General practitioners' home visit tendency and readmission-free survival after COPD hospitalisation: a Danish nationwide cohort study

Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review

Patients with chronic obstructive pulmonary disease (COPD) experience high rates of hospital readmissions, placing substantial clinical and economic strain on the healthcare system. Therefore, it is essential to implement evidence-based strategies for preventing these readmissions. The primary objective of our systematic review was to identify and describe the domains of existing primary research on strategies aimed at reducing hospital readmissions among adult patients with COPD. We also aimed to identify existing gaps in the literature to facilitate future research efforts. A total of 843 studies were captured by the initial search and 96 were included in the final review (25 randomized controlled trials, 37 observational studies, and 34 non-randomized interventional studies). Of the included studies, 72% (n = 69) were considered low risk of bias. The majority of included studies (n = 76) evaluated patient-level readmission prevention strategies (medication and other treatments (n = 25), multi-modal (n = 19), follow-up (n = 16), telehealth (n = 8), education and coaching (n = 8)). Fewer assessed broader system- (n = 13) and policy-level (n = 7) strategies. We observed a trend toward reduced all-cause readmissions with the use of medication and other treatments, as well as a trend toward reduced COPD-related readmissions with the use of multi-modal and broader scale system-level interventions. Notably, much of this evidence supported shorter-term (30-day) readmission outcomes, while little evidence was available for longer-term outcomes. These findings should be interpreted with caution, as considerable between-study heterogeneity was also identified. Overall, this review identified several evidence-based interventions for reducing readmissions among patients with COPD that should be targeted for future research.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1955338 .

Readmission-Free Survival Analysis in Metastatic Spine Tumour Surgical Patients: A Novel Concept

BACKGROUND

Outcomes commonly used to ascertain success of metastatic spine tumour surgery (MSTS) are 30-day complications/mortality and overall/disease-free survival. We believe a new, effective outcome indicator after MSTS would be the absence of unplanned hospital readmission (UHR) after index discharge. We introduce the concept of readmission-free survival (ReAFS), defined as 'the time duration between hospital discharge after index operation and first UHR or death'. The aim of this study is to identify factors influencing ReAFS in MSTS patients.

PATIENTS AND METHODS

We retrospectively analysed 266 consecutive patients who underwent MSTS between 2005 and 2016. Demographics, oncological characteristics, procedural, preoperative and postoperative details were collected. ReAFS of patients within 2 years or until death was reviewed. Perioperative factors predictive of reduced ReAFS were evaluated using multivariate regression analysis.

RESULTS

Of 266 patients, 230 met criteria for analysis. A total of 201 had UHR, whilst 1 in 8 (29/230) had no UHR. Multivariate analysis revealed that haemoglobin ≥ 12 g/dL, ECOG score of ≤ 2, primary prostate, breast and haematological cancers, comorbidities ≤ 3, absence of preoperative radiotherapy and shorter postoperative length of stay significantly prolonged the time to first UHR.

CONCLUSIONS

Readmission-free survival is a novel concept in MSTS, which relies on patients' general condition, appropriateness of interventional procedures and underlying disease burden. Additionally, it may indicate the successful combination of a multi-disciplinary treatment approach. This information will allow oncologists and surgeons to identify patients who may benefit from increased surveillance following discharge to increase ReAFS. We envisage that ReAFS is a concept that can be extended to other surgical oncological fields.

Frailty characteristics and preventive home visits: an audit on elderly patients in Danish general practice

AIM

Preventive home visits (PHVs) to frail elderly patients, provided by the GP, have been widely promoted in many health care systems, including the Danish system. This study investigates to what extent PHVs are provided to patients with characteristics of frailty.

METHODS

During a four-week period, GPs and their staff in three different parts of Denmark filled in a questionnaire for each patient aged 75 years or older who attended the clinic or received a home visit. The association between 20 different frailty characteristics and the receipt of a PHV was assessed through logistic regression.

RESULTS

A total of 73 GPs and 41 staff members sampled information about 3133 patients, of whom 332 patients (10.7%) had received a PHV within one year prior to their audit date. A PHV was closely associated with the patient's number of frailty characteristics. The adjusted odds ratios show that the receipt of a PHV was associated with a low walking distance 2.34 (1.65-3.31), dementia 3.35 (2.26-4.96), depression 2.24 (1.38-3.63) and a need for home care 3.40 (2.45-4.73), and increased with the GP's tendency to provide PHVs.

CONCLUSION

Most PHV-receiving elderly patients have several characteristics of frailty, the most significant being impaired mobility, dementia, depression and a need for home care. PHVs are also more often provided to patients listed with a GP who has an overall high tendency to conduct these visits.

COPD Readmissions: Addressing COPD in the Era of Value-based Health Care

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.

Quaternary prevention, an answer of family doctors to overmedicalization

In response to the questioning of Health Policy and Management (HPAM) by colleagues on the role of rank and file family physicians in the same journal, the author, a family physician in Belgium, is trying to highlight the complexity and depth of the work of his colleagues and their contribution to the understanding of the organization and economy of healthcare. It addresses, in particular, the management of health elements throughout the ongoing relationship of the family doctor with his/her patients. It shows how the three dimensions of prevention, clearly included in the daily work, are complemented with the fourth dimension, quaternary prevention or prevention of medicine itself, whose understanding could help to control the economic and human costs of healthcare.