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Tran-Nguyen S, Asha SE. A collaborative pharmacist-led intervention to prevent hospital readmissions among elderly patients discharged from the emergency department: a retrospective cohort study. Sci Rep 2024; 14:15285. [PMID: 38961098 PMCID: PMC11222493 DOI: 10.1038/s41598-024-64968-8] [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: 11/21/2023] [Accepted: 06/14/2024] [Indexed: 07/05/2024] Open
Abstract
Unplanned hospital readmission is a safety and quality healthcare measure, conferring significant costs to the healthcare system. Elderly individuals, particularly, are at high risk of readmissions, often due to issues related to medication management. Pharmacists play a pivotal role in addressing medication-related concerns, which can potentially reduce readmissions. This retrospective single-centre cohort study, conducted from November 2022 to February 2023 in an emergency department, aimed to determine if integrating emergency medicine pharmacists into Emergency Department care models reduces unplanned hospital readmissions within 28 days and to identify the interventions they employ. The inclusion criteria included patients aged ≥ 65, taking ≥ 3 medications, and presenting with falls, cognition changes, or reduced mobility and were planned for discharge to home from the emergency department. Collaborating with the Emergency Department Aged Care Service Emergency Team, a pharmacist provided comprehensive medication management consultations, discharge liaison services, and other pharmacy related interventions to eligible participants whenever the pharmacist was available. Patients who met the eligibility criteria but did not receive pharmacist interventions due to the pharmacist's unavailability served as the control group. This method was chosen to ensure that the control group consisted of comparable patients who only differed in terms of receiving the pharmacist intervention. The study included 210 participants, with 120 receiving pharmacist interventions and 90 acting as controls. The results revealed a significant reduction in unplanned hospital readmissions among participants who received pharmacist interventions (10.0%, n = 12) compared to controls (22.2%, n = 20), with a notable difference of 12.2% (95% confidence interval 2.4-23.4%, p = 0.01). A total of 107 interventions were documented, emphasising medication selection recommendations (28.0%) and identification of adverse drug reactions/drug-drug interactions (21.5%) as primary areas of focus. These findings suggest that integrating skilled pharmacists into Emergency Department Aged Care Service Emergency Team (ASET) lowered the rate of unplanned hospital readmission within 28 days resulting in improved hospital performance metric outcomes. This highlights the potential role of pharmacists in addressing medication-related issues and enhancing the quality and safety of healthcare delivery, particularly for elderly patients transitioning from the ED to home care settings.
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Affiliation(s)
- Susan Tran-Nguyen
- Pharmacy Department, St George Hospital South Eastern Sydney Local Health District (SESLHD), Kogarah, Sydney, 2217, Australia.
- Emergency Department, St George Hospital South Eastern Sydney Local Health District (SESLHD), Kogarah, Sydney, 2217, Australia.
| | - Stephen Edward Asha
- Emergency Department, St George Hospital South Eastern Sydney Local Health District (SESLHD), Kogarah, Sydney, 2217, Australia
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2
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Vauterin D, Van Vaerenbergh F, Vanoverschelde A, Quint JK, Verhamme K, Lahousse L. Methods to assess COPD medications adherence in healthcare databases: a systematic review. Eur Respir Rev 2023; 32:230103. [PMID: 37758274 PMCID: PMC10523153 DOI: 10.1183/16000617.0103-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/20/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The Global Initiative for Chronic Obstructive Lung Disease 2023 report recommends medication adherence assessment in COPD as an action item. Healthcare databases provide opportunities for objective assessments; however, multiple methods exist. We aimed to systematically review the literature to describe existing methods to assess adherence in COPD in healthcare databases and to evaluate the reporting of influencing variables. METHOD We searched MEDLINE, Web of Science and Embase for peer-reviewed articles evaluating adherence to COPD medication in electronic databases, written in English, published up to 11 October 2022 (PROSPERO identifier CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. Methods to assess initiation (dispensing of medication after prescribing), implementation (extent of use over a specific time period) and/or persistence (time from initiation to discontinuation) were listed descriptively. Each included study was evaluated for reporting variables with an impact on adherence assessment: inpatient stays, drug substitution, dose switching and early refills. RESULTS 160 studies were included, of which four assessed initiation, 135 implementation and 45 persistence. Overall, one method was used to measure initiation, 43 methods for implementation and seven methods for persistence. Most of the included implementation studies reported medication possession ratio, proportion of days covered and/or an alteration of these methods. Only 11% of the included studies mentioned the potential impact of the evaluated variables. CONCLUSION Variations in adherence assessment methods are common. Attention to transparency, reporting of variables with an impact on adherence assessment and rationale for choosing an adherence cut-off or treatment gap is recommended.
