1
|
Saifan AR, Elshatarat RA, Sawalha MA, Khraim F, Ibrahim AM, Zaghamir DE, Saleh ZT, Hamdan KM, AbuRuz ME, Al-Bashaireh AM. Assessing the impact of a respiratory care bundle on health status and quality of life of chronic obstructive pulmonary disease patients in Jordan: A quasi-experimental study. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2024; 13:191. [PMID: 39268425 PMCID: PMC11392283 DOI: 10.4103/jehp.jehp_1110_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/03/2023] [Indexed: 09/15/2024]
Abstract
BACKGROUND This study aimed to evaluate the effectiveness of a respiratory care bundle, including deep breathing exercises, incentive spirometry, and airway clearance techniques, on the quality of life (QoL) of chronic obstructive pulmonary disease (COPD) patients in Jordan. MATERIALS AND METHODS A quasi-experimental study design and convenience sampling method was used to recruit 120 COPD patients, with 54 in the intervention group and 66 in the control group. The intervention group received additional respiratory care bundle training, while the control group received only discharge instructions and an education program. The St. George's Respiratory Questionnaire (SGRQ-C) was used to assess participants' QoL before and after the intervention. Independent t-tests, paired t-tests, and analysis of covariance (ANCOVA) analysis were used to analyze the data. RESULTS The study found no significant differences between patients' characteristics, health status, and SGRQ-C scores between the two groups at baseline. After the intervention, there were statistically significant differences in all SGRQ-C subscales, which were lower in the intervention group compared to the control group. The paired t-test showed significant reductions in all SGRQ-C symptoms components (t = 7.62, P < .001), activity component (t = 7.58, P < .001), impact component (t = 7.56, P < .001), and total scores post-intervention (t = 7.52, P < .001) for the intervention group. The ANCOVA analysis showed significant differences in scores of SGRQ-C components and total scores (f = 11.3, P < .001) post-intervention between the two groups. CONCLUSION The study's findings suggest that providing additional respiratory care bundle training for COPD patients can significantly improve their QoL, as measured by the SGRQ-C scores. The respiratory care bundle intervention was effective in reducing COPD symptoms and improving the QoL of COPD patients. Healthcare providers should consider implementing respiratory care bundles as part of COPD management to improve patients' outcomes.
Collapse
Affiliation(s)
- Ahmad R Saifan
- Department of Nursing, Applied Science Private University, Amman, Jordan
| | - Rami A Elshatarat
- Department of Medical and Surgical Nursing, College of Nursing, Taibah University, Madinah, Saudi Arabia
| | - Murad A Sawalha
- Department of Maternal, Child and Family Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Fadi Khraim
- College of Nursing, Qatar University, Doha, Qatar
| | - Ateya M Ibrahim
- Department of Nursing, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, AlKharj, Saudi Arabia
- Family and Community Health Nursing, Faculty of Nursing, Port Said University, Egypt
| | - Donia E Zaghamir
- Department of Nursing, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, AlKharj, Saudi Arabia
- Pediatric Nursing, Faculty of Nursing, Port Said University, Egypt
| | - Zyad T Saleh
- Department of Clinical Nursing, School of Nursing, The University of Jordan, Amman, Jordan
| | | | - Mohannad E AbuRuz
- Department of Medical and Surgical Nursing, College of Nursing, Taibah University, Madinah, Saudi Arabia
| | - Ahmad M Al-Bashaireh
- Faculty of Health Science, Higher Colleges of Technologies, Fujairah, United Arab Emirates
| |
Collapse
|
2
|
Canning ML, Barras M, McDougall R, Yerkovich S, Coombes I, Sullivan C, Whitfield K. Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach. Int J Clin Pharm 2024; 46:451-462. [PMID: 38240963 DOI: 10.1007/s11096-023-01681-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/28/2023] [Indexed: 03/24/2024]
Abstract
BACKGROUND Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes. AIM To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service. METHOD A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed. RESULTS Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days. CONCLUSION Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.
