Hospital re-admission in patients with acute exacerbation of chronic obstructive pulmonary disease

Prescription patterns and effectiveness of medications for chronic obstructive pulmonary disease: A retrospective study of real-world settings

This study aimed to define real-world prescription patterns in Korea and compare the effectiveness of chronic obstructive pulmonary disease (COPD) medications. We used national claims data provided by the Health Insurance Review and Assessment Service in Korea and examined patients who were first diagnosed with COPD and started treatment between May 1, 2017, and April 30, 2018, with no change in drug regimen. Among 30,784 patients with COPD, long-acting β2 agonist (LABA) combined with long-acting muscarinic antagonist (LAMA) (32.7%), inhaled corticosteroid-LABA (ICS-LABA) (25.6%), LAMA (18.3%), ICS (5.8%), or LABA (4.6%) were prescribed as the first-choice inhalers. The use of LABA-LAMA (hazard ratio [HR], 0.248-0.584), LAMA (HR, 0.320-0.641), ICS-LABA (HR, 0.325-0.643), and xanthine (HR, 0.563-0.828) significantly reduced the total and severe exacerbation rates compared with no use of each medication. However, the use of ICS or LABA individually did not yield such effects. The continued use of LABA-LAMA, LAMA, and ICS-LABA showed a significant effect on exacerbation rate, whereas the long-term use of ICS, LABA, and xanthine did not. Moreover, some high doses of ICS-LABA did not show significant effects. This real-world study revealed that LAMA and/or LABA could be the first choice of therapy, as recommended by recent guidelines. However, ICS, xanthine, and high-dose ICS-LABA are still being prescribed frequently as first-line drugs in Korea.

Implementation of the Care Bundle for the Management of Chronic Obstructive Pulmonary Disease with/without Heart Failure

Chronic obstructive pulmonary disease (COPD) is often part of a more complex cardiopulmonary disease, especially in older patients. The differential diagnosis of the acute exacerbation of COPD and/or heart failure (HF) in emergency settings is challenging due to their frequent coexistence and symptom overlap. Both conditions have a detrimental impact on each other's prognosis, leading to increased mortality rates. The timely diagnosis and treatment of COPD and coexisting factors like left ventricular overload or HF in inpatient and outpatient care can improve prognosis, quality of life, and long-term outcomes, helping to avoid exacerbations and hospitalization, which increase future exacerbation risk. This work aims to address existing gaps, providing management recommendations for COPD with/without HF, particularly when both conditions coexist. During virtual meetings, a panel of experts (the authors) discussed and reached a consensus on the differential and paired diagnosis of COPD and HF, providing suggestions for risk stratification, accurate diagnosis, and appropriate therapy for inpatients and outpatients. They emphasize that when COPD and HF are concomitant, both conditions should receive adequate treatment and that recommended HF treatments are not contraindicated in COPD and have favorable effects. Accurate diagnosis and therapy is crucial for effective treatment, reducing hospital readmissions and associated costs. The management considerations discussed in this study can potentially be extended to address other cardiopulmonary challenges frequently encountered by COPD patients.

The rate of ward to intensive care transfer and its predictors among hospitalized COPD patients, a retrospective study in a local tertiary center in Saudi Arabia

OBJECTIVE

To investigate the prevalence of intensive care unit (ICU) admission and its predictors among hospitalized chronic obstructive pulmonary disease (COPD) patients.

METHODS

An observational retrospective study was conducted. All patients with a confirmed diagnosis of COPD according to the GOLD guidelines between 28 and 2020 and 1 March 2023 at Al-Noor Specialist Hospital were included in this study. Patients were excluded if a preemptive diagnosis of COPD was made clinically without spirometry evidence of fixed airflow limitation. Descriptive results were presented as frequency (percentage) for categorical variables and mean (SD) for continuous variables and to estimate prevalence of ICU admission. Predictors of ICU admission among hospitalized COPD patients were determined using logistic regression analysis. A SPSS (Statistical Package for the Social Sciences) version 25 was used to perform all statistical analysis.

RESULTS

A total of 705 patients with COPD were included in this study. The mean age was 65.4 (25.3) years. Around 12.4% of the hospitalized patients were admitted to the ICD. Logistic regression analysis identified that older age (OR; 1.92, (1.41-2.62)), smoking (OR; 1.60 (1.17-2.19)), and having specific comorbidities (Hypertension (OR; 1.98 (1.45-2.71)), Diabetes mellitus (OR; 1.42 (1.04-1.93)), GERD (OR; 2.81 (1.99-3.96)), Ischemic heart disease (OR; 3.22 (2.19-4.75)), Obstructive sleep apnea syndrome (OR; 2.14 (1.38-3.33)), stroke (OR; 4.51 (2.20-9.26))) were predictors of ICU admissions among patients with COPD.

CONCLUSIONS

Our study found that a step-up approach to inpatient COPD management requires admission to the ICU in 12.4%, for which age, smoking status, cardiovascular, and stroke were important predictors. Further clinical research is needed to provide a validated model that can be incorporated into clinical practice to monitor this patient population during their admission and identify at-risk individuals for early transfer to higher acuity settings and intensive care units.

Readmission rate for acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

The readmission rate following hospitalization for chronic obstructive pulmonary disease (COPD) exacerbations is extremely high and has become a common and challenging clinical problem. This study aimed to systematically summarize COPD readmission rates for acute exacerbations and their underlying risk factors.

METHODS

A comprehensive search was performed using PubMed, Embase, Cochrane Library, and Web of Science, published from database inception to April 2, 2022. Methodological quality was evaluated using the Newcastle-Ottawa Scale (NOS). We used a random-effects model or a fixed-effects model to estimate the pooled COPD readmission rate for acute exacerbations and underlying risk factors.

RESULTS

A total of 46 studies were included, of which 24, 7, 17, 7, and 20 summarized the COPD readmission rates for acute exacerbations within 30, 60, 90, 180, and 365 days, respectively. The pooled 30-, 60-, 90-, 180-, and 365-day readmission rates were 11%, 17%, 17%, 30%, and 37%, respectively. The study design type, age stage, WHO region, and length of stay (LOS) were initially considered to be sources of heterogeneity. We also identified potential risk factors for COPD readmission, including male sex, number of hospitalizations in the previous year, LOS, and comorbidities such as heart failure, tumor or cancer, and diabetes, whereas obesity was a protective factor.

CONCLUSIONS

Patients with COPD had a high readmission rate for acute exacerbations, and potential risk factors were identified. Therefore, we should propose clinical interventions and adjust or targeted the control of avoidable risk factors to prevent and reduce the negative impact of COPD readmission.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42022333581.

The Association with COPD Readmission Rate and Access to Medical Institutions in Elderly Patients

Purpose

Up to 20% of patients with chronic obstructive pulmonary disease (COPD) require re-admission within 30 days of discharge after hospitalization for acute exacerbations of the disease. These re-admissions can increase morbidity and the economic burden of COPD. Reducing re-admissions has become a policy target in many developed countries. We investigated the risk factors for COPD re-admissions among older adults with COPD.

Patients and Methods

Data obtained from the National Health Insurance Service-Senior Cohort (NHIS-SC) in Korea were analyzed. The subjects included 558,147 patients aged ≥70 who had been admitted for COPD between 2013 and 2015. Re-admission was defined as being re-hospitalized within 30 days after discharge. The key variables selected from the database included income-based insurance contributions, demographical variables, information on inpatient medical services, types of healthcare facilities, and emergency time relevance index (TRI). The TRI is a regional medical-use analysis index that evaluates whether the capacity of the medical services available is appropriate for the medical needs of the target residents.