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Affiliation(s)
- Delphine Vauterin
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Frauke Van Vaerenbergh
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Anna Vanoverschelde
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jennifer K Quint
- School of Public Health and National Heart and Lung Institute, Imperial College London, London, UK
| | - Katia Verhamme
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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3
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Rafferty JL, Mills KD, Morano M, Pogodzinski J, Chilbert MR, Clark CM. Impact of a pharmacist collaborative drug therapy management protocol on utilization of a discharge prescription program and hospital readmissions. Am J Health Syst Pharm 2023; 80:1056-1062. [PMID: 37061822 DOI: 10.1093/ajhp/zxad079] [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: 04/13/2023] [Indexed: 04/17/2023] Open
Abstract
PURPOSE To evaluate the impact of a collaborative drug therapy management (CDTM) agreement allowing a pharmacist to automatically prescribe refills of discharge medications to patients' preferred outpatient pharmacy on utilization of a hospital discharge prescription program and hospital readmission rates. METHODS This was a single-center, quasi-experimental pre-post intervention study. Patients aged 18 years or older discharged from the cardiology services to home were eligible for inclusion in the study. The CDTM agreement was initiated on July 1, 2019. Patients discharged to home from July 1, 2018, to June 30, 2019, were assigned to the historical control group. The primary outcome was the difference in the proportion of
patients who used the bedside medication delivery service at hospital discharge between the groups. Secondary outcomes included 30-day hospital readmissions and a descriptive analysis of medications prescribed by a pharmacist through the program. A χ2 test was used to assess the primary outcome, and multivariable logistic regression was used to assess hospital readmissions. RESULTS In total, 1,704 and 2,200 patients were discharged in the control and CDTM groups, respectively. The CDTM group had a greater proportion of patients who participated in the discharge prescription program compared to the historical control group (77.8% vs 68.7%; P < 0.0001). There was no difference in 30-day hospital readmission rate between the groups (adjusted odds ratio, 1.01; 95% confidence interval, 0.83-1.23;
P = 0.94). CONCLUSION A CDTM protocol to improve the availability of medication refills at a patient's regular outpatient pharmacy improved utilization of a bedside medication delivery service but did not change 30-day readmission rates.
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Affiliation(s)
- Jennifer L Rafferty
- University of Rochester Medical Center Specialty Pharmacy, Rochester, NY, USA
| | | | | | | | - Maya R Chilbert
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | - Collin M Clark
- University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
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Harris M, Moore V, Barnes M, Persha H, Reed J, Zillich A. Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review. J Am Pharm Assoc (2003) 2022; 62:1477-1498.e8. [PMID: 35718715 DOI: 10.1016/j.japh.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive patient readmissions. Because of this program, hospitals have developed transitions of care (TOC) programs to improve patient outcomes. OBJECTIVES To identify and uniformly summarize the impact of pharmacy-led TOC interventions on 30-day readmission rates since the implementation of CMS HRRP. METHODS This study followed an a-priori protocol that was registered to International Prospective Register of Systematic Reviews. A systematic search was conducted using PubMed, EMBASE, International Pharmaceutical Abstracts, and CINAHL from January 1, 2013 through January 14, 2022. Studies were included if they met the following criteria: pharmacy-led intervention, 30-day readmission outcomes, patients at least 18 years old, original research performed in the United States, and English language only articles. Descriptive statistics were used to summarize study characteristics, outcomes, and elements of the study interventions. RESULTS A total of 1964 abstracts were screened with 123 studies being included in the review. A total of 110 (89.4%) studies showed a decrease in readmission rates. The largest decrease in readmission rates was 44.5% (range 0.2%-44.5%, median = 7.4%) and the most common pharmacy-led intervention was patient counseling (n = 119, 96.7%) followed by medication reconciliation (n = 111, 90.2%). High-risk patient populations were commonly targeted with 52 studies (42.3%) focusing on CMS HRRP related diagnoses. CONCLUSION Most pharmacist-led TOC interventions contributed to lower rates of 30-day readmission. Future studies should investigate the types of interventions that most significantly impact readmission rates.