Collapse
Affiliation(s)
- Martin Luke Canning
- Pharmacy Department, The Prince Charles Hospital, Rode Rd, Chermside, QLD, 4032, Australia.
| | - Michael Barras
- Princess Alexandra Hospital, Woolloongabba, Australia
- The University of Queensland, Woolloongabba, Australia
| | - Ross McDougall
- Pharmacy Department, The Prince Charles Hospital, Rode Rd, Chermside, QLD, 4032, Australia
| | - Stephanie Yerkovich
- Menzies School of Health Research, Casuarina, Australia
- Queensland University of Technology, Brisbane, Australia
| | - Ian Coombes
- The University of Queensland, Woolloongabba, Australia
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Clair Sullivan
- The University of Queensland, Woolloongabba, Australia
- Digital Metro North, Herston, Australia
| | | |
Collapse
|
3
|
Price E, Ahmad S, Althobiani MA, Ayoob T, Burgoyne T, De Soyza A, Dobson M, Echevarria C, Martin G, Mendes RG, Preston AM, Rahman NM, Sapey E, Usmani OS, Hurst JR. Development and evaluation of a tool to optimise inhaler selection prior to hospital discharge following an exacerbation of COPD. ERJ Open Res 2024; 10:00010-2024. [PMID: 38444664 PMCID: PMC10910267 DOI: 10.1183/23120541.00010-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 03/07/2024] Open
Abstract
Introduction Rates of mortality and re-admission after a hospitalised exacerbation of COPD are high and resistant to change. COPD guidelines do not give practical advice about the optimal selection of inhaled drugs and device in this situation. We hypothesised that a failure to optimise inhaled drug and drug delivery prior to discharge from hospital after an exacerbation would be associated with a modifiable increased risk of re-admission and death. We designed a study to 1) develop a practical inhaler selection tool to use at the point of hospital discharge and 2) implement this tool to understand the potential impact on modifying inhaler prescriptions, clinical outcomes, acceptability to clinicians and patients, and the feasibility of delivering a definitive trial to demonstrate potential benefit. Methods We iteratively developed an inhaler selection tool for use prior to discharge following a hospitalised exacerbation of COPD using surveys with multiprofessional clinicians and a focus group of people living with COPD. We surveyed clinicians to understand their views on the minimum clinically important difference (MCID) for death and re-admission following a hospitalised exacerbation of COPD. We conducted a mixed-methods implementation feasibility study using the tool at discharge, and collated 30- and 90-day follow-up data including death and re-admissions. Additionally, we observed the tool being used and interviewed clinicians and patients about use of the tool in this setting. Results We completed the design of an inhaler selection tool through two rounds of consultations with 94 multiprofessional clinicians, and a focus group of four expert patients. Regarding MCIDs, there was majority consensus for the following reductions from baseline being the MCID: 30-day readmissions 5-10%, 90-day readmissions 10-20%, 30-day mortality 5-10% and 90-day mortality 5-10%. 118 patients were assessed for eligibility and 26 had the tool applied. A change in inhaled medication was recommended in nine (35%) out of 26. Re-admission or death at 30 days was seen in 33% of the switch group and 35% of the no-switch group. Re-admission or death at 90 days was seen in 56% of the switch group and 41% of the no-switch group. Satisfaction with inhalers was generally high, and switching was associated with a small increase in the Feeling of Satisfaction with Inhaler questionnaire of 3 out of 50 points. Delivery of a definitive study would be challenging. Conclusion We completed a mixed-methods study to design and implement a tool to aid optimisation of inhaled pharmacotherapy prior to discharge following a hospitalised exacerbation of COPD. This was not associated with fewer re-admissions, but was well received and one-third of people were eligible for a change in inhalers.
