Efficacy of a home discharge care bundle after acute exacerbation of COPD

[Medico-economic evaluation of the PRADO-BPCO post-exacerbation support program]

INTRODUCTION

The "Programme d'Accompagnement du retour à Domicile" (PRADO) COPD is a home discharge support program dedicated to organizing care pathways following hospitalization for COPD exacerbation. This study aimed at assessing its medico-economic impact.

METHODS

This was a retrospective database study of patients included in the PRADO BPCO between 2017 and 2019. Data were extracted from the National Health Data System. A control group was built using propensity score matching. Morbi-mortality and costs (national health insurance perspective) were measured during the year following hospitalization.

RESULTS

While the proportion of patients with a care pathway complying with recommendations from the National Health Authority was higher in the PRADO group, there was no significant effect on mortality and 12-month rehospitalization. In the PRADO group, the rehospitalization rate was lower when the care pathway was optimal. Healthcare costs per patient were 670 € higher in the PRADO group.

CONCLUSIONS

The PRADO COPD improves quality of care but without decreasing rehospitalizations and mortality, although rehospitalizations did decrease among PRADO group patients benefiting from an optimal care pathway.

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.

Are We Missing the Opportunity to Disseminate GOLD Recommendations Through AECOPD Discharge Letters?

Introduction

Acute exacerbations in chronic obstructive pulmonary disease (AECOPD) lead to poor outcomes and increased burden for patients and healthcare systems. The Global Initiative for COPD (GOLD) includes specific recommendations for AECOPD interventions, discharge criteria, and follow-up. Aligning the AECOPD discharge letters (DL) with GOLD guidelines could facilitate dissemination of recommendations among general practitioners (GPs).

Purpose

This study was conducted to assess the compliance of DL with the GOLD recommendations in Croatia.

Methods

Pre-pandemic DL of patients presenting for AECOPD to emergency room (ER) were analyzed and stratified by clinical decision to hospitalize (HDL) or discharge patients for outpatient treatment (ERDL). Experienced pulmonologists checked the information from DL against guidelines by using online study-specific questionnaires.

Results

In total, 225 HDL and 368 ERDL were analyzed. In most cases, the GOLD ABCD categories (85% HDL, 92% ERDL) or the spirometry-based degree of severity (90% HDL, 91% ERDL) were not included. The number of AEs in the previous year was recorded, but the specific frequent exacerbator phenotype not explicitly stated. The AE phenotype was included in two thirds of HDL and one third of ERDL. The blood eosinophil count was frequently available, but not considered decision-relevant information. Adjustments of previous maintenance therapy, mostly escalation, were recommended in 58.4% HDL and 27.9% ERDL, respectively. Education on proper use of inhalers was recommended only in 15.6% of HDL. Smoking cessation measures were advised in 23.1% HDL and 7.9% ERDL; pulmonary rehabilitation in 35.6% HDL and 0.8% ERDL. Early follow-up was frequently advised (>50%), but rarely appointed.

Conclusion

Significant deficiencies in compliance with the GOLD guidelines were identified, translating into a missed opportunity for GPs to become acquainted with GOLD recommendations. These findings emphasize the necessity to increase compliance with guidelines first at specialist level and consequent standardization of DL.

Developing a Multidisciplinary Approach to the COPD Care Pathway

Chronic obstructive pulmonary disease (COPD) is characterized as a predominately preventable and treatable inflammatory lung disease caused by progressive obstructed airflow from the lungs. In the United States and worldwide, it is becoming a major cause in hospital admissions as well as an increase in morbidity and mortality. The rising total cost of care for COPD is concerning for all health care industries. The disease has significant impact on the patient's quality of life and psychological well-being. A worldwide initiative is underway in developing a care model that is multifactorial through continuous monitoring of patients to manage and control symptoms, achieve medication adherence, and provide socioeconomic resources. The primary aim of this study was to prevent exacerbations, hospital admissions, and readmissions. Various models have shown positive results; however, the significant financial investment is the major barrier to success. Recently, one health system in the United States was able to improve care, decrease readmissions, and reduce total cost of care by investing in a multidisciplinary team of specialists. In the utilization of the care model, the primary endpoint will conclude that COPD is financially and socioeconomically manageable.

