Does pay-for-performance improve patient outcomes in acute exacerbation of COPD admissions?

Pay-for-performance and patient safety in acute care: A systematic review

Pay-for-performance (p4p) has been tried in all healthcare settings to address ongoing deficiencies in the quality and outcomes of care. The evidence for the effect of these policies has been inconclusive, especially in acute care. This systematic review focused on patient safety p4p in the hospital setting. Using the PRISMA guidelines, we searched five biomedical databases for quantitative studies using at least one outcome metric from database inception to March 2023, supplemented by reference tracking and internet searches. We identified 6,122 potential titles of which 53 were included: 39 original investigations, eight literature reviews and six grey literature reports. Only five system-wide p4p policies have been implemented, and the quality of evidence was low overall. Just over half of the studies (52 %) included failed to observe improvement in outcomes, with positive findings heavily skewed towards poor quality evaluations. The exception was the Fragility Hip Fracture Best Practice Tariff (BPT) in England, where sustained improvement was observed across various evaluations. All policies had a miniscule impact on total hospital revenue. Our findings underscore the importance of simple and transparent design, involvement of the clinical community, explicit links to other quality improvement initiatives, and gradual implementation of p4p initatives. We also propose a research agenda to lift the quality of evidence in this field.

Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations

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.

Exacerbations of COPD

COPD exacerbations are associated with significant morbidity, mortality, and increased health care expenditures. The recently published Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations have further refined the definition of an exacerbation. A better understanding of the risk factors associated with the development of an exacerbation exists, and improvements are being made in earlier detection approaches. Pharmacologic treatment strategies have been the cornerstone of effective therapy. In addition, both pharmacologic and non-pharmacologic strategies have been proven successful in the prevention of future exacerbations. Newer technologies, including the use of artificial intelligence and wearable monitoring devices, are now being used to help in the earlier detection of exacerbations. Such preventive and earlier detection strategies can help to develop a more personalized care model and improve outcomes for patients with COPD.

Advances in chronic obstructive pulmonary disease: management of exacerbations

Exacerbations of chronic obstructive pulmonary disease are important events to people living with this condition and a common cause of emergency hospital admission. In the absence of a confirmatory biomarker, an exacerbation remains a clinical diagnosis of exclusion and clinicians must be alert to alternative diagnoses. Most exacerbations are caused by airway infection, particularly with respiratory viruses. The mainstay of exacerbation treatment is an increase in the dose and/or frequency of short-acting beta-agonists, with short-course oral corticosteroids and/or antibiotics. Although there have been no new interventions to treat exacerbations in many years, there is still much variation in care and opportunity to improve outcomes. There has been a new focus on both the management of comorbidities and the optimisation of future care to reduce the risk of further events. This review summarises advances in managing exacerbations of chronic obstructive pulmonary disease, focusing on hospitalised patients.