Results

In 814 COPD re-admission cases among 4867 total admissions due to COPD in elderly subjects, higher re-admission rates were associated with male sex, admission to district hospitals, medical aid recipients, and a longer hospital stay. When additionally adjusting the TRI to identify the difference in re-admission rates due to medical service accessibility, the same results were found, except for the areas of residence. The TRI was lower in re-admission cases (odds ratio 0.991 [95% CI, 0.984‒0.998], P = 0.013).

Conclusion

In this study, COPD re-admission rates among older adults were significantly associated with sex, length of hospital stay, and the type of hospital. The capacity of the medical services provided was also related to the COPD re-admission rate. Better access to appropriate emergency services is associated with reduction of COPD re-admission rates.

Risk factors and associated outcomes of hospital readmission in COPD: A systematic review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of unplanned readmission. There is need to identify risk factors for, and strategies to prevent readmission in patients with COPD.

AIM

To systematically review and summarise the prevalence, risk factors and outcomes associated with rehospitalisation due to COPD exacerbation.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Five databases were searched for relevant studies.

RESULTS

Fifty-seven studies from 30 countries met the inclusion criteria. The prevalence of COPD-related readmission varied from 2.6 to 82.2% at 30 days, 11.8-44.8% at 31-90 days, 17.9-63.0% at 6 months, and 25.0-87.0% at 12 months post-discharge. There were differences in the reported factors associated with readmissions, which may reflect variations in the local context, such as the availability of community-based services to care for exacerbations of COPD. Hospitalisation in the previous year prior to index admission was the key predictor of COPD-related readmission. Comorbidities (in particular asthma), living in a deprived area and living in or discharge to a nursing home were also associated with readmission. Relative to those without readmissions, readmitted patients had higher in-hospital mortality rates, shorter long-term survival, poorer quality of life, longer hospital stay, increased recurrence of subsequent readmissions, and accounted for greater healthcare costs.

CONCLUSIONS

Hospitalisation in the previous year was the principal risk factor for COPD-related readmissions. Variation in the prevalence and the reported factors associated with COPD-related readmission indicate that risk factors cannot be generalised, and interventions should be tailored to the local healthcare environment.

Frailty in Chronic Obstructive Pulmonary Disease and Risk of Exacerbations and Hospitalizations

Background

Frailty is a complex clinical syndrome associated with vulnerability to adverse health outcomes. While frailty is thought to be common in chronic obstructive pulmonary disease (COPD), the relationship between frailty and COPD-related outcomes such as risk of acute exacerbations of COPD (AE-COPD) and hospitalizations is unclear.

Purpose

To examine the association between physical frailty and risk of acute exacerbations, hospitalizations, and mortality in patients with COPD.

Methods

A longitudinal analysis of data from a cohort of 280 participants was performed. Baseline frailty measures included exhaustion, weakness, low activity, slowness, and undernutrition. Outcome measures included AE-COPD, hospitalizations, and mortality over 2 years. Negative binomial regression and Cox proportional hazard modeling were used.

Results

Sixty-two percent of the study population met criteria for pre-frail and 23% were frail. In adjusted analyses, the frailty syndrome was not associated with COPD exacerbations. However, among the individual components of the frailty syndrome, weakness measured by handgrip strength was associated with increased risk of COPD exacerbations (IRR 1.46, 95% CI 1.09–1.97). The frailty phenotype was not associated with all-cause hospitalizations but was associated with increased risk of non-COPD-related hospitalizations.

Conclusion

This longitudinal cohort study shows that a high proportion of patients with COPD are pre-frail or frail. The frailty phenotype was associated with an increased risk of non-COPD hospitalizations but not with all-cause hospitalizations or COPD exacerbations. Among the individual frailty components, low handgrip strength was associated with increased risk of COPD exacerbations over a 2-year period. Measuring handgrip strength may identify COPD patients who could benefit from programs to reduce COPD exacerbations.

Comorbidities and Readmissions in Survivors of Acute Hypercapnic Respiratory Failure

Chronic obstructive pulmonary disease (COPD) is defined by chronic airflow obstruction, but is presently considered as a complex, heterogeneous, and multicomponent disease in which comorbidities and extrapulmonary manifestations make important contributions to disease expression. COPD-related hospital readmission. In particular frequent intensive care unit (ICU) readmissions for exacerbations represent a major challenge and place a high burden on patient outcomes and health-related quality of life, as well as on the healthcare system.In this narrative review, we first address major and often undiagnosed comorbidities associated with COPD that could have an impact on hospital readmission after an index ICU admission for acute hypercapnic respiratory failure. Some guidance for treatment is discussed. Second, we present predictors of hospital and ICU readmission and discuss various strategies to reduce such events.There is a strong rationale to detect and treat major comorbidities early after index ICU admission for acute hypercapnic respiratory failure. It still remains unclear, however, if a comprehensive and holistic approach to comorbidities in frail patients surviving hypercapnic respiratory failure can efficiently reduce the readmission rate.

Using machine learning approaches to predict high-cost chronic obstructive pulmonary disease patients in China

The accurate identification and prediction of high-cost Chronic obstructive pulmonary disease (COPD) patients is important for addressing the economic burden of COPD. The objectives of this study were to use machine learning approaches to identify and predict potential high-cost patients and explore the key variables of the forecasting model, by comparing differences in the predictive performance of different variable sets. Machine learning approaches were used to estimate the medical costs of COPD patients using the Medical Insurance Data of a large city in western China. The prediction models used were logistic regression, random forest (RF), and extreme gradient boosting (XGBoost). All three models had good predictive performance. The XGBoost model outperformed the others. The areas under the ROC curve for Logistic Regression, RF and XGBoost were 0.787, 0.792 and 0.801. The precision and accuracy metrics indicated that the methods achieved correct and reliable results. The results of this study can be used by healthcare data analysts, policy makers, insurers, and healthcare planners to improve the delivery of health services.

Improving acceptance and uptake of pulmonary rehabilitation after acute exacerbation of COPD: Acceptability, feasibility, and safety of a PR "taster" session delivered before hospital discharge

The objectives of this study were to (1) assess the acceptability, feasibility, and safety of delivering a pulmonary rehabilitation (PR) "taster" session to patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease; (2) evaluate the changes in patient knowledge and readiness to commence PR; and (3) make recommendations for future intervention iterations. Acceptability was measured by the proportion of patients that accepted to participate. Feasibility was measured by the proportion of eligible participants. Knowledge was evaluated using the modified versions of the Understanding COPD (UCOPD) and Bristol COPD Knowledge (BCKQ) questionnaires. Readiness to commence PR was measured by a modified version of the Readiness to Change Exercise Questionnaire. All measures were delivered pre- and post-intervention. Thirty-one of 34 eligible individuals were able to be approached. Prospective acceptability was low, with 24 individuals declining the intervention, 1 being discharged without making a decision, and only 6 participating. Positive median change was recorded in the modified UCOPD questionnaire (+8), but not the BCKQ (0). Three of the patients were already in the action phase pre-intervention, with all but one in that phase post-intervention. The delivery of a PR "taster" session was not prospectively acceptable to a large portion of patients and only feasible with modifications to the original protocol.

Healthcare utilization and costs associated with COPD among SEER-Medicare beneficiaries with NSCLC

AIM

To estimate the healthcare utilization and costs in elderly lung cancer patients with and without pre-existing chronic obstructive pulmonary disease (COPD).

