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Bell J, Lim S, Mikami T, Bahk J, Argiro S, Steiger D. The impact on thirty day readmissions for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease admitted to an observation unit versus an inpatient medical unit: A retrospective observational study. Chron Respir Dis 2024; 21:14799731241242490. [PMID: 38545901 PMCID: PMC10981268 DOI: 10.1177/14799731241242490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/01/2023] [Accepted: 02/19/2024] [Indexed: 04/01/2024] Open
Abstract
OBJECTIVES We aimed to evaluate the utility of an Observation Unit (OU) in management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and to identify the clinical characteristics of patients readmitted within 30-days for AECOPD following index admission to the OU or inpatient floor from the OU. METHODS This is a retrospective observational study of patients admitted from January to December 2017 for AECOPD to an OU in an urban-based tertiary care hospital. Primary outcome was rate of 30-day readmission after admission for AECOPD for patients discharged from the OU versus inpatient service after failing OU management. Regression analyses were used to define risk factors. RESULTS 163 OU encounters from 92 unique patients were included. There was a lower readmission rate (33%) for patients converted from OU to inpatient care versus patients readmitted after direct discharge from the OU (44%). Patients with 30-day readmissions were more likely to be undomiciled, with history of congestive heart failure (CHF), pulmonary embolism (PE), or had previous admissions for AECOPD. Patients with >6 annual OU visits for AECOPD had higher rates of substance abuse, psychiatric diagnosis, and prior PE; when these patients were excluded, the 30-day readmission rate decreased to 13.5%. CONCLUSION Patients admitted for AECOPD with a history of PE, CHF, prior AECOPD admissions, and socioeconomic deprivation are at higher risk of readmission and should be prioritized for direct inpatient admission. Further prospective studies should be conducted to determine the clinical impact of this approach on readmission rates.
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Affiliation(s)
- Jacob Bell
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
- Department of Pulmonary and Critical Care Medicine, Mount Sinai West Hospital, New York, NY, USA
| | - Steven Lim
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
- Department of Pulmonary and Critical Care Medicine, Mount Sinai West Hospital, New York, NY, USA
| | - Takahisa Mikami
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Jeeyune Bahk
- Department of Internal Medicine, Mount Sinai West Hospital, New York, NY, USA
| | - Stephen Argiro
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - David Steiger
- Department of Pulmonary and Critical Care Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
- Department of Pulmonary and Critical Care Medicine, Mount Sinai West Hospital, New York, NY, USA
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Parrott TD, Wallace MD, Niehoff KM, Eble SH, Blumenfeld L, Sevin CM, Choma NN, Gao Y, Choi L, Lindsell CJ, Zuckerman AD. Pharmacist Review of Chronic Inhaler Therapy Appropriateness for Hospitalized Patients with COPD or Asthma. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2023; 6:1304-1312. [PMID: 38352722 PMCID: PMC10861239 DOI: 10.1002/jac5.1862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/06/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Patients with asthma and chronic obstructive pulmonary disease rely on inhaler therapy to reduce disease progression and exacerbation risk. Patients admitted to the hospital are at an increased risk for exacerbations and readmission if their inhaler therapy upon discharge is not aligned with current guidelines and/or affordable. OBJECTIVE Assess the appropriateness of the chronic inhaler regimen for patients admitted to the hospital based on clinical practice guidelines and insurance coverage. METHODS A sub-study was designed to analyze a cohort of a single-center, pragmatic, prospective randomized controlled trial at a large academic medical center. Patients admitted to a medicine service with a pharmacist and prescribed a long-acting inhaler were included. Participants randomized to a pharmacist-led intervention were assessed for inhaler appropriateness based on clinical guidelines and patient insurance. The objective of this sub-study is to assess the number of inhalers identified as inappropriate based on the pharmacist's review. A patient was considered to have an inappropriate inhaler regimen if any of their inhalers were inconsistent with guideline recommendations or not covered by insurance. Descriptive statistics were used to characterize appropriate inhaler use. RESULTS The study pharmacist reviewed 552 unique inhalers for 348 patients. Overall, 42% of inhalers were inappropriate, affecting 50.3% of participants. 20% of inhalers were inappropriate based on insurance, 26% were inappropriate based on guidelines, and 7% were inappropriate based on both criteria. Recommendations were placed via a pharmacy consult for 198 patients (57%), most recommending an inhaler initiation (55%), followed by inhaler discontinuation (38%). CONCLUSION A pharmacist-led review of chronic inhaler therapy for patients admitted to the hospital identified the need for a change in therapy based on financial or clinical guidelines in over half of the patients reviewed. Interventions to increase the appropriateness of prescribed inhalers are needed to reduce disease progression and disease exacerbation.