Collapse
Affiliation(s)
- Evleen Price
- THIS Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Shanaz Ahmad
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London, UK
| | | | - Tareq Ayoob
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London, UK
| | | | - Anthony De Soyza
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Carlos Echevarria
- Respiratory Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - Graham Martin
- THIS Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Renata Gonçalves Mendes
- Cardiopulmonary Physiotherapy Laboratory, Federal University of Sao Carlos, Sao Carlos, Brazil
| | - Anne-Marie Preston
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - Najib M. Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham NIHR Biomedical Research Unit, and HDR UK Medicines Driver Programme, Birmingham, UK
| | - Omar S. Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John R. Hurst
- UCL Respiratory, University College London, London, UK
| |
Collapse
|
4
|
Woods O, MacDonell R, Brennan J, Prihodova L, Cushen B, Costello RW, McDonnell TJ. The Irish national chronic obstructive pulmonary disease quality improvement collaborative: an adaptive learning collaborative. BMJ Open Qual 2024; 13:e002356. [PMID: 38191216 PMCID: PMC10806582 DOI: 10.1136/bmjoq-2023-002356] [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: 03/20/2023] [Accepted: 12/02/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is the the most common disease-specific cause of adult emergency hospital admissions in Ireland. Preliminary groundwork indicated that treatment of acute exacerbations of COPD (AECOPD) in Ireland is not standardised between public hospitals. Applying Institute for Healthcare Improvement Breakthrough Series and Model for Improvement methodologies, Royal College of Physicians of Ireland designed and conducted a novel flexible and adaptive quality improvement (QI) collaborative which, using embedded evaluation, aimed to deliver QI teaching to enable teams to implement bespoke, locally applicable changes to improve and standardise acute COPD care at presentation, admission and discharge stages within their hospitals. METHODS Eighteen teams from 19 hospitals across Ireland participated over 13 months. QI teaching was facilitated through inperson learning sessions, site visits, programme manager and coaching support. Teams submitted monthly anonymised patient data (n=10) for 22 measures of AECOPD care for ongoing QI evaluation. A mixed-methods survey was administered at the final learning session to retrospectively evaluate participants' experiences of QI learning and patient care changes. RESULTS Participants reported that they learnt QI and improved patient care during the collaborative. Barriers included increased workload and lack of stakeholder buy-in. Statistically significant improvements (mean±SD) were seen for 'documented dyspnoea, eosinopenia, consolidation, acidaemia and atrial Fibrillation (DECAF) assessment' (7.3 (±14.4)% month(M)1 (n=15 sites); 49.6 (±37.7)% M13 (n=16 sites); p<0.001, 95% CI (14.3 to 66.7)), 'Documented diagnosis - spirometry' (42.5 (± 30.0)% M1 (n=16 sites); 69.1 (±29.9)% M13 (n=16 sites); p=0.0176, 95% CI 5.0 to 48.2) and 'inhaler technique review completed' (45.6 (± 34.1)% M1 (n=16 sites); 76.3 (±33.7)% M13 (n=16 sites); p=0.0131, 95% CI 10.0 to 65.0). 'First respiratory review' demonstrated improved standardisation. CONCLUSION This flexible QI collaborative provided adaptive collaborative learning that facilitated participating teams to improve AECOPD patient care based on the unique context of their own hospitals. Findings indicate that involvement in the QI collaborative facilitated teams in achieving their improvements.
Collapse
Affiliation(s)
- Orla Woods
- Research, Royal College of Physicians of Ireland, Dublin 2, Ireland
| | - Rachel MacDonell
- Quality Improvement, Royal College of Physicians of Ireland, Dublin 2, Ireland
| | - John Brennan
- Quality Improvement, Royal College of Physicians of Ireland, Dublin 2, Ireland
| | - Lucia Prihodova
- Research, Royal College of Physicians of Ireland, Dublin 2, Ireland
| | - Breda Cushen
- Respiratory Medicine, Beaumont Hospital, Dublin 9, Ireland
| | | | - Timothy J McDonnell
- National Clinical Programme for Respiratory, Health Service Executive, Dublin 8, Ireland
| |
Collapse
|
5
|
Miravitlles M, Bhutani M, Hurst JR, Franssen FME, van Boven JFM, Khoo EM, Zhang J, Brunton S, Stolz D, Winders T, Asai K, Scullion JE. Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations. Adv Ther 2023; 40:4236-4263. [PMID: 37537515 PMCID: PMC10499689 DOI: 10.1007/s12325-023-02609-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023]
Abstract
Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.
