comorbid conditions, associated with these outcomes. METHODS A retrospective analysis was conducted using a nationally representative 5% sample of Medicare fee-for-service claims data from the U.S. Centers for Medicare and Medicaid Services to identify Medicare beneficiaries 65 years or older who had an acute care episode for an AE-COPD between January 1, 2006, and December 31, 2010 (n = 52,741). Outcomes of interest were all-cause mortality, repeat acute care encounters for any cause, and repeat acute care encounters for AE-COPD at 30 days, 1 year, and 3 years. MEASUREMENTS AND MAIN RESULTS Acute care encounters, including hospitalizations and emergency department visits for AE-COPD, were associated with substantial subsequent mortality risk, with 4.6, 24.4, and 48.2% dying by 30 days, 1 year, and 3 years, respectively. The risk of repeat hospitalization or emergency department visit was similarly high, with 1 in 4 patients having a repeat acute care encounter within 30 days of discharge, increasing to 9 in 10 in the next 3 years. Several comorbid conditions and other patient factors, including heart failure, malnutrition, dual eligibility for Medicare and Medicaid, and prior supplemental oxygen use, were independently associated with increased risk of repeat acute care encounter. CONCLUSIONS Repeat hospitalizations and emergency department visits and death are common in older fee-for-service Medicare beneficiaries seen in acute care for AE-COPD. Our results suggest that addressing important comorbid conditions, such as heart failure or malnutrition, and targeting resources to oxygen-dependent or dual Medicare- and Medicaid-eligible patients may help modify these outcomes.
Collapse
Affiliation(s)
- Liza Genao
- Department of Medicine
- Durham VA Medical Center Geriatrics Research Education and Clinical Center, Durham, North Carolina
| | | | | | - Jamie L. Todd
- Department of Medicine
- Duke Clinical Research Institute, and
| | - Heather E. Whitson
- Department of Medicine
- Department of Ophthalmology
- Duke Aging Center, Duke University School of Medicine, Durham, North Carolina; and
- Durham VA Medical Center Geriatrics Research Education and Clinical Center, Durham, North Carolina
| | | |
Collapse
|
86
|
Maneechotesuwan K, Wongkajornsilp A, Adcock IM, Barnes PJ. Simvastatin Suppresses Airway IL-17 and Upregulates IL-10 in Patients With Stable COPD. Chest 2015; 148:1164-76. [PMID: 26043025 PMCID: PMC4631035 DOI: 10.1378/chest.14-3138] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/15/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Statins have immunomodulatory properties that may provide beneficial effects in the treatment of COPD. We investigated whether a statin improves the IL-17/IL-10 imbalance in patients with COPD, as has previously been demonstrated in patients with asthma. METHODS Thirty patients with stable COPD were recruited to a double-blind, randomized, controlled, crossover trial comparing the effect of simvastatin, 20 mg po daily, with that of a matched placebo on sputum inflammatory markers and airway inflammation. Each treatment was administered for 4 weeks separated by a 4-week washout period. The primary outcome was the presence of T-helper 17 cytokines and indoleamine 2,3-dioxygenase (IDO) in induced sputum. Secondary outcomes included sputum inflammatory cells, FEV1, and symptoms using the COPD Assessment Test (CAT). RESULTS At 4 weeks, there was a significant reduction in sputum IL-17A, IL-22, IL-6, and CXCL8 concentrations (mean difference, -16.4 pg/mL, P = .01; -48.6 pg/mL, P < .001; -45.3 pg/mL, P = .002; and -190.9 pg/mL, P = .007, respectively), whereas IL-10 concentrations, IDO messenger RNA expression (fold change), and IDO activity (kynurenine to tryptophan ratio) were markedly increased during simvastatin treatment compared with placebo treatment periods (mean difference, 24.7 pg/mL, P < .001; 1.02, P < .001; and 0.47, P < .001, respectively). The absolute sputum macrophage count, proportion of macrophages, and CAT score were reduced after simvastatin compared with placebo (mean difference, -0.16 × 106, P = .004; -14.1%, P < .001; and -3.2, P = .02, respectively). Values for other clinical outcomes were similar between the simvastatin and placebo treatments. CONCLUSIONS Simvastatin reversed the IL-17A/IL-10 imbalance in the airways and reduced sputum macrophage but not neutrophil counts in patients with COPD. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01944176; www.clinicaltrials.gov.