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Affiliation(s)
- Tate D Parrott
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232; 615-875-1537
| | - Matthew D Wallace
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232
| | - Kristina M Niehoff
- Vanderbilt Home Care Services, 2120 Belcourt Avenue, Nashville, TN 37212
| | - Sarah H Eble
- Vanderbilt Complex Care Service, Vanderbilt University Medical Center 1301 Medical Center Drive, Nashville, TN 37232
| | - Lauren Blumenfeld
- PGY-1 Pharmacy Resident, Veterans Affairs Tennessee Valley Healthcare System, 1310 24 Ave S, Nashville, TN 37212
| | - Carla M Sevin
- Pulmonary Patient Care Center, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, 1161 21 Avenue S, T-1218 MCN, Nashville, TN 37232
| | - Neesha N Choma
- Vanderbilt University Hospital & Clinics, 2135 Blakemore Avenue, Nashville, TN 37212; 615-343-1203; Department of Medicine, Department of Quality, Safety & Risk Prevention
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1100, Nashville, TN 37203
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1100, Nashville, TN 37203
| | | | - Autumn D Zuckerman
- Specialty Pharmacy Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232
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Atwood CE, Bhutani M, Ospina MB, Rowe BH, Leigh R, Deuchar L, Faris P, Michas M, Mrklas KJ, Graham J, Aceron R, Damant R, Green L, Hirani N, Longard K, Meyer V, Mitchell P, Tsai W, Walker B, Stickland MK. Optimizing COPD Acute Care Patient Outcomes Using a Standardized Transition Bundle and Care Coordinator. Chest 2022; 162:321-330. [DOI: 10.1016/j.chest.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/09/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022] Open
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Adeloye D, Elneima O, Daines L, Poinasamy K, Quint JK, Walker S, Brightling CE, Siddiqui S, Hurst JR, Chalmers JD, Pfeffer PE, Novotny P, Drake TM, Heaney LG, Rudan I, Sheikh A, De Soyza A. The long-term sequelae of COVID-19: an international consensus on research priorities for patients with pre-existing and new-onset airways disease. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1467-1478. [PMID: 34416191 PMCID: PMC8372501 DOI: 10.1016/s2213-2600(21)00286-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/22/2021] [Accepted: 06/07/2021] [Indexed: 12/21/2022]
Abstract
Persistent ill health after acute COVID-19-referred to as long COVID, the post-acute COVID-19 syndrome, or the post-COVID-19 condition-has emerged as a major concern. We undertook an international consensus exercise to identify research priorities with the aim of understanding the long-term effects of acute COVID-19, with a focus on people with pre-existing airways disease and the occurrence of new-onset airways disease and associated symptoms. 202 international experts were invited to submit a minimum of three research ideas. After a two-phase internal review process, a final list of 98 research topics was scored by 48 experts. Patients with pre-existing or post-COVID-19 airways disease contributed to the exercise by weighting selected criteria. The highest-ranked research idea focused on investigation of the relationship between prognostic scores at hospital admission and morbidity at 3 months and 12 months after hospital discharge in patients with and without pre-existing airways disease. High priority was also assigned to comparisons of the prevalence and severity of post-COVID-19 fatigue, sarcopenia, anxiety, depression, and risk of future cardiovascular complications in patients with and without pre-existing airways disease. Our approach has enabled development of a set of priorities that could inform future research studies and funding decisions. This prioritisation process could also be adapted to other, non-respiratory aspects of long COVID.
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Affiliation(s)
| | - Omer Elneima
- The Institute for Lung Health, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Luke Daines
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Jennifer K Quint
- National Heart & Lung Institute, Imperial College London, London, UK
| | | | - Chris E Brightling
- The Institute for Lung Health, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Salman Siddiqui
- The Institute for Lung Health, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | | | - Paul E Pfeffer
- Barts Health NHS Trust and Queen Mary University of London, London, UK
| | - Petr Novotny
- The Institute for Lung Health, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | | | - Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, N Ireland, UK
| | - Igor Rudan
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Anthony De Soyza
- Population Health Science Institute, NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle, UK.
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Myers LC, Cash R, Liu VX, Camargo CA. Reducing Readmissions for Chronic Obstructive Pulmonary Disease in Response to the Hospital Readmissions Reduction Program. Ann Am Thorac Soc 2021; 18:1506-1513. [PMID: 33476524 PMCID: PMC8489864 DOI: 10.1513/annalsats.202007-786oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/21/2021] [Indexed: 11/20/2022] Open
Abstract
Rationale: In August 2013, the Hospital Readmission Reduction Program announced financial penalties on hospitals with higher than expected risk-adjusted 30-day readmission rates for Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation. In October 2014, penalties were imposed. We hypothesized that penalties would be associated with decreased readmissions after COPD hospitalizations. Objectives: To determine whether the announcement and enactment of financial penalties for COPD were associated with decreases in hospital readmissions for COPD. Methods: We used data from California's Office of Statewide Health Planning and Development to examine unplanned 30-day all-cause and COPD-related readmissions after COPD hospitalization. The preannouncement period was January 2010 to July 2013. The postannouncement period was August 2013 to September 2014. The postenactment period was October 2014 to December 2017. Using interrupted time series, we investigated the immediate change after the intervention (level change) and differences in the preintervention and postintervention trends (slope change). Results: We identified 333,429 index hospitalizations for COPD from 449 California hospitals. Overall, 69% of patients had Medicare insurance. For all-cause readmissions, the level change at announcement was 0.16% (95% confidence interval [CI], -1.07 to 1.38; P = 0.80); the change in slope between preannouncement and postannouncement periods was -0.01% (95% CI, -0.15 to 0.13; P = 0.92). The level change at enactment was 0.29% (95% CI, -1.11 to 1.69; P = 0.68); the change in slope between postannouncement and postenactment was 0.04% (95% CI, -0.10 to 0.18; P = 0.57). For patients with COPD-related readmissions, the level change at the time of the announcement was 0.09% (95% CI, -0.68 to 0.85; P = 0.83); the change in slope was 0.003% (95% CI, -0.08 to 0.09; P = 0.94). The level change at the time of the enactment was 0.22% (95% CI, -0.69 to 1.12; P = 0.64); the change in slope was -0.02% (95% CI, -0.10 to 0.07; P = 0.72). Conclusions: We did not detect decreases in either all-cause or COPD-related readmission rates at either time point. Although this would suggest that the Hospital Readmission Reduction Program penalty was ineffective for COPD, COPD readmissions had decreased at an earlier time point (October 2012) when penalties were announced for conditions other than COPD. Based on this, we believe early, broad interventions decreased readmissions, such that no difference was seen at this later time points despite institution of COPD-specific penalties.