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Howard O, Thomas A, Henry H, Wallace J. Impact of a Pharmacist-led Outpatient Telemedicine Clinic on Chronic Obstructive Pulmonary Disease in a Veteran Population. J Am Pharm Assoc (2003) 2022; 62:1919-1924. [DOI: 10.1016/j.japh.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/25/2022] [Accepted: 06/21/2022] [Indexed: 11/29/2022]
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Alshaya OA, Arab OO, Alhifany AA, Alhossan A, Alomar M, Alqahtani AG, Almolaiki MA, Mubarki S, Alruwaisan R, Alturaiki A, Alzuman S, Alsaqer AI, Korayem GB. Ambulatory care pharmacy in Saudi Arabia; definition, history, present, future potentials, and expected challenges. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Omar A. Alshaya
- Department of Pharmacy Practice, College of Pharmacy King Saud bin Abdulaziz University for Health Sciences Riyadh Saudi Arabia
- Pharmaceutical Care Services King Abdulaziz Medical City, Ministry of National Guard Health Affairs Riyadh Saudi Arabia
- King Abdullah International Medical Research Center Riyadh Saudi Arabia
| | - Omaima Osama Arab
- King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia
| | | | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, College of Pharmacy King Saud University Riyadh Saudi Arabia
| | - Mukhtar Alomar
- Clinical Pharmacy Section, Pharmaceutical Care Services Dammam Health Network, Eastern Health Cluster Dammam Saudi Arabia
| | | | - Maha A. Almolaiki
- Pharmaceutical Care Services King Abdulaziz Medical City, Ministry of National Guard Health Affairs Riyadh Saudi Arabia
| | | | - Rana Alruwaisan
- Pharmacy Services Administration, King Fahad Medical City Riyadh Saudi Arabia
| | - Abdulrahman Alturaiki
- Department of Pharmacy Practice, College of Pharmacy King Saud bin Abdulaziz University for Health Sciences Riyadh Saudi Arabia
- Pharmaceutical Care Services King Abdulaziz Medical City, Ministry of National Guard Health Affairs Riyadh Saudi Arabia
- King Abdullah International Medical Research Center Riyadh Saudi Arabia
| | - Sitah Alzuman
- Pharmacy Services, King Khalid Eye Specialist Hospital Riyadh Saudi Arabia
| | | | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy Princess Nourah bint Abdulrahman University Riyadh Saudi Arabia
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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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8
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Morgenthaler TI, Lim K, Larson M, Helfinstine K, Homan J, Schwarz R, Dankbar G. A Practice Redesign Collaborative for Reducing Hospital Readmission for Chronic Obstructive Pulmonary Disease in an Affiliated Network of Health Care Organizations. Jt Comm J Qual Patient Saf 2021; 47:412-421. [PMID: 33910766 DOI: 10.1016/j.jcjq.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/03/2021] [Accepted: 03/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients discharged following admissions for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) frequently require unplanned readmissions, increasing costs and morbidity for thousands of patients suffering from COPD. The Hospital Readmissions Reduction Program provided financial incentives to reduce 30-day readmissions for AE-COPD, but although risk factors for readmission are known, few evidence-based interventions achieve this goal. Members of the Mayo Clinic Care Network (MCCN) formed a collaborative to seek ways to reduce 30-day readmission for patients admitted with AE-COPD. METHODS Seventeen MCCN organizations participated in an improvement collaborative in 2016 and 2017. Mayo Clinic subject matter experts shared improvement webinars, protocols, and educational materials related to AE-COPD and delivered individualized coaching to facilitate improvement at each site over a six-month engagement. Among other recommended interventions, organizations worked to increase the proportion of COPD patients who had a standardized disease severity staging during admission, inhaler appropriateness evaluations, a COPD treatment action plan, and clinical contact at < 48 hours and 10 ± 4 days postdischarge. RESULTS Same-hospital readmission rates improved from 17.7% ± 3.6 to 14.5% ± 4.0 (weighted difference -4.38, p = 0.008, paired t-test). In addition, participating teams stated that the collaborative framework helped them develop strategies that improved patient care and organizational capacity for improvement in other domains. CONCLUSION The collaborative framework, beginning with education delivered in person and via webinars, combined with telephonically delivered coaching and knowledge sharing, assisted most members to improve care. Fourteen of 17 participating sites experienced a reduced AE-COPD readmission rate.