Collapse
|
87
|
Ambrosino N, Casaburi R, Chetta A, Clini E, Donner CF, Dreher M, Goldstein R, Jubran A, Nici L, Owen CA, Rochester C, Tobin MJ, Vagheggini G, Vitacca M, ZuWallack R. 8th international conference on management and rehabilitation of chronic respiratory failure: the long summaries – part 1. Multidiscip Respir Med 2015. [PMCID: PMC4595244 DOI: 10.1186/s40248-015-0026-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This paper summarizes the Part 1 of the proceedings of the 8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations. This paper (Part 1) includes sections regarding: Advances in Asthma and COPD Therapy (Novel Therapeutic Targets for Asthma: Proteinases, Blood Biomarker Changes in COPD Patients); The problem of Hospital Re-Admission following Discharge after the COPD Exacerbation (Characteristics of the Hospitalized COPD Patient, Reducing Hospital Readmissions Following COPD Exacerbation).
Collapse
|
88
|
Andruska A, Micek ST, Shindo Y, Hampton N, Colona B, McCormick S, Kollef MH. Pneumonia Pathogen Characterization Is an Independent Determinant of Hospital Readmission. Chest 2015; 148:103-111. [PMID: 25429607 PMCID: PMC7127757 DOI: 10.1378/chest.14-2129] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hospital readmissions for pneumonia occur often and are difficult to predict. For fiscal year 2013, the Centers for Medicare & Medicaid Services readmission penalties have been applied to acute myocardial infarction, heart failure, and pneumonia. However, the overall impact of pneumonia pathogen characterization on hospital readmission is undefined. METHODS This was a retrospective 6-year cohort study (August 2007 to September 2013). RESULTS We evaluated 9,624 patients with a discharge diagnosis of pneumonia. Among these patients, 4,432 (46.1%) were classified as having culture-negative pneumonia, 1,940 (20.2%) as having pneumonia caused by antibiotic-susceptible bacteria, 2,991 (31.1%) as having pneumonia caused by potentially antibiotic-resistant bacteria, and 261 (2.7%) as having viral pneumonia. The 90-day hospital readmission rate for survivors (n = 7,637, 79.4%) was greatest for patients with pneumonia attributed to potentially antibiotic-resistant bacteria (11.4%) followed by viral pneumonia (8.3%), pneumonia attributed to antibiotic-susceptible bacteria (6.6%), and culture-negative pneumonia (5.8%) (P < .001). Multiple logistic regression analysis identified pneumonia attributed to potentially antibiotic-resistant bacteria to be independently associated with 90-day readmission (OR, 1.75; 95% CI, 1.56-1.97; P < .001). Other independent predictors of 90-day readmission were Charlson comorbidity score > 4, cirrhosis, and chronic kidney disease. Culture-negative pneumonia was independently associated with lower risk for 90-day readmission. CONCLUSIONS Readmission after hospitalization for pneumonia is relatively common and is related to pneumonia pathogen characterization. Pneumonia attributed to potentially antibiotic-resistant bacteria is associated with an increased risk for 90-day readmission, whereas culture-negative pneumonia is associated with lower risk for 90-day readmission.