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Affiliation(s)
- Laura C. Myers
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Rebecca Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California; and
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Sharpe I, Bowman M, Kim A, Srivastava S, Jalink M, Wijeratne DT. Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review. COPD 2021; 18:456-468. [PMID: 34378468 DOI: 10.1080/15412555.2021.1955338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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 .
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Affiliation(s)
- Isobel Sharpe
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Meghan Bowman
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Andrew Kim
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Siddhartha Srivastava
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Matthew Jalink
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Don Thiwanka Wijeratne
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
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Heiden BT, Subramanian MP, Nava R, Patterson AG, Meyers BF, Puri V, Oncken C, Keith A, Guthrie TJ, Epstein DJ, Lenk MA, Kozower BD. Routine Collection of Patient Reported Outcomes in Thoracic Surgery: A Quality Improvement Study. Ann Thorac Surg 2021; 113:1845-1852. [PMID: 34224723 DOI: 10.1016/j.athoracsur.2021.05.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/03/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient reported outcomes (PROs) are critical for delivering high quality surgical care yet they are seldom collected in routine clinical practice. The objective of this quality improvement study was to improve routine PROs collection in a thoracic surgery clinic. METHODS Thoracic surgery patients at a single academic institution were prospectively followed from April 2019 to March 2020. The National Institutes of Health (NIH)-validated Patient-Reported Outcomes Measurement Information System (PROMIS) was employed. Using a Model for Improvement design and through multidisciplinary participant observation, multiple plan-do-study-act (PDSA) cycles (an iterative, four-stage model for rapidly testing interventions) were performed to improve routine collection reliability. RESULTS Over the study period, a total of 2,315 patient visits occurred. The baseline PROMIS assessment collection rate was 53%. After convening a multidisciplinary stakeholder team, the key drivers for PROMIS collection were having engaged staff, engaged patients, adequate technological capacity, and adequate time for survey completion (including when to complete the survey during the patient visits). Regular meetings between stakeholders were initiated to promote these key drivers. Several PDSA cycles were then employed to test different interventions, resulting in several positive system shifts as demonstrated on statistical process control (SPC) chart. Adherence to survey collection reached 91% of office visits by approximately 7 months, a 72% relative improvement, which was sustained. CONCLUSIONS Routine collection of PROs, such as PROMIS, are critical for improving thoracic surgical care. Our study shows that reliably collecting these data is possible in a clinical setting with minimal additional hospital resources.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Alexander G Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Christian Oncken
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Angela Keith
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tracey J Guthrie
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Deirdre J Epstein
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Mary Anne Lenk
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO.
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Kinnear B, Kelleher M, Sall D, Schauer DP, Warm EJ, Kachelmeyer A, Martini A, Schumacher DJ. Development of Resident-Sensitive Quality Measures for Inpatient General Internal Medicine. J Gen Intern Med 2021; 36:1271-1278. [PMID: 33105001 PMCID: PMC8131459 DOI: 10.1007/s11606-020-06320-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 10/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Graduate medical education (GME) training has long-lasting effects on patient care quality. Despite this, few GME programs use clinical care measures as part of resident assessment. Furthermore, there is no gold standard to identify clinical care measures that are reflective of resident care. Resident-sensitive quality measures (RSQMs), defined as "measures that are meaningful in patient care and are most likely attributable to resident care," have been developed using consensus methodology and piloted in pediatric emergency medicine. However, this approach has not been tested in internal medicine (IM). OBJECTIVE To develop RSQMs for a general internal medicine (GIM) inpatient residency rotation using previously described consensus methods. DESIGN The authors used two consensus methods, nominal group technique (NGT) and a subsequent Delphi method, to generate RSQMs for a GIM inpatient rotation. RSQMs were generated for specific clinical conditions found on a GIM inpatient rotation, as well as for general care on a GIM ward. PARTICIPANTS NGT participants included nine IM and medicine-pediatrics (MP) residents and six IM and MP faculty members. The Delphi group included seven IM and MP residents and seven IM and MP faculty members. MAIN MEASURES The number and description of RSQMs generated during this process. KEY RESULTS Consensus methods resulted in 89 RSQMs with the following breakdown by condition: GIM general care-21, diabetes mellitus-16, hyperkalemia-14, COPD-13, hypertension-11, pneumonia-10, and hypokalemia-4. All RSQMs were process measures, with 48% relating to documentation and 51% relating to orders. Fifty-eight percent of RSQMs were related to the primary admitting diagnosis, while 42% could also be related to chronic comorbidities that require management during an admission. CONCLUSIONS Consensus methods resulted in 89 RSQMs for a GIM inpatient service. While all RSQMs were process measures, they may still hold value in learner assessment, formative feedback, and program evaluation.