METHODS

Using Surveillance, Epidemiology and End Results (SEER)-Medicare data, this study identified patients with lung cancer between 2006-2010, at least 66 years of age, and continuously enrolled in Medicare Parts A and B in the 12 months prior to cancer diagnosis. The diagnosis of pre-existing COPD in lung cancer patients was identified using ICD-9 codes. Healthcare utilization and costs were categorized as inpatient hospitalizations, skilled nursing facility (SNF) use, physician office visits, ER visits, and outpatient encounters for every stage of lung cancer. The adjusted analysis was performed using a generalized linear model for healthcare costs and a negative binomial model for healthcare utilization.

RESULTS

Inpatient admissions in the COPD group increased for each stage of non-small cell lung cancer (NSCLC) compared to the non-COPD group per 100 person-months (Stage I: 14.67 vs 9.49 stays, p < .0001; Stage II: 14.13 vs 10.78 stays, p < .0001; Stage III: 28.31 vs 18.91 stays, p < .0001; Stage IV: 49.5 vs 31.24 stays, p < .0001). A similar trend was observed for outpatient visits, with an increase in utilization among the COPD group (Stage I: 1136.04 vs 796 visits, p < .0001; Stage II: 1325.12 vs 983.26 visits, p < .0001; Stage III: 2025.47 vs 1656.64 visits, p < .0001; Stage IV: 2825.73 vs 2422.26 visits, p < .0001). Total direct costs per person-month in patients with pre-existing COPD were significantly higher than the non-COPD group across all services ($54,799.16 vs $41,862.91). Outpatient visits represented the largest cost category across all services in both groups, with higher costs among the COPD group ($41,203 vs $31,140.08).

CONCLUSION

Healthcare utilization and costs among lung cancer patients with pre-existing COPD was ∼2-3-times higher than the non-COPD group.

Continuity of care and its effect on readmissions for COPD patients: A comparative study of Norway and Germany

BACKGROUND

This study compares continuity of care between Germany - a social health insurance country, and Norway - a national health service country with gatekeeping and patient lists for COPD patients before and after initial hospitalization. We also investigate how subsequent readmissions are affected.

METHODS

Continuity of Care Index (COCI), Usual Provider Index (UPC) and Sequential Continuity Index (SECON) were calculated using insurance claims and national register data (2009-14). These indices were used in negative binomial and logistic regressions to estimate incident rate ratios (IRR) and odds ratios (OR) for comparing readmissions.

RESULTS

All continuity indices were significantly lower in Norway. One year readmissions were significantly higher in Germany, whereas 30-day rates were not. All indices measured one year after discharge were negatively associated with one-year readmissions for both countries. Significant associations between indices measured before hospitalization and readmissions were only observed in Norway - all indices for one-year readmissions and SECON for 30-day readmissions.

CONCLUSION

Our findings indicate higher continuity is associated with reductions in readmissions following initial COPD admission. This is observed both before and after hospitalization in a system with gatekeeping and patient lists, yet only after for a system lacking such arrangements. These results emphasize the need for policy strategies to further investigate and promote care continuity in order to reduce hospital readmission burden for COPD patients.

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease: factors predicting readmission

Rationale

Readmissions are common following acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and are partially responsible for increased morbidity and mortality in COPD. Numerous factors have been shown to predict readmission of patients previously admitted to hospital for AECOPD; however, factors related to readmission in patients who are triaged in emergency departments (EDs) and sent directly home are poorly understood. We postulate that patients seen in the ED for AECOPD and directly sent home have a high readmission rate, and we suspect that inadequate management and follow-up contribute to this high readmission rate.

Methods

We conducted a 1-year retrospective study of all patients seen in the ED for AECOPD at an inner-city tertiary care hospital; 30- and 90-day readmission rates for COPD and all-cause admissions to the ED and hospital were determined. Patients discharged directly home from the ED were compared with those admitted to hospital for management. Patient, treatment, and system variables that could potentially impact readmission were documented. Multivariate Poisson regression models were used to determine which factors predicted readmissions.

Results

The readmission rates in the ED group (n=240) were significantly higher than that in the hospitalized group (n=271): 1) the 90-day ED readmissions (1.29 vs 0.51, p<0.0001) and 30-day ED readmissions (0.54 vs 0.20, p<0.0001) (ED vs hospitalized groups) were significantly higher in the ED group; 2) the time to first readmission was significantly shorter in the ED group than in the hospitalized group (24.1±22 vs 31.8±27.8 days; p<0.05). Cardiovascular comorbidities (p<0.00001), substance abuse disorder (p<0.001), and mental illness (p<0.001) were the strongest predictors of readmission in the ED group. Age (p<0.01), forced expiratory volume in 1 second (p<0.001), and cardiovascular comorbidities (p<0.05) were the best predictors for both 30- and 90-day COPD readmission rates in the ED group. Only 50% of the ED group patients received bronchodilators, oral steroids, and antibiotics inclusively, and only 68% were referred for community follow-up. The need for oral steroids to treat AECOPD predicted future 90-day COPD readmissions in the ED group (p<0.003).

Conclusion

Patients discharged directly home from EDs have a significantly higher risk of readmission to EDs than those who are hospitalized. One possible reason for this is that COPD management is variable in EDs with <50% receiving appropriate therapy.

Cost-effectiveness of FreeO2 in patients with chronic obstructive pulmonary disease hospitalised for acute exacerbations: analysis of a pilot study in Quebec

OBJECTIVE

Conduct a cost-effectiveness analysis of FreeO2 technology versus manual oxygen-titration technology for patients with chronic obstructive pulmonary disease (COPD) hospitalised for acute exacerbations.

SETTING

Tertiary acute care hospital in Quebec, Canada.

PARTICIPANTS

47 patients with COPD hospitalised for acute exacerbations.

INTERVENTION

An automated oxygen-titration and oxygen-weaning technology.

METHODS AND OUTCOMES

The costs for hospitalisation and follow-up for 180 days were calculated using a microcosting approach and included the cost of FreeO2 technology. Incremental cost-effectiveness ratios (ICERs) were calculated using bootstrap resampling with 5000 replications. The main effect variable was the percentage of time spent at the target oxygen saturation (SpO2). The other two effect variables were the time spent in hyperoxia (target SpO2+5%) and in severe hypoxaemia (SpO2 <85%). The resamplings were based on data from a randomised controlled trial with 47 patients with COPD hospitalised for acute exacerbations.

RESULTS

FreeO2 generated savings of 20.7% of the per-patient costs at 180 days (ie, -$C2959.71). This decrease is nevertheless not significant at the 95% threshold (P=0.13), but the effect variables all improved (P<0.001). The improvement in the time spent at the target SpO2 was 56.3%. The ICERs indicate that FreeO2 technology is more cost-effective than manual oxygen titration with a savings of -$C96.91 per percentage point of time spent at the target SpO2 (95% CI -301.26 to 116.96).

CONCLUSION

FreeO2 technology could significantly enhance the efficiency of the health system by reducing per-patient costs at 180 days. A study with a larger patient sample needs to be carried out to confirm these preliminary results.

TRIAL REGISTRATION NUMBER

NCT01393015; Post-results.