Collapse
Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Vall d'Hebron University Hospital/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Frits M E Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- International Primary Care Respiratory Group, Leicester, UK
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Daiana Stolz
- Clinic of Respiratory Medicine and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tonya Winders
- Global Allergy and Airways Patient Platform, Vienna, Austria
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Osaka Metropolitan University, Osaka, Japan
| | | |
Collapse
|
6
|
Nygård T, Wright D, Nazar H, Haavik S. Enhancing potential impact of hospital discharge interventions for patients with COPD: a qualitative systematic review. BMC Health Serv Res 2023; 23:684. [PMID: 37349764 DOI: 10.1186/s12913-023-09712-0] [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: 02/19/2023] [Accepted: 06/18/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) are frequently readmitted to hospital resulting in avoidable healthcare costs. Many different interventions designed to reduce hospital readmissions are reported with limited evidence for effectiveness. Greater insight into how interventions could be better designed to improve patient outcomes has been recommended. AIM To identify areas for optimisation within previously reported interventions provided to reduce COPD rehospitalisation to improve future intervention development. METHODS A systematic review was conducted by searching Medline, Embase, CINAHL, PsycINFO, and CENTRAL in June 2022. Inclusion criteria were interventions provided to patients with COPD in the transition from hospital to home or community. Exclusion criteria were lack of empirical qualitative results, reviews, drug trials, and protocols. Study quality was assessed using the Critical Appraisal Skills Programme tool and results were synthesised thematically. RESULTS A total of 2,962 studies were screened and nine studies included. Patients with COPD experience difficulties when transitioning from hospital to home. It is therefore important for interventions to facilitate a smooth transition process and give appropriate follow-up post-discharge. Additionally, interventions should be tailored for each patient, especially regarding information provided. CONCLUSION Very few studies specifically consider processes underpinning COPD discharge intervention implementation. There is a need to recognise that the transition itself creates problems, which require addressing, before introducing any new intervention. Patients report a preference for interventions to be individually adapted-in particular the provision of patient information. Whilst many intervention aspects were well received, feasibility testing may have enhanced acceptability. Patient and public involvement may address many of these concerns and greater use of process evaluations should enable researchers to learn from each other's experiences. TRIAL REGISTRATION The review was registered in PROSPERO with registration number CRD42022339523.
Collapse
Affiliation(s)
- Torbjørn Nygård
- Department of Clinical Science, University of Bergen, P.O. box 7804, 5020, Bergen, Norway.
| | - David Wright
- School of Healthcare, University of Leicester, Leicester, UK
| | - Hamde Nazar
- School of Pharmacy, Newcastle University, Newcastle Upon Tyne, UK
| | - Svein Haavik
- Department of Clinical Science, University of Bergen, P.O. box 7804, 5020, Bergen, Norway
| |
Collapse
|
7
|
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
|
8
|
Shaw A, Morton K, King A, Chalder M, Calvert J, Jenkins S, Purdy S. Using and implementing care bundles for patients with acute admission for COPD: qualitative study of healthcare professionals' experience in four hospitals in England. BMJ Open Respir Res 2021; 7:7/1/e000515. [PMID: 32213536 PMCID: PMC7173984 DOI: 10.1136/bmjresp-2019-000515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 12/03/2022] Open
Abstract
Background Care bundles are sets of evidence-based interventions to improve quality of hospital care at admission and discharge. Within a wider multi-method evaluation of care bundles for adults with an emergency admission for acute exacerbations of chronic obstructive pulmonary disease, a qualitative study was conducted. The aim was to evaluate how bundles were used, and healthcare professionals’ experiences of the impact of bundles on the process of care delivery. Methods Within the wider evaluation, four acute hospitals that were using COPD care bundles were purposefully sampled for geographical variation. Qualitative data were gathered through non-participant observation of patient care and interviews with healthcare professionals, patients and carers. This paper reports a thematic analysis of data from observation and interviews with professionals. Results Healthcare professionals generally experienced care bundles as positive for standardising working practices and patient care, valuing how bundles could support a clear care pathway for patients, enable transitions between settings and identify postdischarge support required by patients. Successful use of bundles was perceived as more likely with the presence of either (or both) a clinical champion for bundles and system-based initiatives such as financial incentives, within a local culture of quality improvement. Challenges in accurately diagnosing COPD hampered bundle use, including delivery of bundles to those subsequently considered ineligible, or missed opportunities to deliver admission bundles to those with COPD. Conclusion Care bundles shape admission and discharge care processes for patients with COPD, from the perspective of staff involved in their delivery. However, different organisational, staff and clinical factors aid or hinder bundle use in an acute hospital context, suggesting potentially resolvable reasons for variable implementation of bundles. Finally, bundles may enhance staff experience of care delivery, even if the impact on patient outcomes remains uncertain.