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Affiliation(s)
- Benjamin Kinnear
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA. .,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Matthew Kelleher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA.,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dana Sall
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel P Schauer
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric J Warm
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Kachelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Abigail Martini
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Daniel J Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
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Press VG, Myers LC, Feemster LC. Preventing COPD Readmissions Under the Hospital Readmissions Reduction Program: How Far Have We Come? Chest 2021; 159:996-1006. [PMID: 33065106 PMCID: PMC8501005 DOI: 10.1016/j.chest.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 01/06/2023] Open
Abstract
The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.
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Affiliation(s)
- Valerie G Press
- Section of General Internal Medicine University of Chicago Medicine.
| | - Laura C Myers
- Divisions of Research and Pulmonary/Critical Care Medicine, Kaiser Permanente Northern California
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, VA Puget Sound Health Care System
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Sengupta R, Loftus TM, Doers M, Jandarov RA, Phillips M, Ko J, Panos RJ, Zafar MA. Resting Borg score as a predictor of safe discharge of chronic obstructive pulmonary disease from the emergency department observation unit. Acad Emerg Med 2020; 27:1302-1311. [PMID: 32678934 DOI: 10.1111/acem.14091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 06/26/2020] [Accepted: 07/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease exacerbations (eCOPD) can be life-threatening and costly. Emergency department (ED) observation units (ED-Obs) offer short-term care to safely reduce preventable hospitalizations. Accurately identifying eCOPD patients who can be discharged safely will improve outcomes. OBJECTIVES The objective were to: I) evaluate utility of conventional clinical variables as predictors of safe discharge and II) assess utility of serial resting Borg score and novel Dyspnea Assessment Score (DAS) for identifying eCOPD patients who can be safely discharged from ED-Obs. METHODS This study was carried out in a 680-bed tertiary, academic hospital with >700 annual eCOPD ED encounters and a 16-bed ED-Obs. A two-phase study of eCOPD patients admitted to ED-Obs was performed. Objective I was a retrospective study including all eCOPD admits from April 2016 to May 2017. Predictor variables (demographics, COPD severity, comorbid conditions, exacerbation severity, clinical care in ED) and outcome variables (ED-Obs disposition, ED revisits) were obtained through electronic medical records. Safe discharge was defined as home disposition from ED-Obs without 7-day revisit. A stepwise regression was performed for predictors of safe discharge. Objective II was a prospective observation study for change in every 4-hour serial resting Borg score and DAS as identifiers of safe discharge. Comparative and receiver operating characteristic (ROC) analyses were performed. A p-value of <0.05 was considered significant. RESULTS In Objective I, 171 patients with age, FEV1 %, and body mass index of 59.8 (±9.5) years, 35 (±24)%, and 28.8 (±8) m2 /kg were included. After ED-Obs treatment 78 (45.6%) were hospitalized and 93 (54.4%) were discharged home, of whom 11 (6.4%) had 7-day ED revisit. Safe discharge occurred in 82 (48%). None of the predictor variables correlated with safe discharge. In Objective II, of 38 patients included, 20 (52.6%) had safe discharge. Among others, 16 (42%) were hospitalized and two (5.2%) had 7-day ED revisit. The admission Borg scores and DASs were similar in both groups. The predisposition Borg score was significantly lower in patients with safe discharge (2.75 vs. 5.28, p < 0.001) and had the highest area under curve on ROC (0.77) for safe discharge. DAS was not significantly different between groups. CONCLUSIONS Routine clinical variables do not identify eCOPD patients who can be safely discharged from ED-Obs. Change in resting Borg score during the course of ED-Obs treatment safely identifies patients for discharge. Prospective, external validation is needed to incorporate serial Borg scores in ED-Obs disposition decision for improved safety.
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Affiliation(s)
- Ruchira Sengupta
- From the Division of Pulmonary and Critical Care Medicine Department of Internal Medicine University of Cincinnati College of Medicine CincinnatiOHUSA
| | - Timothy M. Loftus
- the Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Matthew Doers
- From the Division of Pulmonary and Critical Care Medicine Department of Internal Medicine University of Cincinnati College of Medicine CincinnatiOHUSA
| | - Roman A. Jandarov
- and the Division of Biostatistics and Bioinformatics Department of Environmental Health University of Cincinnati College of Medicine CincinnatiOHUSA
| | - Michael Phillips
- and the Department of Respiratory Therapy University of Cincinnati Medical Center Cincinnati OHUSA
| | - Jonathan Ko
- and the Department of Respiratory Therapy University of Cincinnati Medical Center Cincinnati OHUSA
| | - Ralph J. Panos
- From the Division of Pulmonary and Critical Care Medicine Department of Internal Medicine University of Cincinnati College of Medicine CincinnatiOHUSA
- and the Department of Medicine Veterans Affairs Medical Center Cincinnati OHUSA
| | - Muhammad A. Zafar
- From the Division of Pulmonary and Critical Care Medicine Department of Internal Medicine University of Cincinnati College of Medicine CincinnatiOHUSA
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11
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MacDonell R, Woods O, Whelan S, Cushen B, Carroll A, Brennan J, Kelly E, Bolger K, McNamara N, Lanigan A, McDonnell T, Prihodova L. Interventions to standardise hospital care at presentation, admission or discharge or to reduce unnecessary admissions or readmissions for patients with acute exacerbation of chronic obstructive pulmonary disease: a scoping review. BMJ Open Respir Res 2020; 7:e000733. [PMID: 33262103 PMCID: PMC7709517 DOI: 10.1136/bmjresp-2020-000733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/01/2020] [Accepted: 11/08/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that may be punctuated by episodes of worsening symptoms, called exacerbations. Acute exacerbations of COPD (AECOPD) are detrimental to clinical outcomes, reduce patient quality of life and often result in hospitalisation and cost for the health system. Improved diagnosis and management of COPD may reduce the incidence of hospitalisation and death among this population. This scoping review aims to identify improvement interventions designed to standardise the hospital care of patients with AECOPD at presentation, admission and