Impact and prevention of severe exacerbations of COPD: a review of the evidence

Severe exacerbations of COPD, ie, those leading to hospitalization, have profound clinical implications for patients and significant economic consequences for society. The prevalence and burden of severe COPD exacerbations remain high, despite recognition of the importance of exacerbation prevention and the availability of new treatment options. Severe COPD exacerbations are associated with high mortality, have negative impact on quality of life, are linked to cardiovascular complications, and are a significant burden on the health-care system. This review identified risk factors that contribute to the development of severe exacerbations, treatment options (bronchodilators, antibiotics, corticosteroids [CSs], oxygen therapy, and ventilator support) to manage severe exacerbations, and strategies to prevent readmission to hospital. Risk factors that are amenable to change have been highlighted. A number of bronchodilators have demonstrated successful reduction in risk of severe exacerbations, including long-acting muscarinic antagonist or long-acting β2-agonist mono- or combination therapies, in addition to vaccination, mucolytic and antibiotic therapy, and nonpharmacological interventions, such as pulmonary rehabilitation. Recognition of the importance of severe exacerbations is an essential step in improving outcomes for patients with COPD. Evidence-based approaches to prevent and manage severe exacerbations should be implemented as part of targeted strategies for disease management.

Frailty is a predictive factor of readmission within 90 days of hospitalization for acute exacerbations of chronic obstructive pulmonary disease: a longitudinal study

BACKGROUND

Readmission after hospital discharge is common in patients with acute exacerbations (AE) of chronic obstructive pulmonary disease (COPD). Although frailty predicts hospital readmission in patients with chronic nonpulmonary diseases, no multidimensional frailty measures have been validated to stratify the risk for patients with COPD.

AIM

The aim of this study was to explore multidimensional frailty as a potential risk factor for readmission due to a new exacerbation episode during the 90 days after hospitalization for AE-COPD and to test whether frailty could improve the identification of patients at high risk of readmission. We hypothesized that patients with moderate-to-severe frailty would be at greater risk for readmission within that period of follow up. A secondary aim was to test whether frailty could improve the accuracy with which to discriminate patients with a high risk of readmission. Our investigation was part of a wider study protocol with additional aims on the same study population.

METHODS

Frailty, demographics, and disease-related factors were measured prospectively in 102 patients during hospitalization for AE-COPD. Some of the baseline data reported were collected as part of a previously study. Readmission data were obtained on the basis of the discharge summary from patients' electronic files by a researcher blinded to the measurements made in the previous hospitalization. The association between frailty and readmission was assessed using bivariate analyses and multivariate logistic regression models. Whether frailty better identifies patients at high risk for readmission was evaluated by area under the receiver operator curve (AUC).

RESULTS

Severely frail patients were much more likely to be readmitted than nonfrail patients (45% versus 18%). After adjusting for age and relevant disease-related factors in a final multivariate model, severe frailty remained an independent risk factor for 90-day readmission (odds ratio = 5.19; 95% confidence interval: 1.26-21.50). Age, number of hospitalizations for exacerbations in the previous year and length of stay were also significant in this model. Additionally, frailty improved the predictive accuracy of readmission by improving the AUC.

CONCLUSIONS

Multidimensional frailty predicts the risk of early hospital readmission in patients hospitalized for AE-COPD. Frailty improved the accuracy of discriminating patients at high risk for readmission. Identifying patients with frailty for targeted interventions may reduce early readmission rates.

Variations in the cost of formal and informal health care for patients with advanced chronic disease and refractory breathlessness: A cross-sectional secondary analysis

BACKGROUND

Refractory breathlessness in advanced chronic disease leads to high levels of disability, anxiety and social isolation. These result in high health-resource use, although this is not quantified.

AIMS

To measure the cost of care for patients with advanced disease and refractory breathlessness and to identify factors associated with high costs.

DESIGN

A cross-sectional secondary analysis of data from a randomised controlled trial.

SETTING/PARTICIPANTS

Patients with advanced chronic disease and refractory breathlessness recruited from three National Health Service hospitals and via general practitioners in South London.

RESULTS

Of 105 patients recruited, the mean cost of formal care was £3253 (standard deviation £3652) for 3 months. The largest contributions to formal-care cost were hospital admissions (>60%), and palliative care contributed <1%. When informal care was included, the total cost increased by >250% to £11,507 (standard deviation £9911). Increased patient disability resulting from breathlessness was associated with high cost (£629 per unit increase in disability score; p = 0.006). Increased breathlessness on exertion and the presence of an informal carer were also significantly associated with high cost. Patients with chronic obstructive pulmonary disease tended to have higher healthcare costs than other patients.

CONCLUSION

Informal carers contribute significantly to the care of patients with advanced disease and refractory breathlessness. Disability resulting from breathlessness is an important clinical cost driver. It is important for policy makers to support and acknowledge the contributions of informal carers. Further research is required to assess the clinical- and cost-effectiveness of palliative care interventions in reducing disability resulting from breathlessness in this patient group.

Impact of a COPD comprehensive case management program on hospital length of stay and readmission rates

Background

COPD accounts for the highest rate of hospital admissions among major chronic diseases. COPD hospitalizations are associated with impaired quality of life, high health care utilization, and poor prognosis and result in an economic and a social burden that is both substantial and increasing.

Aim

The aim of this study is to determine the efficacy of a comprehensive case management program (CCMP) in reducing length of stay (LOS) and risk of hospital admissions and readmissions in patients with COPD.

Materials and methodology

We retrospectively compared outcomes across five large hospitals in Vancouver, BC, Canada, following the implementation of a systems approach to the management of COPD patients who were identified in the hospital and followed up in the community for 90 days. We compared numbers, rates, and intervals of readmission and LOS during 2 years of active program delivery compared to 1 year prior to program implementation.

Results

A total of 1,564 patients with a clinical diagnosis of COPD were identified from 2,719 hospital admissions during the 3 years of study. The disease management program reduced COPD-related hospitalizations by 30% and hospitalizations for all causes by 13.6%. Similarly, the rate of readmission for all causes showed a significant decline, with hazard ratios (HRs) of 0.55 (year 1) and 0.51 (year 2) of intervention (P<0.001). In addition, patients’ mean LOS (days) for COPD-related admissions declined significantly from 10.8 to 6.8 (P<0.05).

Conclusion

A comprehensive disease management program for COPD patients, including education, case management, and follow-up, was associated with significant reduction in hospital admissions and LOS.

Comorbidity as a contributor to frequent severe acute exacerbation in COPD patients

Background

Comorbidities have a serious impact on the frequent severe acute exacerbations (AEs) in patients with COPD. Previous studies have used the Charlson comorbidity index to represent a conglomerate of comorbidities; however, the respective contribution of each coexisting disease to the frequent severe AEs remains unclear.

Methods

A retrospective, observational study was performed in 77 COPD patients who experienced severe AE between January 2012 and December 2014 and had at least 1-year follow-up period from the date of admission for severe AE. We explored the incidence of frequent severe AEs (≥2 severe AEs during 1-year period) in these patients and investigated COPD-related factors and comorbidities as potential risk factors of these exacerbations.

Results

Out of 77 patients, 61 patients (79.2%) had at least one comorbidity. During a 1-year follow-up period, 29 patients (37.7%) experienced frequent severe AEs, approximately two-thirds (n=19) of which occurred within the first 90 days after admission. Compared with patients not experiencing frequent severe AEs, these patients were more likely to have poor lung function and receive home oxygen therapy and long-term oral steroids. In multiple logistic regression analysis, coexisting asthma (adjusted odds ratio [OR] =4.02, 95% confidence interval [CI] =1.30–12.46, P=0.016), home oxygen therapy (adjusted OR =9.39, 95% CI =1.60–55.30, P=0.013), and C-reactive protein (adjusted OR =1.09, 95% CI =1.01–1.19, P=0.036) were associated with frequent severe AEs. In addition, poor lung function, as measured by forced expiratory volume in 1 second (adjusted OR =0.16, 95% CI =0.04–0.70, P=0.015), was inversely associated with early (ie, within 90 days of admission) frequent severe AEs.