Collapse
Affiliation(s)
- Adam Andruska
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Yuichiro Shindo
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO; Institute for Advanced Research, Nagoya University, Nagoya, Japan
| | - Nicholas Hampton
- BJC Healthcare (Dr Hampton, Mr Colona, and Ms McCormick), Center for Clinical Excellence, St. Louis, MO
| | - Brian Colona
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Sandra McCormick
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
| |
Collapse
|
89
|
Candrilli SD, Dhamane AD, Meyers JL, Kaila S. Factors associated with inpatient readmission among managed care enrollees with COPD. Hosp Pract (1995) 2015; 43:199-207. [PMID: 26357878 DOI: 10.1080/21548331.2015.1085797] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess factors associated with inpatient readmission among a US managed care population with chronic obstructive pulmonary disease (COPD). BACKGROUND COPD is often accompanied by intermittent acute exacerbations, which may result in hospitalizations. These exacerbations are often associated with an increased frequency of subsequent exacerbations, which may lead to inpatient readmissions. METHODS We assessed US managed care claims data for enrollees≥40 years old with an inpatient admission with a primary diagnosis of COPD (ICD-9-CM codes 491.xx, 492.xx or 496.xx) between 1 January 2010 and 31 December 2013 (discharge date of first observed inpatient admission defined the "index date"). Patients were required to be continuously enrolled for ≥12 months before the index date. Two non-mutually exclusive cohorts were analyzed: (1) patients with ≥30 days of post-index date continuous enrollment (to evaluate 30-day readmission) and (2) patients with ≥90 days of post-index date continuous enrollment (to evaluate 90-day readmission). Logistic regression evaluated the association between patient characteristics and risk of 30- and 90-day COPD-related and all-cause readmission. RESULTS After applying selection criteria, 140,981 patients had ≥30 days of enrollment post-index date, and 123,545 patients had ≥90 days of enrollment post-index date. Within 30 days, nearly 20% of patients had an all-cause readmission and 7% had a COPD-related readmission. Within 90 days, 28% had an all-cause readmission and 12% had a COPD-related readmission. Logistic regression indicated that longer length of stay, older age, greater comorbidity burden, specific comorbidities and COPD complexity were associated with significantly greater odds of COPD-related 30- and 90-day readmission. Results for all-cause readmission were generally similar. CONCLUSIONS Many of the factors associated with inpatient readmission documented here can be ascertained at discharge and may be used to inform discharge plans, with the end goal of improving patient outcomes, including reducing the risk of readmission.
Collapse
Affiliation(s)
- Sean D Candrilli
- a 1 RTI Health Solutions , 200 Park Offices Dr., Research Triangle Park, NC 27709, USA
| | - Amol D Dhamane
- b 2 Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield, CT 06877, USA
| | - Juliana L Meyers
- a 1 RTI Health Solutions , 200 Park Offices Dr., Research Triangle Park, NC 27709, USA
| | - Shuchita Kaila
- b 2 Boehringer Ingelheim Pharmaceuticals, Inc. , Ridgefield, CT 06877, USA
| |
Collapse
|
90
|
Picker D, Heard K, Bailey TC, Martin NR, LaRossa GN, Kollef MH. The number of discharge medications predicts thirty-day hospital readmission: a cohort study. BMC Health Serv Res 2015; 15:282. [PMID: 26202163 PMCID: PMC4512093 DOI: 10.1186/s12913-015-0950-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 07/14/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hospital readmission occurs often and is difficult to predict. Polypharmacy has been identified as a potential risk factor for hospital readmission. However, the overall impact of the number of discharge medications on hospital readmission is still undefined. METHODS To determine whether the number of discharge medications is predictive of thirty-day readmission using a retrospective cohort study design performed at Barnes-Jewish Hospital from January 15, 2013 to May 9, 2013. The primary outcome assessed was thirty-day hospital readmission. We also assessed potential predictors of thirty-day readmission to include the number of discharge medications. RESULTS The final cohort had 5507 patients of which 1147 (20.8 %) were readmitted within thirty days of their hospital discharge date. The number of discharge medications was significantly greater for patients having a thirty-day readmission compared to those without a thirty-day readmission (7.2 ± 4.1 medications [7.0 medications (4.0 medications, 10.0 medications)] versus 6.0 ± 3.9 medications [6.0 medications (3.0 medications, 9.0 medications)]; P < 0.001). There was a statistically significant association between increasing numbers of discharge medications and the prevalence of thirty-day hospital readmission (P < 0.001). Multiple logistic regression identified more than six discharge medications to be independently associated with thirty-day readmission (OR, 1.26; 95 % CI, 1.17-1.36; P = 0.003). Other independent predictors of thirty-day readmission were: more than one emergency department visit in the previous six months, a minimum hemoglobin value less than or equal to 9 g/dL, presence of congestive heart failure, peripheral vascular disease, cirrhosis, and metastatic cancer. A risk score for thirty-day readmission derived from the logistic regression model had good predictive accuracy (AUROC = 0.661 [95 % CI, 0.643-0.679]). CONCLUSIONS The number of discharge medications is associated with the prevalence of thirty-day hospital readmission. A risk score, that includes the number of discharge medications, accurately predicts patients at risk for thirty-day readmission. Our findings suggest that relatively simple and accessible parameters can identify patients at high risk for hospital readmission potentially distinguishing such individuals for interventions to minimize readmissions.