discharge, and/or aim to reduce unnecessary admissions/readmissions. METHODS The review followed a published protocol based on methodology set out by Arksey and O'Malley and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic database searches for peer-reviewed primary evidence were conducted in Web of Science, EMBASE (Elsevier) and PubMed. Abstract, full-text screening and data extraction were completed independently by a panel of expert reviewers. Data on type of intervention, implementation supports and clinical outcomes were extracted. Findings were grouped by theme and are presented descriptively. RESULTS 21 articles met the inclusion criteria. Eight implemented a clinical intervention bundle at admission and/or discharge; six used a multidisciplinary care pathway; five used coordinated case management and two ran a health coaching intervention with patients. CONCLUSION The findings indicate that when executed reliably, improvement initiatives are associated with positive outcomes, such as reduction in length of stay, readmissions or use of health resources. Most of the studies reported an improvement in staff compliance with the initiatives and in the patient's understanding of their disease. Implementation supports varied and included quality improvement methodology, multidisciplinary team engagement, staff education and development of written or in-person delivery of patient information. Consideration of the implementation strategy and methods of support will be necessary to enhance the likelihood of success in any future intervention.
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Affiliation(s)
- Rachel MacDonell
- Quality Improvement, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Orla Woods
- Research Department, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Stephanie Whelan
- Research Department, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Breda Cushen
- Dept. of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Aine Carroll
- Healthcare Integration and Improvement, University College Dublin, Dublin, Ireland
| | - John Brennan
- Quality Improvement, Royal College of Physicians of Ireland, Dublin, Ireland
| | - Emer Kelly
- Acute Medicine & Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Kenneth Bolger
- Dept. of Respiratory Medicine, South Tipperary General Hospital, Clonmel, Tipperary, Ireland
| | - Nora McNamara
- Dept. of Respiratory Medicine, South Tipperary General Hospital, Clonmel, Tipperary, Ireland
| | - Anne Lanigan
- Respiratory Physiotherapy, Midland Regional Hospital Portlaoise, Portlaoise, Laois, Ireland
| | - Timothy McDonnell
- National Clinical Programme Respiratory, Health Service Executive, Dublin, Ireland
| | - Lucia Prihodova
- Research Department, Royal College of Physicians of Ireland, Dublin, Ireland
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12
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Novakovic A, Marshall AH. Introducing the DM-P approach for analysing the performances of real-time clinical decision support systems. Knowl Based Syst 2020. [DOI: 10.1016/j.knosys.2020.105877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Freedman N. Reducing COPD Readmissions: Strategies for the Pulmonologist to Improve Outcomes. Chest 2020; 156:802-807. [PMID: 31590710 DOI: 10.1016/j.chest.2019.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/02/2019] [Accepted: 06/10/2019] [Indexed: 11/17/2022] Open
Abstract
Hospitalizations for patients with acute exacerbations of COPD are associated with several adverse patient outcomes as well as with significant health-care costs. Despite many interventions targeted at reducing readmissions following an initial hospitalization, there are few strategies that have been consistently associated with reductions in this outcome. Despite the lack of consensus as to the best strategies to deploy to reduce readmissions related to acute exacerbations of COPD, efforts must continue to focus on determining the best approaches for this population. These tactics will need to be cost-effective for payers while not being cost-prohibitive for providers. In addition, these interventions will need to be relatively easy to institute while not being overbearing for patients or providers. Larger systems with their greater financial resources will likely find success with technology and data-driven comprehensive programs; independent hospitals and practices are more likely to succeed with less resource-intensive interventions such as early postdischarge follow-up, coaching, action plans, self-management education, and pulmonary rehabilitation. Choosing the right interventions that will utilize financial and human resources in a cost-effective manner, while tailoring the approaches to meet the needs of a specific patient group, will be of key importance.
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Affiliation(s)
- Neil Freedman
- Division of Pulmonary, Critical Care, Allergy and Immunology, Department of Medicine, Northshore University Health System, Evanston, IL.
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14
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Kong CW, Wilkinson TM. Predicting and preventing hospital readmission for exacerbations of COPD. ERJ Open Res 2020; 6:00325-2019. [PMID: 32420313 PMCID: PMC7211949 DOI: 10.1183/23120541.00325-2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/06/2020] [Indexed: 12/17/2022] Open
Abstract
More than a third of patients hospitalised for acute exacerbation of COPD are readmitted to hospital within 90 days. Healthcare professionals and service providers are expected to collaboratively drive efforts to improve hospital readmission rates, which can be challenging due to the lack of clear consensus and guidelines on how best to predict and prevent readmissions. This review identifies these risk factors, highlighting the contribution of multimorbidity, frailty and poor socioeconomic status. Predictive models of readmission that address the multifactorial nature of readmissions and heterogeneity of the disease are reviewed, recognising that in an era of precision medicine, in-depth understanding of the intricate biological mechanisms that heighten the risk of COPD exacerbation and re-exacerbation is needed to derive modifiable biomarkers that can stratify accurately the highest risk groups for targeted treatment. We evaluate conventional and emerging strategies to reduce these potentially preventable readmissions. Here, early recognition of exacerbation symptoms and the delivery of prompt treatment can reduce risk of hospital admissions, while patient education can improve treatment adherence as a key component of self-management strategies. Care bundles are recommended to ensure high-quality care is provided consistently, but evidence for their benefit is limited to date. The search continues for interventions which are effective, sustainable and applicable to a diverse population of patients with COPD exacerbations. Further research into mechanisms that drive exacerbation and affect recovery is crucial to improve our understanding of this complex, highly prevalent disease and to advance the development of more effective treatments.