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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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10
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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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11
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Buhr RG, Jackson NJ, Dubinett SM, Kominski GF, Mangione CM, Ong MK. Factors Associated with Differential Readmission Diagnoses Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease. J Hosp Med 2020; 15:219-227. [PMID: 32118572 PMCID: PMC7153488 DOI: 10.12788/jhm.3367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Readmissions after exacerbations of chronic obstructive pulmonary disease (COPD) are penalized under the Hospital Readmissions Reduction Program (HRRP). Understanding attributable diagnoses at readmission would improve readmission reduction strategies. OBJECTIVES Determine factors that portend 30-day readmissions attributable to COPD versus non-COPD diagnoses among patients discharged following COPD exacerbations. DESIGN, SETTING, AND PARTICIPANTS We analyzed COPD discharges in the Nationwide Readmissions Database from 2010 to 2016 using inclusion and readmission definitions in HRRP. MAIN OUTCOMES AND MEASURES We evaluated readmission odds for COPD versus non-COPD returns using a multilevel, multinomial logistic regression model. Patient-level covariates included age, sex, community characteristics, payer, discharge disposition, and Elixhauser Comorbidity Index. Hospital-level covariates included hospital ownership, teaching status, volume of annual discharges, and proportion of Medicaid patients. RESULTS Of 1,622,983 (a weighted effective sample of 3,743,164) eligible COPD hospitalizations, 17.25% were readmitted within 30 days (7.69% for COPD and 9.56% for other diagnoses). Sepsis, heart failure, and respiratory infections were the most common non-COPD return diagnoses. Patients readmitted for COPD were younger with fewer comorbidities than patients readmitted for non-COPD. COPD returns were more prevalent the first two days after discharge than non-COPD returns. Comorbidity was a stronger driver for non-COPD (odds ratio [OR] 1.19) than COPD (OR 1.04) readmissions. CONCLUSION Thirty-day readmissions following COPD exacerbations are common, and 55% of them are attributable to non-COPD diagnoses at the time of return. Higher burden of comorbidity is observed among non-COPD than COPD rehospitalizations. Readmission reduction efforts should focus intensively on factors beyond COPD disease management to reduce readmissions considerably by aggressively attempting to mitigate comorbid conditions.
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Affiliation(s)
- Russell G Buhr
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- Corresponding Author: Russell G. Buhr, MD, PhD; E-mail: ; Telephone: 310-267-2614; Twitter: @rgbMDPhD
| | - Nicholas J Jackson
- Department of Medicine Statistics Core, University of California, Los Angeles, California
| | - Steven M Dubinett
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Gerald F Kominski
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Center for Health Policy Research, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
| | - Carol M Mangione
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael K Ong
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California
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12
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Morais LDA, Cavalcante SYIEDS, Conde MB, Rabahi MF. Evaluating the disease and treatment information provided to patients with chronic obstructive pulmonary disease at the time of discharge according to GOLD discharge guidelines. EINSTEIN-SAO PAULO 2019; 18:eAO4706. [PMID: 31826076 PMCID: PMC6905159 DOI: 10.31744/einstein_journal/2020ao4706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 02/01/2019] [Indexed: 11/10/2022] Open
Abstract
Objective To evaluate the disease and treatment information provided to patients with chronic obstructive pulmonary disease at hospital discharge. Methods This was a cross-sectional study including hospitalized patients with chronic obstructive pulmonary disease at three tertiary hospitals. The study was based on seven items of the Global Initiative for Obstructive Lung Disease (GOLD) discharge guidelines. Two hospitals in this study had a Medical Residency Program in Pulmonology, and one did not have the program. Results Fifty-four patients were evaluated. Large amounts of information were provided concerning effective pharmacological maintenance (item 1), blood gas evaluation/measurement of oxygen saturation (item 2), assessment of inhalation technique (item 4), and maintenance therapy (item 5). Less information was provided regarding comorbidity management planning (item 3), the completion of antibiotic/corticosteroid therapy (item 6) and follow-up with the attending physician or specialist (item 7) had less information. We observed significant differences between hospitals for items 1, 4 and 7, and better performance in hospitals with medical residency in pulmonology. Conclusion Hospitalized patients with chronic obstructive pulmonary disease received little to no information about the seven items addressed by GOLD discharge guidelines. This finding suggests that these guidelines should be used more often by clinicians in hospital with or without medical residency in pulmonology. The lack of specialized care resulted in insufficient amount of information for patients with chronic obstructive pulmonary disease at discharge.