Collapse
Affiliation(s)
- Ali Shaw
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | - Katherine Morton
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | - Anna King
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | - Melanie Chalder
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | - James Calvert
- Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
| | - Sue Jenkins
- Independent Affiliated Consultant, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| |
Collapse
|
9
|
Stone PW, Adamson A, Hurst JR, Roberts CM, Quint JK. Does pay-for-performance improve patient outcomes in acute exacerbation of COPD admissions? Thorax 2021; 77:239-246. [PMID: 34272333 PMCID: PMC8867277 DOI: 10.1136/thoraxjnl-2021-216880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/04/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The COPD Best Practice Tariff (BPT) is a pay-for-performance scheme in England that incentivises review by a respiratory specialist within 24 hours of admission and completion of a list of key care components prior to discharge, known as a discharge bundle, for patients admitted with acute exacerbation of COPD (AECOPD). We investigated whether the two components of the COPD BPT were associated with lower 30-day mortality and readmission in people discharged following AECOPD. METHODS Longitudinal study of national audit data containing details of AECOPD admissions in England and Wales between 01 February 2017 and 13 September 2017. Data were linked with national admissions and mortality data. Mixed-effects logistic regression, using a random intercept for hospital to adjust for clustering of patients, was used to determine the relationship between the COPD BPT criteria (combined and separately) and 30-day mortality and readmission. Models were adjusted for age, sex, socioeconomic status, length of stay, smoking status, Charlson comorbidity index, mental illness and requirement for oxygen or noninvasive ventilation during admission. RESULTS 28 345 patients discharged from hospital following AECOPD were included. 37% of admissions conformed to the two COPD BPT criteria. No relationship was observed between BPT conforming admissions and 30-day mortality (OR: 1.09 (95% CI 0.92 to 1.29)) or readmissions (OR: 0.96 (95% CI 0.90 to 1.02)). No relationship was observed between either of the individual COPD BPT components and 30-day mortality or readmissions. However, a specialist review at any time during admission was associated with lower inpatient mortality (OR: 0.69 (95% CI 0.58 to 0.81)). CONCLUSION Completion of the combined COPD BPT criteria does not appear associated with a reduction in 30-day mortality or readmission. However, specialist review was associated with reduced inpatient mortality. While it is difficult to argue that discharge bundles do not improve care, this analysis questions whether the pay-for-performance model improves mortality or readmissions.
Collapse
Affiliation(s)
- Philip W Stone
- Respiratory Epidemiology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Alexander Adamson
- Respiratory Epidemiology, National Heart and Lung Institute, Imperial College London, London, UK
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - C Michael Roberts
- Institute of Population Health Sciences, Queen Mary University of London, London, UK.,UCLPartners, London, UK.,Clinical Quality Improvement Department, Royal College of Physicians, London, UK
| | - Jennifer K Quint
- Respiratory Epidemiology, National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
10
|
Quan Z, Yan G, Wang Z, Li Y, Zhang J, Yang T, Piao H. Current status and preventive strategies of chronic obstructive pulmonary disease in China: a literature review. J Thorac Dis 2021; 13:3865-3877. [PMID: 34277076 PMCID: PMC8264680 DOI: 10.21037/jtd-20-2051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 04/22/2021] [Indexed: 12/04/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common respiratory disease that seriously threatens human health and wellbeing, thereby representing an important public health problem. At present, it is the fourth leading cause of death worldwide, and is estimated to become the third greatest cause of death by 2030. In China, the prevalence of COPD is increasing, secondary to an increase in smoking, air pollution and an aging population, resulting in a current the mortality of COPD in China which is higher than the global average. Moreover, the disability-adjusted life year (DALY) rate of COPD in China is still relatively high, with an associated heavy economic burden to patients, their families and society. Unfortunately, current measures for treatment and prevention of COPD in China are not optimal. This primarily results from limited public awareness of COPD and pulmonary function tests amongst residents of China, and the generally poor disease-specific knowledge of primary care doctors. In recent years, a series of preventative strategies have been introduced in China across at the level of national policy, societies and associations, and scientific research. This review focuses upon both the epidemiology of COPD and the current status of preventative and treatment strategies in China.