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Affiliation(s)
- Chia Wei Kong
- Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University Hospital Southampton, Southampton, UK
| | - Tom M.A. Wilkinson
- Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
- Clinical and Experimental Sciences, Faculty of Medicine, University Hospital Southampton, Southampton, UK
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15
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Gentene AJ, Guido MR, Woolf B, Dalhover A, Boesken TA, Mueller EW, Zafar MA. Multidisciplinary Team Utilizing Pharmacists in Multimodal, Bundled Care Reduce Chronic Obstructive Pulmonary Disease Hospital Readmission Rates. J Pharm Pract 2019; 34:110-116. [PMID: 31769330 DOI: 10.1177/0897190019889440] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a major contributor of morbidity and mortality in the United States resulting in high hospitalization and readmission rates. For health systems, identifying an effective strategy to reduce COPD readmissions has remained difficult. Multiple COPD care bundles have been developed with varying degrees of success. Bundles that were multidisciplinary and included pharmacists were successful in reducing readmissions. OBJECTIVE To describe and assess a multidisciplinary, 5-element, COPD care bundle that was implemented in an academic, urban safety-net hospital to reduce COPD readmissions and the role of pharmacists in bundle implementation. METHODS A multidisciplinary team collaborated to develop a 5-element COPD care bundle that met unmet patient needs. The bundle elements included the following, with pharmacy responsible for the first two: optimization of COPD inhalers, 30-day supply of insurance-compatible inhalers, individualized patient inhaler teaching, provision of standardized discharge instructions, and scheduling of a 15-day discharge follow-up appointment. Bundle was implemented with multiple Plan-Do-Study-Act (PDSA) cycles to develop intra- and interdepartment processes. RESULTS Prior to bundle implementation, the health system COPD readmission rates were 22.7%. Reliable implementation of the bundle reduced readmissions to 14.7% over a 6-month period. Pharmacy adherence to completion of the bundle was over 95% over 2 years of bundle use. CONCLUSION Pharmacists have a crucial role in hospital-based transitions of care to reduce COPD readmissions.
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Affiliation(s)
- Anthony J Gentene
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Maria Rose Guido
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Brittany Woolf
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amber Dalhover
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH
| | - Timmi Anne Boesken
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH
| | - Eric W Mueller
- Department of Pharmacy Services, 24267University of Cincinnati Medical Center, Cincinnati, OH.,Division of Pharmacy Practice and Administration, 24267University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Muhammad Ahsan Zafar
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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16
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Zafar MA, Nguyen B, Gentene A, Ko J, Otten L, Panos RJ, Alessandrini EA. Pragmatic Challenge of Sustainability: Long-Term Adherence to COPD Care Bundle Maintains Lower Readmission Rate. Jt Comm J Qual Patient Saf 2019; 45:639-645. [DOI: 10.1016/j.jcjq.2019.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/26/2022]
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17
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Morton K, Sanderson E, Dixon P, King A, Jenkins S, MacNeill SJ, Shaw A, Metcalfe C, Chalder M, Hollingworth W, Benger J, Calvert J, Purdy S. Care bundles to reduce re-admissions for patients with chronic obstructive pulmonary disease: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07210] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BackgroundChronic obstructive pulmonary disease (COPD) is the commonest respiratory disease in the UK, accounting for 10% of emergency hospital admissions annually. Nearly one-third of patients are re-admitted within 28 days of discharge.ObjectivesThe study aimed to evaluate the effectiveness of introducing standardised packages of care (i.e. care bundles) as a means of improving hospital care and reducing re-admissions for COPD.DesignA mixed-methods evaluation with a controlled before-and-after design.ParticipantsAdults admitted to hospital with an acute exacerbation of COPD in England and Wales.InterventionCOPD care bundles.Main outcome measuresThe primary outcome was re-admission to hospital within 28 days of discharge. The study investigated secondary outcomes including length of stay, total number of bed-days, in-hospital mortality, 90-day mortality, context, process and costs of care, and staff, patient and carer experience.Data sourcesRoutine NHS data, including numbers of COPD admissions and re-admissions, in-hospital mortality and length of stay data, were provided by 31 sites for 12 months before and after the intervention roll-out. Detailed pseudo-anonymised data on care during admission were collected from a subset of 14 sites, in addition to information about delivery of individual components of care collected from random samples of medical records at each location. Six case study sites provided data from interviews, observation and documentary review to explore implementation, engagement and perceived impact on delivery of care.ResultsThere is no evidence that care bundles reduced 28-day re-admission rates for COPD. All-cause re-admission rates, in-hospital mortality, length of stay, total number of bed-days, and re-admission and mortality rates in the 90 days following discharge were similar at implementation and comparator sites, as were resource utilisation, NHS secondary care costs and cost-effectiveness of care. However, the rate of emergency department (ED) attendances decreased more in implementation sites than in comparator sites {implementation: incidence rate ratio (IRR) 0.63 [95% confidence interval (CI) 0.56 to 0.70]; comparator: IRR 1.14 (95% CI 1.04 to 1.26) interactionp < 0.001}. Admission bundles appear to be more complex to implement than discharge bundles, with 3.7% of comparator patients receiving all five admission bundle elements, compared with 7.6% of patients in implementation sites, and 28.3% of patients in implementation sites receiving all five discharge bundle elements, compared with 0.8% of patients in the comparator sites. Although patients and carers were unaware that care was