Conclusion

Based on our study, among COPD-related comorbidities, coexisting asthma has a significant impact on the frequent severe AEs in COPD patients.

Factors Related to Chronic Obstructive Pulmonary Disease Readmission in Taiwan

This study examines the relationships among physiological, psychological, and social factors and hospital readmission to develop a model predicting chronic obstructive pulmonary disease (COPD) readmission for 145 patients with COPD following hospital discharge at 14 days and 90 days in Taiwan. Daily functioning, comorbidity, severity of illness, self-efficacy, depressive symptoms, and perceived informal support were regressed on hospital readmission. Daily functioning was the only significant variable to predict COPD readmission at 90 days in the Taiwan population living in a rural area. Age was significantly correlated with 14 days readmission. Post hoc analyses examined differences in three ethnic groups. Mainlanders perceived less family support, had higher depressive symptoms and lower daily functioning than the majority culture Fukiens and Hakkas, or the Aborigines. The study reinforced the need for identification of cultural differences and low functioning as risk factors for early readmission so they can be addressed in discharge planning.

Effectiveness of Telemonitoring in Patients with Chronic Obstructive Pulmonary Disease in Taiwan-A Randomized Controlled Trial

Chronic obstructive pulmonary disease (COPD) is the leading cause of death worldwide, and poses a substantial economic and social burden. Telemonitoring has been proposed as a solution to this growing problem, but its impact on patient outcome is equivocal. This randomized controlled trial aimed to investigate effectiveness of telemonitoring in improving COPD patient outcome. In total, 106 subjects were randomly assigned to the telemonitoring (n = 53) or usual care (n = 53) group. During the two months following discharge, telemonitoring group patients had to report their symptoms daily using an electronic diary. The primary outcome measure was time to first re-admission for COPD exacerbation within six months of discharge. During the follow-up period, time to first re-admission for COPD exacerbation was significantly increased in the telemonitoring group than in the usual care group (p = 0.026). Telemonitoring was also associated with a reduced number of all-cause re-admissions (0.23 vs. 0.68/patient; p = 0.002) and emergency room visits (0.36 vs. 0.91/patient; p = 0.006). In conclusion, telemonitoring intervention was associated with improved outcomes among COPD patients admitted for exacerbation in a country characterized by a small territory and high accessibility to medical services. The findings are encouraging and add further support to implementation of telemonitoring as part of COPD care.

Utilization due to chronic obstructive pulmonary disease and its predictors: a study using the U.S. National Emergency Department Sample (NEDS)

Background

Previous studies of healthcare utilization for chronic obstructive pulmonary disease (COPD) have focused on time-trends in COPD visits or COPD treatments, or the effect of hospital volume on mortality. Few data are available regarding outcomes after an ED visit (and subsequent hospitalization) for COPD, which are both very common in patients with COPD. Our objective was to assess time-trends and predictors of emergency department and subsequent inpatient health care utilization and charges associated with COPD in the U.S.

Method

We used the 2009-12 U.S. Nationwide Emergency Department Sample (NEDS) to study the incidence of ED visits and subsequent hospitalizations with COPD as the primary diagnosis. We used the 2012 NEDS data to study key patient/hospital factors associated with outcomes, including charges, hospitalization and dischage from hospital to home.

Results

ED visits for COPD as the primary diagnosis increased from 1.02 million in 2009 to 1.04 in 2010 to 1.10 million in 2012 (0.79–0.82 % of all ED visits); respective charges were $2.13, $2.32, and $3.09 billion. In 2012, mean ED charges/visit were $2,812, hospitalization charges/visit were $29,043 and the length of hospital stay was 4.3 days. 49 % were hospitalized after an ED visit. Older age, higher median income, metropolitan residence and comorbidities (diabetes, hypertension, HF, hyperlipidemia, CHD, renal failure and osteoarthritis) were associated with higher risk whereas male sex, Medicaid or self pay insurance status, hospital location in Midwest, South or West U.S. were associated with lower risk of hospitalization. 65.4 % of all patients hospitalized for COPD from ED were discharged home. Older age, comorbidities (diabetes, HF, CHD, renal failure, osteoarthritis) and metropolitan residence were associated with lower odds of discharge to home, whereas male sex, payer other than Medicare, Midwest, South or West U.S. hospital location were associated with higher odds.

Conclusion

Health care utilization and costs in patients with COPD are significant and increasing. COPD constitutes a major public health burden in the U.S. We identified risk factors for hospitalization, costs, and home discharge in patients with COPD that will allow future studies to investigate interventions to potentially reduce COPD-associated utilization.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-015-0319-y) contains supplementary material, which is available to authorized users.

Pulmonary rehabilitation and severe exacerbations of COPD: solution or white elephant?

Hospitalisations for severe exacerbations of chronic obstructive pulmonary disease are associated with significant physical and psychological consequences including an increase in symptom severity, severe reductions in physical activity, a deleterious effect on skeletal muscle, impaired exercise tolerance/ability to self-care, decline in quality of life, and increased anxiety and depression. As these consequences are potentially amenable to exercise training, there is a clear rationale for pulmonary rehabilitation in the peri/post-exacerbation setting. Although a 2011 Cochrane review was overwhelmingly positive, subsequent trials have shown less benefit and real-life observational studies have revealed poor acceptability. Qualitative studies have demonstrated that the patient experience is a determining factor while the presence of comorbidities may influence referral, adherence and response to pulmonary rehabilitation. Systematic reviews of less supervised interventions, such as self-management, have shown limited benefits in the post-exacerbation setting. The recent update of the Cochrane review of peri-exacerbation pulmonary rehabilitation showed that benefits were associated with the "comprehensive" nature of the intervention (the number of sessions received, the intensity of exercise training and education delivered, and the degree of supervision) but implementation is demanding. The challenge is to develop interventions that are deliverable and acceptable around the time of an acute exacerbation but also deliver the desired clinical impact.

Chronic obstructive pulmonary disease exacerbation: A single-center perspective on hospital readmissions

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third most common cause in the United States of hospital readmission within 30 days of discharge. Readmissions, which are attributed to poor quality of care, are costly. We examined the factors associated with 30-day readmission in patients hospitalized with acute exacerbation of COPD. Our hypothesis was that early readmissions among patients with COPD are related to patient factors rather than system or provider factors.

METHODS

We performed a retrospective chart review of all patients discharged from our facility from June 2010 to May 2011 with a primary discharge diagnosis of COPD. Detailed patient characteristics were obtained from the electronic medical record. Patients were followed for 30 days post-discharge date. We examined the differences in baseline characteristics of patients readmitted within 30 days and those not readmitted.

RESULTS

A total of 160 patients were admitted for 192 hospitalizations during the study period; 31 patients (19.4%) were readmitted within 30 days. Patients who were readmitted did not differ from those who were not readmitted of the following factors: baseline medication use, length of stay, and outpatient follow-up postdischarge. Readmitted patients were more likely to be black, to have coronary artery disease, to have a history of alcohol abuse, and to be on supplemental oxygen. Multivariate analysis showed a 2.17 odds of 30-day readmission (95% CI, 1.16-4.09) in patients with alcohol abuse, and 2.52 (95% CI, 1.18-5.38) in those on supplemental oxygen.

CONCLUSION

In our study population, 19.4% of acute exacerbation COPD patients were readmitted within 30 days. Patient factors (such as alcohol abuse and advanced disease) were associated with 30-day readmission.