Collapse
Affiliation(s)
- Zhenyu Quan
- Department of Public Health, Yanbian University Medical College, Yanji, China
| | - Guanghai Yan
- Jilin Key Laboratory for Immune and Targeting Research on Common Allergic Diseases, Yanbian University, Yanji, China.,Department of Anatomy, Histology and Embryology, Yanbian University Medical College, Yanji, China
| | - Zhiguang Wang
- Jilin Key Laboratory for Immune and Targeting Research on Common Allergic Diseases, Yanbian University, Yanji, China.,Department of Respiratory Medicine, Affiliated Hospital of Yanbian University, Yanji, China
| | - Yan Li
- Jilin Key Laboratory for Immune and Targeting Research on Common Allergic Diseases, Yanbian University, Yanji, China.,Department of Respiratory Medicine, Affiliated Hospital of Yanbian University, Yanji, China
| | - Jie Zhang
- Department of Respiratory and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Ting Yang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Hongmei Piao
- Jilin Key Laboratory for Immune and Targeting Research on Common Allergic Diseases, Yanbian University, Yanji, China.,Department of Respiratory Medicine, Affiliated Hospital of Yanbian University, Yanji, China
| |
Collapse
|
11
|
Trends in Hospital Admissions for Chronic Obstructive Pulmonary Disease in Men and Women in Spain, 1998 to 2018. J Clin Med 2021; 10:jcm10071529. [PMID: 33917437 PMCID: PMC8038653 DOI: 10.3390/jcm10071529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022] Open
Abstract
The prevalence of chronic obstructive pulmonary disease (COPD) is rising faster in women in some countries. An observational time trends study was performed to assess the evolution of hospital admissions for COPD in men and women in Spain from 1998 to 2018. ICD-9 diagnostic codes (490–492, 496) from the minimum basic data set of hospital discharges were used. Age-standardised admission rates were calculated using the European Standard Population. Joinpoint regression models were fitted to estimate the annual percent change (APC). In 2018, the age-standardised admission rate per 100,000 population/year for COPD was five times higher in men (384.8, 95% CI: 381.7, 387.9) than in women (78.6, 95% CI: 77.4, 79.9). The average annual percent change (AAPC) was negative over the whole study period in men (−1.7%/year, 95% CI: −3.1, −0.2) but positive from 2010 to 2018 (1.1%/year, 95% CI: −0.8, 2.9). In women, the APC was −6.0% (95%CI: −7.1, −4.9) from 1998 to 2010, but the trend reversed direction in the 2010–2018 period (7.8%/year, 95% CI: 5.5, 10.2). Thus, admission rates for COPD decreased from 1998 to 2010 in both men and women but started rising again until 2018, modestly in men and sharply in women.
Collapse
|
12
|
Dixon P, Hollingworth W, Benger J, Calvert J, Chalder M, King A, MacNeill S, Morton K, Sanderson E, Purdy S. Observational Cost-Effectiveness Analysis Using Routine Data: Admission and Discharge Care Bundles for Patients with Chronic Obstructive Pulmonary Disease. PHARMACOECONOMICS - OPEN 2020; 4:657-667. [PMID: 32215856 PMCID: PMC7688870 DOI: 10.1007/s41669-020-00207-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory disease, and accounts for a substantial proportion of unplanned hospital admissions. Care bundles for COPD are a set of standardised, evidence-based interventions that may improve outcomes in hospitalised COPD patients. We estimated the cost effectiveness of care bundles for acute exacerbations of COPD using routinely collected observational data. METHODS Data were collected from implementation (n = 7) and comparator (n = 7) acute hospitals located in England and Wales. We conducted a difference-in-difference cost-effectiveness analysis using a secondary care (i.e. hospital) perspective to examine the effect on National Health Service (NHS) costs and 90-day mortality of implementing care bundles compared with usual care for patients admitted to hospital with an acute exacerbation of COPD. Adjusted models included as covariates patient age, sex, deprivation, ethnicity and seasonal effects and mixed effects for site. RESULTS Outcomes and baseline characteristics of up to 12,532 patients were analysed using both complete case and multiply imputed models. Implementation of bundles varied. COPD care bundles were associated with slightly lower secondary care costs, but there was no evidence that they improved outcomes once adjustments were made for site and baseline covariates. Care bundles were unlikely to be cost effective for the NHS with an estimated net monetary benefit per 90-day death avoided from an adjusted multiply imputed model of -£1231 (95% confidence interval - £2428 to - £35) at a high cost-effectiveness threshold of £50,000 per 90-day death avoided. CONCLUSION AND RECOMMENDATIONS Care bundles for COPD did not appear to be cost effective, although this finding may have been influenced by unmeasured variations in bundle implementation and other potential confounding factors.