bundled, staff view bundles positively, as they help to standardise working practices, support a clear care pathway for patients, facilitate communication between clinicians and identify post-discharge support.LimitationsThe observational nature of the study design means that secular trends and residual confounding cannot be discounted as potential sources of any observed between-site differences. The availability of data from some sites was suboptimal.ConclusionsCare bundles are valued by health-care professionals, but were challenging to implement and there was a blurring of the distinction between the implementation and comparator groups, which may have contributed to the lack of effect on re-admissions and mortality. Care bundles do appear to be associated with a reduced number of subsequent ED attendances, but care bundles are unlikely to be cost-effective for COPD.Future workA longitudinal study using implementation science methodology could provide more in-depth insights into the implementation of care bundles.Trial registrationCurrent Controlled Trials ISRCTN13022442.FundingThis project was funded by the National Institute for Health Research Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Emily Sanderson
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Padraig Dixon
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna King
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Stephanie J MacNeill
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Alison Shaw
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | | | | | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - James Calvert
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Sarah Purdy
- Bristol Medical School, University of Bristol, Bristol, UK
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18
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Morton K, MacNeill S, Sanderson E, Dixon P, King A, Jenkins S, Metcalfe C, Shaw A, Chalder M, Benger J, Hollingworth W, Calvert J, Purdy S. Evaluation of 'care bundles' for patients with chronic obstructive pulmonary disease (COPD): a multisite study in the UK. BMJ Open Respir Res 2019; 6:e000425. [PMID: 31258918 PMCID: PMC6561386 DOI: 10.1136/bmjresp-2019-000425] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/05/2019] [Accepted: 05/08/2019] [Indexed: 11/21/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) accounts for 10% of emergency hospital admissions in the UK annually. Nearly 33% of patients are readmitted within 28 days of discharge. We evaluated the effectiveness of implementing standardised packages of care called 'care bundles' on COPD readmission, emergency department (ED) attendance, mortality, costs and process of care. Methods This is a mixed-methods, controlled before-and-after study with nested case studies. 31 acute hospitals in England and Wales which introduced COPD care bundles (implementation sites) or provided usual care (comparator sites) were recruited and provided monthly aggregate data. 14 sites provided additional individual patient data. Participants were adults admitted with an acute exacerbation of COPD. Results There was no evidence that care bundles reduced 28-day COPD readmission rates: OR=1.02 (95% CI 0.83 to 1.26). However, the rate of ED attendance was reduced in implementation sites over and above that in comparator sites (implementation: IRR=0.63 (95% CI 0.56 to 0.71); comparator: IRR=1.12 (95% CI 1.02 to 1.24); group-time interaction p<0.001). At implementation sites, delivery of all bundle elements was higher but was only achieved in 2.2% (admissions bundle) and 7.6% (discharge bundle) of cases. There was no evidence of cost-effectiveness. Staff viewed bundles positively, believing they help standardise practice and facilitate communication between clinicians. However, they lacked skills in change management, leading to inconsistent implementation. Discussion COPD care bundles were not effectively implemented in this study. They were associated with a reduced number of subsequent ED attendances, but not with change in readmissions, mortality or reduced costs. This is unsurprising given the low level of bundle uptake in implementation sites, and it remains to be determined if COPD care bundles affect patient care and outcomes when they are effectively implemented. Trial registration number ISRCTN13022442.
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Affiliation(s)
- Katherine Morton
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | | | | | - Padraig Dixon
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna King
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Ali Shaw
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jonathan Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
- University of the West of England, Bristol, UK
| | | | - James Calvert
- Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
| | - Sarah Purdy
- Bristol Medical School, University of Bristol, Bristol, UK
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19
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Insights about the economic impact of chronic obstructive pulmonary disease readmissions post implementation of the hospital readmission reduction program. Curr Opin Pulm Med 2019; 24:138-146. [PMID: 29210750 DOI: 10.1097/mcp.0000000000000454] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) affects over 12 million adults in the United States and is the third leading cause of 30-day readmissions. COPD is costly with almost $50 billion in direct costs annually. Total COPD costs can be up to double the identified direct costs because of comorbid disease and numerous indirect costs such as absenteeism. Acute exacerbations of COPD (AECOPD) are responsible for up to 70% of COPD-related healthcare costs; hospital readmissions alone account for over $15 billion annually. In this review, we aim to describe insights about the economic impact of COPD readmissions based on articles published over the last 18 months. RECENT FINDINGS Interventions aimed at reducing readmission, particularly those using interdisciplinary teams with bundled care interventions, were uniformly successful at improving the quality of care provided and demonstrating improved process measures. However, success at reducing readmissions and cost savings based on these interventions varied across the studies. SUMMARY The literature to date points to factors and conditions that may place patients at higher risk of readmissions and may lead to higher costs. Interventions aimed at reducing readmissions after index admissions for AECOPD have demonstrated variable results. Most interventions did not reflect cost-based analyses.