Is the readmission rate a valid quality indicator? A review of the evidence

INTRODUCTION

Hospital readmission rates are increasingly used for both quality improvement and cost control. However, the validity of readmission rates as a measure of quality of hospital care is not evident. We aimed to give an overview of the different methodological aspects in the definition and measurement of readmission rates that need to be considered when interpreting readmission rates as a reflection of quality of care.

METHODS

We conducted a systematic literature review, using the bibliographic databases Embase, Medline OvidSP, Web-of-Science, Cochrane central and PubMed for the period of January 2001 to May 2013.

RESULTS

The search resulted in 102 included papers. We found that definition of the context in which readmissions are used as a quality indicator is crucial. This context includes the patient group and the specific aspects of care of which the quality is aimed to be assessed. Methodological flaws like unreliable data and insufficient case-mix correction may confound the comparison of readmission rates between hospitals. Another problem occurs when the basic distinction between planned and unplanned readmissions cannot be made. Finally, the multi-faceted nature of quality of care and the correlation between readmissions and other outcomes limit the indicator's validity.

CONCLUSIONS

Although readmission rates are a promising quality indicator, several methodological concerns identified in this study need to be addressed, especially when the indicator is intended for accountability or pay for performance. We recommend investing resources in accurate data registration, improved indicator description, and bundling outcome measures to provide a more complete picture of hospital care.

Utility of the combination of serum highly-sensitive C-reactive protein level at discharge and a risk index in predicting readmission for acute exacerbation of COPD

OBJECTIVE

Frequent readmissions for acute exacerbations of COPD (AECOPD) are an independent risk factor for increased mortality and use of health-care resources. Disease severity and C-reactive protein (CRP) level are validated predictors of long-term prognosis in such patients. This study investigated the utility of combining serum CRP level with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) exacerbation risk classification for predicting readmission for AECOPD.

METHODS

This was a prospective observational study of consecutive patients hospitalized for AECOPD at Peking University Third Hospital, in Beijing, China. We assessed patient age; gender; smoking status and history (pack-years); lung function; AECOPD frequency during the last year; quality of life; GOLD risk category (A-D; D indicating the greatest risk); and serum level of high-sensitivity CRP at discharge (hsCRP-D).

RESULTS

The final sample comprised 135 patients. Of those, 71 (52.6%) were readmitted at least once during the 12-month follow-up period. The median (interquartile) time to readmission was 78 days (42-178 days). Multivariate analysis revealed that serum hsCRP-D ≥ 3 mg/L and GOLD category D were independent predictors of readmission (hazard ratio = 3.486; 95% CI: 1.968-6.175; p < 0.001 and hazard ratio = 2.201; 95% CI: 1.342-3.610; p = 0.002, respectively). The ordering of the factor combinations by cumulative readmission risk, from highest to lowest, was as follows: hsCRP-D ≥ 3 mg/L and GOLD category D; hsCRP-D ≥ 3 mg/L and GOLD categories A-C; hsCRP-D < 3 mg/L and GOLD category D; hsCRP-D < 3 mg/L and GOLD categories A-C.

CONCLUSIONS

Serum hsCRP-D and GOLD classification are independent predictors of readmission for AECOPD, and their predictive value increases when they are used in combination.

Pulmonary rehabilitation at the time of the COPD exacerbation

Pulmonary rehabilitation (PR) is associated with improvements in exercise capacity, health related quality of life, psychological symptoms and response to utilization. Acute exacerbations threaten these improvements. An awareness of the clinical sequelae of acute exacerbation of chronic obstructive pulmonary disease enables approaches, such as early post exacerbation rehabilitation to mitigate its negative effects.

Readmissions after hospital discharge with acute exacerbation of COPD: are we missing something?

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an important part of the disease's morbidity, mortality, and progression, and is associated with increasing utilization of health care resources. The concept of integrated care based on a chronic care model is relatively new to chronic obstructive pulmonary disease, but has proved successful in improving clinical outcomes and probably in decreasing health care utilization in other chronic conditions. A comprehensive approach is needed to target a change in behavioral patterns in patients, increase physician's awareness and adherence to evidence-based recommendations, and address system related issues. This article discusses the evidence for various facets of nonpharmacological management of AECOPD and proposes a model of care that might be the missing link for reducing hospital readmissions for AECOPD. This model may decrease the morbidity, slow disease progression, and curb the increasing health care resource utilization without compromising patient care.

Readmissions for COPD: propensity case-matched comparison between pulmonary and non-pulmonary departments

INTRODUCTION

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common cause of hospitalisation, and the readmission rate is high. We aimed to determine whether patients discharged from a pulmonary department (PD) after an AECOPD episode had a lower COPD-related readmission rate during the next 12 months than comparable patients discharged from other internal medicine departments (ODs).

METHODS

The medical records of 566 patients discharged after an episode of AECOPD between March 2006 and December 2008 at Oslo University Hospital, Aker, were reviewed retrospectively. Demographic and medical data, together with number of readmissions because of AECOPD during 12 months following the index admission were extracted. We matched patients discharged from the PD and the ODs using a propensity score and used the paired t-test to compare COPD-related readmission rates between the matched patients.

RESULTS

In total, 481 patients were included in the analysis, 247 patients discharged from the PD and 234 from ODs. The propensity score matching process resulted in 155 well-matched pairs. The mean (standard deviation) number of readmissions within 1 year was 0.8 (1.3) for the PD versus 1.1 (1.9) for ODs (P = 0.09). After adjusting for exposure time, the corresponding readmission rates were 1.1 (2.3) and 1.6 (4.0) per year, respectively (P = 0.17).

CONCLUSION

There was little difference in COPD-related readmission rates between comparable patients discharged from the PD and the ODs after an AECOPD during 1 year following the index admission.

Disproportionate utilization of healthcare resources among veterans with COPD: a retrospective analysis of factors associated with COPD healthcare cost

Background

COPD is a significant cause of morbidity and mortality in the Veterans Health Administration (VHA). To determine the clinical factors associated with the cost of COPD management, we analyzed the relationship between clinical characteristics and COPD healthcare costs at the Cincinnati VAMC.

Methods

We queried the VHA Decision Support System for patients diagnosed with COPD at the Cincinnati VAMC and calculated their VHA COPD-related encounters and costs in FY2008. Patients were ranked by COPD-related cost. We determined the detailed clinical characteristics of patients selected by modified systematic sampling and performed univariate and multivariable ordinary linear regression analysis to determine factors associated with cost.

Results

3263 Veterans had 11,869 encounters with a primary or secondary diagnosis of COPD: 10,032 clinic visits, 505 emergency department (ED) visits, and 1,332 hospitalizations and incurred a total COPD-related healthcare cost of $21.4 M: $2.4 M clinic visits, $0.21 M ED visits, and $18.7 M hospitalizations and $0.89 M for COPD-related prescription costs. When the patients were ranked by VHA healthcare costs, the top 20% of patients accounted for 86% of the total costs and 57% of the total encounters with a primary or secondary diagnosis code of COPD and 90% of the total costs and 75% of the total encounters with a primary diagnosis code of COPD. The clinical characteristics and VHA healthcare costs of 840 of the 3263 unique individuals with COPD were analyzed to determine those characteristics associated with increased COPD-related costs. Univariate analysis showed significant associations with 24 clinical variables; the 4 most highly associated factors were nursing home residence, total hospital admissions, use of oral corticosteroids, and supplemental oxygen (p < 0.001 for all). In multivariate analysis, total number of admissions (p < 0.001), management by a pulmonologist (p < 0.001), number of clinic visits (p < 0.001), use of short acting anticholinergic (p = 0.001), forced expiratory volume in 1 second (FEV1) (p = 0.011), number of prescriptions (p = 0.011), body mass index (BMI) (p = 0.025), and use of inhaled corticosteroid (p = 0.043) were associated with COPD management cost.