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13
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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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14
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Epstein D, Barak-Corren Y, Isenberg Y, Berger G. Clinical Decision Support System: A Pragmatic Tool to Improve Acute Exacerbation of COPD Discharge Recommendations. COPD 2019; 16:18-24. [DOI: 10.1080/15412555.2019.1593342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Danny Epstein
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
| | - Yuval Barak-Corren
- Predictive Medicine Group, Boston Children’s Hospital, Boston, MA, USA
- Shaare Tzedek Medical Center, Jerusalem, Israel
| | - Yoni Isenberg
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
| | - Gidon Berger
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
- Division of Pulmonary Medicine, Rambam Health Care Campus, Haifa, Israel
- The Rappaport's Faculty of Medicine, The Technion Institute, Haifa, Israel
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15
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Petite SE, Murphy JA. Evaluation of Bronchodilator Use During Chronic Obstructive Pulmonary Disease Exacerbation Inpatient Admissions. Hosp Pharm 2019; 54:112-118. [PMID: 30923404 PMCID: PMC6431716 DOI: 10.1177/0018578718769569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: It is unknown whether the timing of initiation of a long-acting bronchodilator (LABD) during a chronic obstructive pulmonary disease (COPD) exacerbation or the method of short-acting bronchodilator (SABD) delivery may aid in improving patient outcomes. Objective: The goal of this study was to determine the impact of bronchodilator management in the hospital setting on clinical outcomes in patients with COPD exacerbation. Methods: This retrospective, single-center study evaluated patients admitted to the non-intensive care unit setting with a COPD exacerbation as defined by the International Classification of Diseases, Ninth Revision codes. The primary outcome was difference in 30-day readmission rates for early LABD therapy (<24 hours from hospital admission) versus late/no LABD therapy (>24 hours from hospital admission or not during hospitalization). Secondary objectives included length of stay (LOS) for this group, and 30-day readmission rates and LOS for the SABD via inhaler versus nebulizer groups. Results: Two hundred twenty patients were included. There was no difference in 30-day readmission rate (15.2% vs 18.2%, P = .6) and LOS (median 4 [interquartile range, IQR 3-6]) days for both groups, P = .34) between early versus late/no LABD therapy initiation, respectively. No difference was observed in 30-day readmission rate (16.7% vs 16.6%) and LOS (median 2.5 [IQR 1.1-3.9] days vs median 4 [IQR 2-6] days) between inhaler and nebulizer SABD therapy groups. Conclusions: No difference was observed in 30-day readmission rates or LOS when utilizing early LABD compared with late/no LABD therapy or comparing inhaler and nebulizer SABD delivery methods during COPD exacerbation.
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16
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Roberts S, Moore LC, Jack B. Improving discharge planning using the re‐engineered discharge programme. J Nurs Manag 2018; 27:609-615. [DOI: 10.1111/jonm.12719] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 08/13/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Sterling Roberts
- School of Nursing Georgia College & State University Milledgeville Georgia
| | - Leslie C. Moore
- School of Nursing Georgia College & State University Milledgeville Georgia
| | - Brian Jack
- Department of Family Medicine Boston University School of Medicine Boston Massachusetts
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17
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Chamberlin SM, White CE, Wheeler JS, Eudaley ST, Franks AS, Rowe AS. Implementation and assessment of a pulmonary diseases elective course for third-year pharmacy students. CURRENTS IN PHARMACY TEACHING & LEARNING 2018; 10:571-578. [PMID: 29986816 DOI: 10.1016/j.cptl.2018.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 11/21/2017] [Accepted: 02/03/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Given the significant public health burden of pulmonary diseases and the vital role pharmacists play in management across the continuum of care (and within transitions in care), an elective course for pharmacy students focused on pulmonary diseases was developed. EDUCATIONAL ACTIVITY A month-long elective course for third-year pharmacy students consisting of 12 class sessions delivered in two-hour periods three times per week, was implemented. The course was delivered using the team-based learning (TBL) format in addition to hands-on skills and simulation sessions. Knowledge and skills assessments were administered before and after completion of the course. Student perceptions of self-confidence and ability regarding management of pulmonary diseases pre- and post-course and their perceptions of the course and TBL as a teaching strategy for this course were evaluated upon course completion. CRITICAL ANALYSIS Nine students completed the course. Mean scores on knowledge and skills assessment significantly improved after completion of the course (54.5% pre-course vs. 79.3% post-course; p < 0.05% and 60.3% pre-course vs. 93.2% post-course; p < 0.05, respectively). Student perceptions of their ability to care for patients with pulmonary diseases significantly increased, compared to pre-assessments, in all areas taught in the course (p< 0.05). Additionally, students' confidence in managing specific disease states significantly improved in all areas (p < 0.05) except for spirometry (p = 0.06). Students' knowledge, skills, and confidence regarding management of common pulmonary disease states improved following this month-long elective course delivered using a combination of TBL activities and hands-on skills sessions.