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20
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Abstract
COPD is an underdiagnosed, undertreated, and yet largely preventable disease. COPD affects millions of Americans on a daily basis, accounts for tens of thousands of deaths per year, and costs billions to the United States health-care system annually. Further, it impacts the quality of life for patients living with the disease. COPD care is fragmented in the United States, with a high level of responsibility placed on patients and their primary care physicians. Pulmonary specialists care for a minority of patients with COPD in the United States. Unfortunately, tobacco dependence, which is the leading cause of COPD, remains prevalent. Further, women and those with low socioeconomic status continue to share a relatively greater burden of disease. Exacerbations are experienced frequently by patients and contribute to high rates of emergency department visits and in-patient admissions and readmissions as well as high medical costs to the United States economy. Numerous strategies have been proposed to combat these high rates, including the use of discharge bundles, hospital at-home programs, telemedicine, and tele-rehabilitation, but no single best strategy has emerged. The COPD National Action Plan was introduced in 2017 as part of a multi-stakeholder endeavor to encourage collaboration among various patients, caregivers, physicians, researchers, and policymakers to optimize awareness, diagnosis, and treatment of this disease. It is time to make COPD care a public health priority.
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Affiliation(s)
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan.
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21
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Boozary AS, Shojania KG. Pathology of poverty: the need for quality improvement efforts to address social determinants of health. BMJ Qual Saf 2018; 27:421-424. [PMID: 29511090 DOI: 10.1136/bmjqs-2017-007552] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Andrew S Boozary
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Kaveh G Shojania
- Department of Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario, Canada
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22
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Ospina MB, Michas M, Deuchar L, Leigh R, Bhutani M, Rowe BH, Marciniuk D, Goodridge D, Dechman G, Bourbeau J, Balter M, Camp P, Hernandez P, Goldstein RS, Stickland MK. Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease. BMJ Open Respir Res 2018; 5:e000265. [PMID: 29468074 PMCID: PMC5812389 DOI: 10.1136/bmjresp-2017-000265] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/15/2018] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Hospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD. METHODS A purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July-November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80% endorsement for Likert values 5-7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting. RESULTS Seven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient's and caregiver's comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme. CONCLUSION We present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle.
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Affiliation(s)
- Maria B Ospina
- Department of Obstetrics and Gynecology and Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marta Michas
- Division of Pulmonary Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Richard Leigh
- Section of Respiratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- Division of Pulmonary Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Alberta Health Services, Edmonton, Alberta, Canada
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Darcy Marciniuk
- Division of Respirology, Critical Care and Sleep Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Donna Goodridge
- Division of Respirology, Critical Care and Sleep Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gail Dechman
- School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montreal, Québec, Canada
| | - Meyer Balter
- University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Pat Camp
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roger S Goldstein
- Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
| | - Michael K Stickland
- Division of Pulmonary Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Alberta Health Services, Edmonton, Alberta, Canada
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23
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Hakim MA, Garden FL, Jennings MD, Dobler CC. Performance of the LACE index to predict 30-day hospital readmissions in patients with chronic obstructive pulmonary disease. Clin Epidemiol 2017; 10:51-59. [PMID: 29343987 PMCID: PMC5751805 DOI: 10.2147/clep.s149574] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and objective Patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (COPD) have a high 30-day hospital readmission rate, which has a large impact on the health care system and patients’ quality of life. The use of a prediction model to quantify a patient’s risk of readmission may assist in directing interventions to patients who will benefit most. The objective of this study was to calculate the rate of 30-day readmissions and evaluate the accuracy of the LACE index (length of stay, acuity of admission, co-morbidities, and emergency department visits within the last 6 months) for 30-day readmissions in a general hospital population of COPD patients. Methods All patients admitted with a principal diagnosis of COPD to Liverpool Hospital, a tertiary hospital in Sydney, Australia, between 2006 and 2016 were included in the study. A LACE index score was calculated for each patient and assessed using receiver operator characteristic curves. Results During the study period, 2,662 patients had 5,979 hospitalizations for COPD. Four percent of patients died in hospital and 25% were readmitted within 30 days; 56% of all 30-day readmissions were again due to COPD. The most common reasons for readmission, following COPD, were heart failure, pneumonia, and chest pain. The LACE index had moderate discriminative ability to predict 30-day readmission (C-statistic =0.63). Conclusion The 30-day hospital readmission rate was 25% following hospitalization for COPD in an Australian tertiary hospital and as such comparable to international published rates. The LACE index only had moderate discriminative ability to predict 30-day readmission in patients hospitalized for COPD.
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Affiliation(s)
- Maryam A Hakim
- Department of Respiratory Medicine, Liverpool Hospital.,South Western Sydney Clinical School, University of New South Wales
| | - Frances L Garden
- South Western Sydney Clinical School, University of New South Wales.,Ingham Institute for Applied Medical Research
| | | | - Claudia C Dobler
- Department of Respiratory Medicine, Liverpool Hospital.,South Western Sydney Clinical School, University of New South Wales.,Ingham Institute for Applied Medical Research.,Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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