Collapse
Affiliation(s)
- David Picker
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Kevin Heard
- Center for Clinical Excellence, BJC Learning Institute (BLI), 8300 Eager Road, St. Louis, MO, 63144, USA.
| | - Thomas C Bailey
- Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8051, St. Louis, MO, 63110, USA.
| | - Nathan R Martin
- Division of Hospital Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8058, St. Louis, MO, 63110, USA.
| | - Gina N LaRossa
- Division of Hospital Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8058, St. Louis, MO, 63110, USA.
| | - Marin H Kollef
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8052, St. Louis, MO, 63110, USA.
| |
Collapse
|
91
|
Predictors of Readmission in a Period of 30 Days or Less in Acute Exacerbation of Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2015. [DOI: 10.1097/cpm.0000000000000090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
92
|
Ford ES. Hospital discharges, readmissions, and ED visits for COPD or bronchiectasis among US adults: findings from the nationwide inpatient sample 2001-2012 and Nationwide Emergency Department Sample 2006-2011. Chest 2015; 147:989-998. [PMID: 25375955 DOI: 10.1378/chest.14-2146] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Numbers and rates of hospitalizations and ED visits by patients with COPD are important metrics for surveillance purposes. The objective of this study was to examine trends in these rates from 2001 to 2012 among adults aged ≥ 18 years in the United States. METHODS Data from the Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS) were examined for temporal trends in the numbers and rates of hospitalizations by patients with COPD or bronchiectasis, mean length of stay, in-hospital case-fatality rate, 30-day readmission rate, and numbers and rates of ED visits. RESULTS The national number of discharges with COPD or bronchiectasis as the principal diagnosis was about 88,000 higher in 2012 than in 2001, but the age-adjusted rate of discharges did not change significantly (range, 242.7-286.0 per 100,000 population, P trend = .554). In contrast, hospitalization rates for common cardiovascular disorders, pneumonia, and lung cancer decreased significantly by 27% to 68%, whereas the mean charge doubled and mean cost increased by 40%. From 2006 to 2011, the numbers of ED visits increased from 1,480,363 to 1,787,612. The age-adjusted rate increased nonsignificantly from 654 to 725 per 100,000 population (P trend = .072). CONCLUSIONS Despite many local and national efforts to reduce the burden of COPD, total hospitalizations and ED visits over the past decade have increased for COPD, and the age-adjusted rates of hospitalizations and ED visits for COPD or bronchiectasis have not changed significantly in the United States.