Collapse
Affiliation(s)
- Padraig Dixon
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
- MRC Integrative Epidemiology Unit, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK.
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Jonathan Benger
- Department of Health and Applied Sciences, University of the West of England, Bristol, BS16 1DD, UK
| | - James Calvert
- North Bristol Trust, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Melanie Chalder
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Anna King
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Stephanie MacNeill
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Katherine Morton
- Department of Health and Applied Sciences, University of the West of England, Bristol, BS16 1DD, UK
| | - Emily Sanderson
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Sarah Purdy
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Sarkies M, Long JC, Pomare C, Wu W, Clay-Williams R, Nguyen HM, Francis-Auton E, Westbrook J, Levesque JF, Watson DE, Braithwaite J. Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes. Implement Sci 2020; 15:91. [PMID: 33087147 PMCID: PMC7579904 DOI: 10.1186/s13012-020-01049-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/01/2020] [Indexed: 12/31/2022] Open
Abstract
Background Studies of clinical effectiveness have demonstrated the many benefits of programmes that avoid unnecessary hospitalisations. Therefore, it is imperative to examine the factors influencing implementation of these programmes to ensure these benefits are realised across different healthcare contexts and settings. Numerous factors may act as determinants of implementation success or failure (facilitators and barriers), by either obstructing or enabling changes in healthcare delivery. Understanding the relationships between these determinants is needed to design and tailor strategies that integrate effective programmes into routine practice. Our aims were to describe the implementation determinants for hospital avoidance programmes for people with chronic conditions and the relationships between these determinants. Methods An electronic search of four databases was conducted from inception to October 2019, supplemented by snowballing for additional articles. Data were extracted using a structured data extraction tool and risk of bias assessed using the Hawker Tool. Thematic synthesis was undertaken to identify determinants of implementation success or failure for hospital avoidance programmes for people with chronic conditions, which were categorised according to the Consolidated Framework for Implementation Research (CFIR). The relationships between these determinants were also mapped. Results The initial search returned 3537 articles after duplicates were removed. After title and abstract screening, 123 articles underwent full-text review. Thirteen articles (14 studies) met the inclusion criteria. Thematic synthesis yielded 23 determinants of implementation across the five CFIR domains. ‘Availability of resources’, ‘compatibility and fit’, and ‘engagement of interprofessional team’ emerged as the most prominent determinants across the included studies. The most interconnected implementation determinants were the ‘compatibility and fit’ of interventions and ‘leadership influence’ factors. Conclusions Evidence is emerging for how chronic condition hospital avoidance programmes can be successfully implemented and scaled across different settings and contexts. This review provides a summary of key implementation determinants and their relationships. We propose a hypothesised causal loop diagram to represent the relationship between determinants within a complex adaptive system. Trial registration PROSPERO 162812
Collapse
Affiliation(s)
- Mitchell Sarkies
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia.
| | - Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Chiara Pomare
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Wendy Wu
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Robyn Clay-Williams
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Hoa Mi Nguyen
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Emilie Francis-Auton
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Jean-Frédéric Levesque
- Agency for Clinical Innovation, New South Wales, Australia.,Centre for Primary Health Care and Equity, University of New South Wales, New South Wales, Australia
| | - Diane E Watson
- Bureau of Health Information, New South Wales, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| |
Collapse
|
15
|
Dummer J, Stokes T. Improving continuity of care of patients with respiratory disease at hospital discharge. Breathe (Sheff) 2020; 16:200161. [PMID: 33447276 PMCID: PMC7792832 DOI: 10.1183/20734735.0161-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/04/2020] [Indexed: 11/06/2022] Open
Abstract
Continuity of care refers to the delivery of coherent, logical and timely care to an individual. It is threatened during the transition of care at hospital discharge, which can contribute to worse patient outcomes. In a traditional acute care model, the roles of hospital and community healthcare providers do not overlap and this can be a barrier to continuity of care at hospital discharge. Furthermore, the transition from inpatient to outpatient care is associated with a transition from acute to chronic disease management and, in a busy hospital, attention to this can be crowded out by the pressures of providing acute care. This model is suboptimal for the large proportion of patients admitted to hospital with acute-on-chronic respiratory disease. In a chronic care model, the healthcare system is designed to give adequate priority to care of chronic disease. Integrated care for the patient with respiratory disease fits the chronic care model and responds to the fragmentation of care in a traditional acute care model: providers integrate their respiratory services to provide continuous, holistic care tailored to individuals. This promotes greater continuity of care for individuals, and can improve patient outcomes both at hospital discharge and more widely. EDUCATIONAL AIMS To understand the concept of continuity of care and its effect at the transition between inpatient and outpatient care.To understand the difference between the acute and chronic models of healthcare.To understand the effect of integration of care on continuity of care for patients with respiratory disease and their health outcomes.
Collapse
Affiliation(s)
- Jack Dummer
- Dept of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Tim Stokes
- Dept of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| |
Collapse
|
16
|
Michas M, Deuchar L, Leigh R, Bhutani M, Rowe BH, Stickland MK, Ospina MB. Factors influencing the implementation and uptake of a discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease: a qualitative focus group study. Implement Sci Commun 2020; 1:3. [PMID: 32924018 PMCID: PMC7477849 DOI: 10.1186/s43058-020-00017-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is one of the most common causes of mortality and morbidity in high-income countries. In addition to the high costs of initial hospitalization, COPD patients frequently return to the emergency department (ED) and are readmitted to hospital within 30 days of discharge. A COPD acute care discharge care bundle focused on optimizing care for patients with an acute exacerbation of COPD has been shown to reduce ED revisits and hospital readmissions. The aim of this study was to explore and understand factors influencing implementation and uptake of COPD discharge care bundle items in acute care facilities from the perspective of health care providers and patients. METHODS Qualitative methodology was adopted. Nine focus groups were conducted using a semi-structured guide: seven with acute and primary/community health care providers and two with patients/family members. Focus groups were audiotaped, transcribed verbatim, and coded and analyzed using a thematic approach. RESULTS Forty-six health care providers and 14 patients/family members participated in the focus groups. Health care providers and patients identified four factors that can challenge the implementation of COPD discharge care bundles: process of care complexities, human capacity in care settings, communication and engagement, and attitudes and perceptions towards change. Both health care providers and patients recognized process of care complexity as the most important determinant of the COPD discharge bundle uptake. Processes of care complexity include patient activities in seeking and receiving care, as well as practitioner activities in making a diagnosis and recommending or implementing treatment. Important issues linked to human capacity in care settings included time constraints, high patient volume, and limited staffing. Communication during transitions in care across settings and patient engagement were also broadly discussed. Other important issues were linked to patients', providers', and system attitudes towards change and level of involvement in COPD discharge bundle implementation. CONCLUSIONS Complexities in the process of care were perceived as the most important determinant of COPD discharge bundle implementation. Early engagement of health providers and patients in the uptake of COPD discharge bundle items as well as clear communication between acute and post-acute settings can contribute positively to bundle uptake and implementation success.
Collapse
Affiliation(s)
- Marta Michas
- Division of Pulmonary Medicine, Faculty of Medicine & 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 & Dentistry, University of Alberta, Edmonton, Alberta Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta Canada
- School of Public Health, University of Alberta, Edmonton, Alberta Canada
| | - Michael K. Stickland
- Division of Pulmonary Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta Canada
- Alberta Health Services, Edmonton, Alberta Canada
| | - Maria B. Ospina
- School of Public Health, University of Alberta, Edmonton, Alberta Canada
- Department of Obstetrics & Gynecology and Medicine, Faculty of Medicine & Dentistry, University of Alberta, 220B Heritage Medical Research Centre, Edmonton, Alberta T6G 2S2 Canada
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|