Conclusion

The total number of admissions, clinic visits, physiologic impairment, BMI, number of medications, and type of provider are strongly associated with the total cost of COPD management. These factors may be used to focus COPD management toward patients with the potential for high utilization of healthcare resources.

Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) accounts for around 4% of all public hospital annual admissions in Hong Kong. By year 2020, COPD will be ranked fifth among the conditions with the highest burden to the society. This study identifies admission and unplanned readmission of COPD patients, factors affecting unplanned readmission, and estimates its cost burden on the public healthcare system in Hong Kong.

METHODS

This is a retrospective study analyzing COPD admissions to all public hospitals in Hong Kong. All admission episodes to acute medical wards with the principal diagnosis of COPD (ICD-9:490-492, 494-496) from January 2006 to December 2007 were captured. Unplanned readmission was defined as an admission which followed a previous admission within 30 days.

RESULTS

In 2006 and 2007, 65497 (8.0%) of episodes from medical wards were identified as COPD admissions, and among these, 15882 (24.2%) were unplanned readmissions. The mean age of COPD patients was 76.81 ± 9.59 years and 77% were male. Unplanned readmission was significantly associated with male gender, receiving public assistance and living in nursing homes while no association was found with the Charlson comorbidity index. Patients who were readmitted unplanned had a significant longer acute length of stay (β = 0.3894, P < 0.001) after adjustment for other covariates.

CONCLUSIONS

Unplanned readmission of COPD patients has a huge impact on the public healthcare system. A systematic approach in programme provision and a good discharge planning process targeting on COPD patients who are at high risk of unplanned readmission are essential.

Predicting outcomes following hospitalization for acute exacerbations of COPD

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a frequent cause of hospital admission and are associated with significant morbidity, mortality, high readmission rates and high resource utilization. More accurate prediction of survival and readmission in patients hospitalized with AECOPD should help to optimize clinical management and allocation of resources, including targeting of palliative care and strategies to reduce readmissions. We have reviewed the published retrospective and prospective studies in this field to identify the factors most likely to be of value in predicting in-hospital and post-discharge mortality, and readmission of patients hospitalized for AECOPD. The prognostic factors which appear most important vary with the particular outcome under consideration. In-hospital mortality is related most clearly to the patient's acute physiological state and to the development of acute comorbidity, while post-discharge mortality particularly reflects the severity of the underlying COPD, as well as specific comorbidities, especially cardiac disease. Important factors influencing the frequency of readmission include functional limitation and poor health-related quality of life. Large prospective studies which incorporate all the potentially relevant variables are required to refine prediction of the important outcomes of AECOPD and thus to inform clinical decision making, for example on escalation of care, facilitated discharge and provision of palliative care.

Risk factors and outcomes associated with chronic obstructive pulmonary disease exacerbations requiring hospitalization

BACKGROUND

Acute respiratory exacerbations are the most frequent cause of medical visits, hospitalization and death for chronic obstructive pulmonary disease (COPD) patients and, thus, exert a significant social and economic burden on society.

OBJECTIVE

To identify the risk factors associated with hospital readmission(s) for acute exacerbation(s) of COPD (AECOPD).

METHODS

A review of admission records from three large urban hospitals in Vancouver, British Columbia, identified 310 consecutive patients admitted for an AECOPD between April 1, 2001, and December 31, 2002. Logistic regression analysis was performed to identify risk factors for readmissions following an AECOPD.

RESULTS

During the study period, 38% of subjects were readmitted at least once. The mean (+/- SD) duration from the index admission to the first readmission was 5+/-4.08 months. Comparative analysis among the three hospitals identified a significant difference in readmission rates (54%, 36% and 18%, respectively). Logistic regression analysis revealed that preadmission home oxygen use (OR 2.55; 95%CI 1.45 to 4.42; P=0.001), history of a lung infection within the previous year (OR 1.73; 95% CI 1.01 to 2.97; P=0.048), other chronic respiratory disease (OR 1.78; 95% CI 1.06 to 2.99; P=0.03) and shorter length of hospital stay (OR 0.97; 95% CI 0.945 to 0.995; P=0.021) were independently associated with frequent readmissions for an AECOPD.

CONCLUSIONS

Hospital readmission rates for AECOPD were high. Only four clinical factors were found to be independently associated with COPD readmission. There was significant variability in the readmission rate among hospitals. This variability may be a result of differences in the patient populations that each hospital serves or may reflect variability in health care delivery at different institutions.

[Factors associated with hospital readmissions in the elderly]

OBJECTIVE

To identify factors associated with hospital readmissions in the elderly.

DESIGN

Observational descriptive study.

SETTING

Health area 3 of Madrid.

PARTICIPANTS

Patients 74 years-old and over with a hospital admission to Hospital Universitario Príncipe de Asturias in 2006. Those with a hospital admission in the previous 6 months were excluded. A total of 1051 patients were identified.

MAIN MEASURES

Hospital Discharge Minimum Basic Data Set and primary care information system were used to develop logistical regression models. The dependent variable was the hospital readmission in a 6 month period. Independent variables were socio-demographics, health status and health care activity.

RESULTS

There were 22.6% readmissions in the first 6 months. Variables associated with higher risk of readmission were, hospital stay (hospital stay greater than 15 days had an OR: 1.73 (95% CI:1.17-2.54), the total number of medicines prescribed to the patient (OR: 1.05; 95% CI:1.01-1.09), having hypertension (OR:1.56; 95% CI:1.11-2.18), heart failure (OR: 1.56; 95% CI:1.00-2.44) or ischemic heart disease (OR: 1.51; 95% CI:1.00-2.26), and the primary care nursing mean attendance pressure (OR: 0.93; 95% CI:0.87-0.98). The model that integrates information from both systems explains a higher number of factors associated with readmission.

CONCLUSIONS

Hospital readmissions have been associated to patient medical condition and to factors related to the health care received. Integrating information from hospital and primary care administrative data bases improves the capacity to identify factors associated with a higher readmission risk.

Impact of patient characteristics, education and knowledge on emergency room visits in patients with asthma and COPD: a descriptive and correlative study

Background

Asthma and COPD are major health problems and an extensive burden for the patient and the health care system. Patient education has been recommended, but the influence on knowledge and health outcomes is not fully examined. Our aims were to compare patient characteristics, education and knowledge in patients who had an emergency room (ER) visit, to explore factors related to disease knowledge, and to investigate patient characteristics, patient education and knowledge in relation to further ER visits over a 12 month period.

Methods

Eighty-four patients with asthma and 52 with COPD, who had had an ER visit, were included. They were interviewed by telephone 4 to 6 weeks after the ER visit and followed for a year.

Results

Patients with COPD were older, more sedentary, had had more ER visits the previous year, and had more co morbidity than patients with asthma. About 80% of the patients had received information from health professionals or participated in education/rehabilitation, but a minority (< 20%) reported that their knowledge about how to handle the disease was good. Patients with "good knowledge" were younger, were more likely to have asthma diagnose, and had a higher educational background (p < 0.05). Sixty-seven percent of the patients with COPD had repeated ER visits during the following year versus 42% in asthma (p < 0.05) (adjusted HRR: 1.73 (1.03-2.90)). Patients who had had ER visits the year before inclusion had a higher risk of ER visits the following year (adjusted HRR: 3.83 (1.99-7.38)). There were no significant differences regarding patient education and knowledge between the group with and without further ER visits after adjusting for sex, diagnose, age, and educational background.