Collapse
Affiliation(s)
- Earl S Ford
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| |
Collapse
|
93
|
Cardiovascular and Pulmonary Research. Cardiopulm Phys Ther J 2015. [DOI: 10.1097/cpt.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
94
|
|
95
|
Affiliation(s)
- Sim Sai Tin
- Department of Biomedical Science, Medical Center, Shantou, China. E-mail:
| | - Viroj Wiwanitkita
- Department of Public Health Hainan Medical University, China; University of Nis, Serbia; Joseph Ayobabalola University, Nigeria; Surin Rajabhat University, Thailand; Dr. DY Patil Medical University, India
| |
Collapse
|
96
|
Nguyen HQ, Rondinelli J, Harrington A, Desai S, Amy Liu IL, Lee JS, Gould MK. Functional status at discharge and 30-day readmission risk in COPD. Respir Med 2015; 109:238-46. [DOI: 10.1016/j.rmed.2014.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 12/14/2014] [Accepted: 12/15/2014] [Indexed: 12/17/2022]
|
97
|
Bowles KH, Chittams J, Heil E, Topaz M, Rickard K, Bhasker M, Tanzer M, Behta M, Hanlon AL. Successful electronic implementation of discharge referral decision support has a positive impact on 30- and 60-day readmissions. Res Nurs Health 2015; 38:102-14. [PMID: 25620675 DOI: 10.1002/nur.21643] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/05/2022]
Abstract
In a quasi-experimental study, decision support software was installed in three hospitals to study the ability to scale (spread) its use from one hospital on paper to three hospitals as software, and to examine the effect on 30- and 60-day readmissions. The Discharge Decision Support System (D2S2) software analyzes data collected by nurses on admission with a proprietary risk assessment tool, identifies patients in need of post-acute care, and alerts discharge planners. On six intervention units, with a concurrent comparison group of 76 units, we examined the implementation experience and compared readmission outcomes before and after implementation. The software implementation finished one month ahead of schedule, and the software performed reliably. High-risk patients admitted in the experimental phase after implementation of D2S2 decision support had significantly fewer 30-day readmissions (a decrease from 22.2% to 9.4%). When high- and low-risk patients were analyzed together, D2S2 achieved a 33% relative reduction in 30-day readmissions (13.1 to 8.8%) and sustained a 37% relative reduction at 60 days. The software, available commercially through RightCare Solutions, was adopted by the health system and remains in use after 22 months. The D2S2 risk assessment tool can be installed easily in existing EHR systems. Future research will focus on how the tool influences discharge decision-making and how its accuracy can be improved in specific settings.
Collapse
Affiliation(s)
- Kathryn H Bowles
- Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA, 19104
| | | | | | | | | | | | | | | | | |
Collapse
|
98
|
Yu TC, Zhou H, Suh K, Arcona S. Assessing the importance of predictors in unplanned hospital readmissions for chronic obstructive pulmonary disease. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:37-51. [PMID: 25609986 PMCID: PMC4293216 DOI: 10.2147/ceor.s74181] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The all-cause readmission rate within 30 days of index admissions for chronic obstructive pulmonary disease (COPD) was approximately 21% in the United States in 2008. This study aimed to examine patient and clinical characteristics predicting 30-day unplanned readmissions for an initial COPD hospitalization and to determine those predictors' importance. PATIENTS AND METHODS A retrospective study was conducted in patients with COPD-related hospitalizations using commercial claims data from 2010 to 2012. The primary outcome was all-cause unplanned readmission, with secondary outcomes being COPD as primary diagnosis and COPD as any diagnosis unplanned readmissions. Factors predicting unplanned readmissions encompassed demographic, pharmacy, and medical variables identified at baseline and during the index hospitalization. Dominance analysis was conducted to rank the predictors in terms of importance, defined as the contribution to change in model fit of a predictor by itself and in combination with other predictors. RESULTS After applying the inclusion and exclusion criteria, 18,282 patients with index COPD-related admissions were identified. Among them, the rates of unplanned readmissions with COPD as primary diagnosis, COPD as any diagnosis, and all-cause were 2.6%, 5.6%, and 7.3%, respectively. For each outcome, the readmission group was slightly older, had a greater COPD severity score, and required a longer length of stay. Moreover, the readmission group had larger proportions of patients with comorbidities, dyspnea/shortness of breath, intensive care unit stay, or ventilator use, compared to the non-readmission group. Dominance analysis revealed that the three most important predictors - heart failure/heart disease, anemia, and COPD severity score - accounted for 56% of the predicted variance in all-cause unplanned readmissions. CONCLUSION Overall, COPD severity score and heart failure/heart disease emerged as important factors in predicting 30-day unplanned readmissions across all three outcomes. Results from dominance analysis suggest looking beyond COPD-specific complications and focusing on comorbid conditions highly associated with COPD in order to lower all-cause unplanned readmissions.
Collapse
Affiliation(s)
- Tzy-Chyi Yu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Kangho Suh
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Stephen Arcona
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| |
Collapse
|
99
|
Young RP, Hopkins RJ, Agusti A. Statins as adjunct therapy in COPD: how do we cope after STATCOPE? Thorax 2014; 69:891-4. [DOI: 10.1136/thoraxjnl-2014-205814] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|