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Affiliation(s)
- Shaunta' M Chamberlin
- Department of Family Medicine, University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Box U-67, Knoxville, TN 37920, United States.
| | - Cyle E White
- Infectious Diseases Pharmacy Specialist, Department of Pharmacy, Erlanger Health System, 975 E 3rd Street, Chattanooga, TN 37403, United States.
| | - James S Wheeler
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 193 Polk Ave, Suite 2D, Nashville, TN 37210, United States.
| | - Sarah T Eudaley
- Department of Family Medicine, University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Box U-67, Knoxville, TN 37920, United States; Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 1924 Alcoa Highway, Box 117, Knoxville, TN 37920, United States.
| | - Andrea S Franks
- Department of Family Medicine, University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway, Box U-67, Knoxville, TN 37920, United States; Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 1924 Alcoa Highway, Box 117, Knoxville, TN 37920, United States.
| | - A Shaun Rowe
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, 1924 Alcoa Highway, Box 117, Knoxville, TN 37920, United States.
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18
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Chronic obstructive pulmonary disease in the long-term care setting: current practices, challenges, and unmet needs. Curr Opin Pulm Med 2018; 23 Suppl 1:S1-S28. [PMID: 28990958 DOI: 10.1097/mcp.0000000000000416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
: Chronic obstructive pulmonary disease (COPD) is a prevalent and disabling disorder in the United States, especially affecting older individuals, women, and those with a history of smoking. Studies show that COPD may be underrepresented, underdiagnosed, and undertreated in elderly patients residing in long-term care (LTC) facilities. The quality of care for LTC residents with COPD is heterogeneous in regard to both the facility and the patient. For LTC facilities, care should be driven by staff education, interstaff communication, and interfacility communication. From the perspective of the LTC patient, choice of medication and device should be based on appropriate diagnosis, comorbidities, ability to perform treatment, and patient preferences. Nebulization is currently underutilized in LTC settings, although it would benefit older patients with low peak inspiratory flow, cognitive impairment, and/or physical impairment, which may preclude them from using other inhalation devices. Authors developed a COPD treatment algorithm that focuses on three primary patient aspects to consider when deciding on respiratory device in patients in LTC facilities: inspiratory flow, hand dexterity and coordination, and cognitive capacity.