Conclusion

Patients with asthma had a better self reported knowledge of disease management and were less likely to have new exacerbations than patients with COPD. Reported level of knowledge was, however, in it self not a predictor of exacerbations. This indicates that information is not sufficient to reduce the burden of disease. Patient education focused on self-management and behavioral change should be emphasized.

Independent effect of depression and anxiety on chronic obstructive pulmonary disease exacerbations and hospitalizations

RATIONALE

Depression and anxiety are significant comorbid and potentially modifiable conditions in chronic obstructive pulmonary disease (COPD), but their effects on exacerbations are not clear.

OBJECTIVES

To investigate the independent effect of depression and anxiety on the risk of COPD exacerbations and hospitalizations.

METHODS

A multicenter prospective cohort study in 491 patients with stable COPD in China. Multivariate Poisson and linear regression analyses were used, respectively, to estimate adjusted incidence rate ratios (IRRs) and adjusted effects on duration of events.

MEASUREMENTS AND MAIN RESULTS

Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS) at baseline. Other measurements included sociodemographic, clinical, psychosocial, and treatment characteristics. Patients were then monitored monthly for 12 months to document the occurrence and characteristics of COPD exacerbations and hospitalizations. Exacerbation was determined using both symptom-based (worsening of > or =1 key symptom) and event-based definitions (> or =1 symptom worsening plus > or =1 change in regular medications). A total of 876 symptom-based and 450 event-based exacerbations were recorded, among which 183 led to hospitalization. Probable depression (HADS depression score > or = 11) was associated with an increased risk of symptom-based exacerbations (adjusted IRR, 1.51; 95% confidence interval [CI], 1.01-2.24), event-based exacerbations (adjusted IRR, 1.56; 95% CI, 1.02-2.40), and hospitalization (adjusted IRR, 1.72; 95% CI, 1.04-2.85) compared with nondepression (score < or = 7). The duration of event-based exacerbations was 1.92 (1.04-3.54) times longer for patients with probable anxiety (HADS anxiety score > or = 11) than those with no anxiety (score < or = 7).

CONCLUSIONS

This study suggests a possible causal effect of depression on COPD exacerbations and hospitalizations. Further studies are warranted to confirm this finding and to test the effectiveness of antidepressants and psychotherapies on reducing exacerbations and improving health resource utilizations.

Resource use study in COPD (RUSIC): a prospective study to quantify the effects of COPD exacerbations on health care resource use among COPD patients

BACKGROUND

There is increasing interest in health care resource use (HRU) in Canada, particularly in resources associated with acute exacerbations of chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To identify HRU due to exacerbations of COPD.

METHODS

A 52-week, multicentre, prospective, observational study of HRU due to exacerbations in patients with moderate to severe COPD was performed. Patients were recruited from primary care physicians and respirologists in urban and rural centres in Canada.

RESULTS

In total, 524 subjects (59% men) completed the study. Their mean age was 68.2+/-9.4 years, with a forced expiratory volume in 1 s of 1.01+/-0.4 L. Patients had significant comorbidities. There were 691 acute exacerbations of COPD, which occurred in 53% of patients: 119 patients (23%) experienced one acute exacerbation, 70 patients (13%) had two acute exacerbations and 89 patients (17%) had three or more acute exacerbations. Seventy-five patients were admitted to hospital, with an average length of stay of 13.2 days. Fourteen of the patients spent time in an intensive care unit (average length of stay 5.6 days). Factors associated with acute exacerbations of COPD included lower forced expiratory volume in 1 s (P<0.001), high number of respiratory medications prescribed (P=0.037), regular use of oral corticosteroids (OCSs) (P=0.008) and presence of depression (P<0.001). Of the 75 patients hospitalized, only 53 received OCSs, four received referral for rehabilitation and 15 were referred for home care.

CONCLUSIONS

The present study showed a high prevalence of COPD exacerbations, which likely impacted on HRU. There was evidence of a lack of appropriate management of exacerbations, especially with respect to use of OCSs, and referral for pulmonary rehabilitation and home care.

One hundred years of chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, but knowledge about its pathogenesis has increased substantially in recent years. The disease results from interaction between individual risk factors (like enzymatic deficiencies) and environmental exposures to noxious agents, like cigarette smoking, occupational dusts, air pollution and infections in childhood. The main mechanisms that may contribute to airflow limitation in COPD are fixed narrowing of small airways, emphysema and luminal obstruction with mucus secretions. COPD is characterised by a chronic inflammatory process in the pulmonary tissue, with a pattern different from bronchial asthma, associated with extrapulmonary effects and is considered now a complex, systemic disease. Optimal therapeutic targeting of COPD depends on a clear understanding of the precise mechanisms of these complex processes and on early and correct evaluation of disease severity. A combination of pharmacological and non-pharmacological approaches is used to treat COPD. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. The use of LTOT for hypoxemic patients has resulted in increased survival, and expanded drug therapy options have effectively improved dyspnoea and quality of life. Recent studies have documented the benefits of pulmonary rehabilitation. In addition, non-invasive mechanical ventilation offers new alternatives for patients with acute or chronic failure.

Comment évaluer, orienter et suivre un patient ayant une pneumonie aiguë communautaire ? Une exacerbation de bronchopneumopathie chronique obstructive ?

L'objectif de cette revue est de présenter une analyse bibliographique de la littérature de ces cinq dernières années concernant les pneumonies aiguës communautaires (PAC) et les exacerbations aiguës de bronchopneumopathies chroniques obstructives (EABPCO). La PAC et l'EABPCO sont des pathologies fréquentes grevées d'une mortalité et/ou morbidité encore élevée de nos jours. La connaissance des facteurs de risque d'évolution compliquée et l'identification des signes de gravité souvent liés au risque de mortalité permettent d'orienter le patient pour un traitement ambulatoire, en hospitalisation conventionnelle ou en secteur de réanimation ; des règles prédictives ont été établies dans ce sens. La littérature concernant les critères de sortie d'hospitalisation et le suivi des patients est plus pauvre.

Risk Factors for Hospital Readmission in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Hospital readmissions for acute exacerbation of chronic obstructive pulmonary disease (COPD) are one of the leading causes of health care expenditures worldwide.

OBJECTIVES

To identify risk factors for hospital readmission in COPD patients.

METHODS

We prospectively evaluated 129 consecutive patients hospitalized for acute exacerbation of COPD. Clinical, spirometric and arterial blood gas variables were measured during hospitalization. Socioeconomic characteristics, comorbidity, dyspnea, functional dependence, depression, social support and quality of life were also analyzed. Readmission was defined as one or more hospitalizations in the following year.

RESULTS

During the follow-up period, 75 (58.5%) patients were readmitted. In bivariate analysis, readmission was associated with previous hospitalization for COPD in the past year, dyspnea scale, PaCO(2) at discharge, depression, cor pulmonale, chronic domiciliary oxygen and quality of life measured by the St. George's Respiratory Questionnaire. In multivariate analysis, the best predictor of readmission was the combination of hospitalization for COPD in the previous year (odds ratio, OR: 4.27; 95% confidence interval, CI: 1.5-12), the total score of the St. George's Respiratory Questionnaire >or=50 points (OR: 2.36; 95% CI: 1.03-5.04) and PaCO(2) at discharge >or=45 mm Hg (OR: 2.18; 95% CI: 0.84-5.06). With this model, the probability of readmission for patients without any of these variables was 7%, while it was 70% for the patients with all three variables present.

CONCLUSION

The combination of quality of life, hospitalization for COPD in the previous year and hypercapnia at discharge are useful predictors of readmission at 1 year.