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

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.

Effect of internet-based self-management on pulmonary function rehabilitation and living quality in patients with chronic obstructive pulmonary disease

OBJECTIVE

This study explored and analyzed the effect of Internet-based self-management on pulmonary function rehabilitation and living quality in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Altogether, 106 stable-staged COPD patients admitted to our hospital from June 2018 to September 2019 were enrolled as the research subjects, and divided into the control group (n=51) and the observation group (n=55) according to the order of visit. The control group received conventional health education, and the observation group was treated with an educational model by Internet-based self-management. Afterwards, the changes of self-management ability, pulmonary function and living quality before and after intervention were compared between the two groups.

RESULTS

The scores of each dimension of self-management behavior in both groups of patients after intervention were critically higher than those prior to intervention (P<0.05), and the scores in observation-group patients were remarkably higher than thoes in control-group patients (P<0.05). Besides, the two groups of subjects were observed with elevated pulmonary function indexes FVC, FEV1 and 6MWD after intervention compared with that in prior-intervention (P<0.05), and the indexes in the observation-group after intervention were obviously higher than those in the control-group (P<0.05). In addition, the scores of each dimension of living quality in both groups after the intervention had a conspicuously rise compared with the prior-intervention period (P<0.05), and the scores in the observation group were remarkably lower than those in the control group (P<0.05). The satisfaction in observation group was obviously higher than that in control group (P<0.05).

CONCLUSION

Internet-based self-management can effectually improve the self-management ability of COPD patients. It is conducive to improve the patients' pulmonary function, and their living quality, thus it is worthy of clinical popularization and application.

Management of acute COPD exacerbations in France: A qualitative survey in a private practice setting

Background

The current prevalence of chronic obstructive pulmonary disease (COPD) in France is estimated to be 2.6 million and is predicted to increase to 2.8 million by 2025. Presently, there is a lack of data on COPD management within the private healthcare setting. The aim of this study was to investigate the management of COPD exacerbations by pulmonologists within private practices in France.

Methods

A prospective, online, qualitative survey was distributed to private practice pulmonologists in France. The survey covered all aspects of COPD management from diagnosis and therapeutic management, to secondary prevention and organization of care. Survey responses were collected between 27 January 2018 and 18 June 2018 and all data were summarized descriptively.

Results

The survey had a response rate of 20.6%, with 116 out of 563 pulmonologists providing responses. Overall, 87.4% of respondents stated that the management of COPD represented over 15% of their total clinical activity. Most respondents indicated that they work closely with general practitioners and a large multidisciplinary team to manage patients with numerous comorbidities. Following a COPD exacerbation, the majority of respondents (78.4%) were in favor of using respiratory-connected devices (class 2a-connected medical device according to the French HAS classification and available on medical prescription) to assist with patient follow-up at home.

Conclusions

COPD management forms part of the core clinical activity for pulmonologists within the private practice setting in France. Patients with COPD generally have multiple comorbidities and are managed by a multidisciplinary team in line with French guidelines. The use of respiratory-connected devices was highlighted as an important new strategy for improving patient care following a COPD exacerbation.

How may we improve clinical outcomes for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease? A narrative review about possible therapeutic and preventive strategies

Introduction: In a subset of chronic obstructive pulmonary disease (COPD)patients the course of the disease is complicated by a severe acute exacerbations (AECOPD) that may require hospitalization, at which time negative outcomes may occur up to 30 days after discharge. Several predictors of negative outcomes have been documented.Areas covered: We considered five negative outcomes related to patients hospitalized with AECOPD: treatment failure, noninvasive mechanical ventilation (NIMV) failure, prolonged length of hospital stay (LHS), short-term mortality (≤ 90 days from admission and including the in-hospital mortality), and early readmission (≤30 days from discharge). Possible therapeutic and preventive strategies to improve these outcomes are outlined and discussed.Expert opinion: Several strategies have been proposed to improve outcomes. Among these, steroid or antibiotic use may reduce the risks of treatment failure or of prolonged hospital stay. We note that operator-related factors may influence the outcome of NIMV. However, little has been documented about the short-term mortality or early readmission rates. In general, few interventions consistently improve negative outcomes and prognosis of AECOPD.