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19
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Zafar MA, Panos RJ, Ko J, Otten LC, Gentene A, Guido M, Clark K, Lee C, Robertson J, Alessandrini EA. Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science. BMJ Qual Saf 2017; 26:908-918. [PMID: 28733370 DOI: 10.1136/bmjqs-2017-006529] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Readmissions of chronic obstructive pulmonary disease (COPD) have devastating effects on patient quality-of-life, disease progression and healthcare cost. Effective interventions to reduce COPD readmissions are needed. OBJECTIVES Reduce 30-day all-cause readmissions by (1) creating a COPD care bundle that addresses care delivery failures, (2) using improvement science to achieve 90% bundle adherence. SETTING An 800-bed academic hospital in Ohio, USA. The COPD 30-day all-cause readmission rate was 22.7% from August 2013 to September 2015. METHOD We performed a cross-sectional study of COPD 30-day readmissions from October 2014 to March 2015 to identify care delivery failures. We interviewed readmitted patients with COPD to identify their needs after discharge. A multidisciplinary team created a care bundle designed to mitigate system failures. Using a quasi-experimental study and 'Model for Improvement', we redesigned care delivery to improve bundle adherence. We used statistical process control charts to analyse bundle adherence and all-cause 30-day readmissions. RESULTS Cross-sectional review of the index (first-time) admissions revealed COPD was the most common readmission diagnosis and identified 42 system-level failures. The most prevalent failures were deficient inhaler regimen at discharge, late or non-existent follow-up appointments, and suboptimal discharge instructions. Patient interviews revealed confusing discharge instructions, especially regarding inhaler use. The COPD care-bundle components were: (1) appropriate inhaler regimen, (2) 30-day inhaler supply, (3) inhaler education on the device available postdischarge, (4) follow-up within 15 days (5) standardised patient-centred discharge instructions. The adherence to completing bundle components reached 90% in 5.5 months and was sustained. The COPD 30-day readmission rate decreased from 22.7% to 14.7%. Patients receiving all bundle components had a readmission rate of 10.9%. As a balancing measure for the targeted reduction in readmission rate, we assessed length of stay, which did not change (4.8 days before vs 4.6 days after; p=0.45). CONCLUSION System-level failures and unmet patient needs are modifiable risks for readmissions. Development and reliable implementation of a COPD care bundle that mitigates these failures reduced COPD readmissions.
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Affiliation(s)
- Muhammad Ahsan Zafar
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
| | - Ralph J Panos
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Jonathan Ko
- Department of Respiratory Care, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Lisa C Otten
- Department of Respiratory Care, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Anthony Gentene
- Division of Pharmacy Practice and Administration, University of Cincinnati James L Winkle College of Pharmacy, Cincinnati, Ohio, USA.,Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Maria Guido
- Division of Pharmacy Practice and Administration, University of Cincinnati James L Winkle College of Pharmacy, Cincinnati, Ohio, USA.,Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Katherine Clark
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Caroline Lee
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jamie Robertson
- Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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20
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Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD Readmissions: Addressing COPD in the Era of Value-based Health Care. Chest 2016; 150:916-926. [PMID: 27167208 PMCID: PMC5812767 DOI: 10.1016/j.chest.2016.05.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 04/19/2016] [Accepted: 05/01/2016] [Indexed: 11/17/2022] Open
Abstract
Of those patients hospitalized for an exacerbation of COPD, one in five will require rehospitalization within 30 days. Many developed countries are now implementing policies to increase care quality while controlling costs for COPD, known as value-based health care. In the United States, COPD is part of Medicare's Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals for excess 30-day, all-cause readmissions after a hospitalization for an acute exacerbation of COPD, despite minimal evidence to guide hospitals on how to reduce readmissions. This review outlines challenges for improving overall COPD care quality and specifically for the HRRP. These challenges include heterogeneity in the literature for how COPD and readmissions are defined, difficulty finding the target population during hospitalizations, and a lack of literature to guide evidence-based programs for COPD readmissions as defined by the HRRP in the hospital setting. It then identifies risk factors for early readmissions after acute exacerbation of COPD and discusses tested and emerging strategies to reduce these readmissions. Finally, we evaluate the current HRRP and future policy changes and their effect on the goal to deliver value-based COPD care. COPD remains a chronic disease with a high prevalence that has finally garnered the attention of health systems and policy makers, but we still have a long way to go to truly deliver value-based care to patients.
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Affiliation(s)
- Tina Shah
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago, Chicago, IL
| | - Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Steven R White
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
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Abstract
PURPOSE OF REVIEW This article examines factors associated with readmission for chronic obstructive pulmonary disease and interventions that may decrease readmissions. RECENT FINDINGS The literature on this topic is relatively sparse. Drug therapy revolves around appropriate use of bronchodilators, antibiotics, and steroids. Patient education and participation and a multidisciplinary approach to the transition out of hospital can lead to decreased rehospitalizations. Patients who cannot participate in self-care may do better in skilled nursing facilities. SUMMARY We must optimize in-hospital care and see that patients receive a continuum of care upon discharge. We must also recognize that some patients have received optimal care and yet continue to suffer with end-stage disease on an ongoing basis; palliative medications such as long-acting narcotics and end-of-life discussions need to be considered in patients unable to survive for long outside of hospital.
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