Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review

Barriers and enablers to medicine-taking behaviours in chronic obstructive pulmonary disease: a qualitative interview study

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is associated with low health-related quality of life and high costs to healthcare systems, particularly due to hospital admissions and exacerbations. Medicines, inhalers especially, reduce the risk of hospitalisations and exacerbations, but factors influencing medicine-taking behaviours are not fully understood.

AIM

To explore experiences of people with COPD related to medicines, and followingly identify and characterise any barriers and enablers related to medicine-taking behaviours using the Theoretical Domains Framework (TDF).

METHOD

Semi-structured qualitative interviews were conducted and included ten people with COPD who had previously been admitted to hospital. Systematic text condensation was used inductively in the primary analysis of the interviews. In the secondary analysis, meaning units from the primary analysis were mapped to the TDF and summarised as barriers and enablers.

RESULTS

Five major themes were developed in the primary analysis: (1) health literacy and information needs, (2) patient autonomy, (3) lack of access to medicines, (4) lack of effect from medicines, and (5) experiences of medicines-related issues. In the secondary analysis, thirteen barriers and nine enablers were mapped to nine out of the fourteen domains of the TDF.

CONCLUSION

People with COPD experience challenges related to medicines which need to be addressed by researchers and healthcare providers. The identified barriers and enablers mapped to the TDF can guide and inform future design of interventions and health care services.

Associations between outpatient care and later hospital admissions for patients with chronic obstructive pulmonary disease - a registry study from Norway

BACKGROUND

Although chronic obstructive pulmonary disease (COPD) admissions put a substantial burden on hospitals, most of the patients' contacts with health services are in outpatient care. Traditionally, outpatient care has been difficult to capture in population-based samples. In this study we describe outpatient service use in COPD patients and assess associations between outpatient care (contact frequency and specific factors) and next-year COPD hospital admissions or 90-day readmissions.

METHODS

Patients over 40 years of age residing in Oslo or Trondheim at the time of contact in the period 2009-2018 were identified from the Norwegian Patient Registry (in- and outpatient hospital contacts, rehabilitation) and the KUHR registry (contacts with GPs, contract specialists and physiotherapists). These were linked to the Regular General Practitioner registry (characteristics of the GP practice), long-term care data (home and institutional care, need for assistance), socioeconomic and-demographic data from Statistics Norway and the Cause of Death registry. Negative binomial models were applied to study associations between combinations of outpatient care, specific care factors and next-year COPD hospital admissions and 90-day readmissions. The sample consisted of 24,074 individuals.

RESULTS

A large variation in the frequency and combination of outpatient service use for respiratory diagnoses (GP, emergency room, physiotherapy, contract specialist and outpatient hospital contacts) was apparent. GP and outpatient hospital contact frequency were strongly associated to an increased number of next-year hospital admissions (1.2-3.2 times higher by increasing GP frequency when no outpatient hospital contacts, 2.4-5 times higher in combination with outpatient hospital contacts). Adjusted for healthcare use, comorbidities and sociodemographics, outpatient care factors associated with lower numbers of next-year hospitalisations were fees indicating interaction between providers (7% reduction), spirometry with GP or specialist (7%), continuity of care with GP (15%), and GP follow-up (8%) or rehabilitation (18%) within 30 days vs. later following any current year hospitalisations. For 90-day readmissions results were less evident, and most variables were non-significant.

CONCLUSION

As increased use of outpatient care was strongly associated with future hospitalisations, this further stresses the need for good communication between providers when coordinating care for COPD patients. The results indicated possible benefits of care continuity within and interaction between providers.

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.

Sprint Team Approach Yields Rapid Improvement in Leapfrog Quality Indicators

GOAL

Patient safety and quality care are two critical areas that every healthcare organization strives to grow and improve upon. At Scripps Health, specific efforts reviewed for this article were implemented to reduce hospital-acquired conditions and hospital readmissions that are components of Centers for Medicare & Medicaid Services programs and Leapfrog Hospital Survey scores.

METHODS

Sprint teams, a novel approach to rapidly develop a checklist for lower-performing care improvement areas, were implemented after an internal review of existing tools and an evidence-based literature review. These areas included catheter-associated urinary tract infections (CAUTIs), central-line associated bloodstream infections (CLABSIs), Clostridioides difficile (C. diff.) and methicillin-resistant Staphylococcus aureus (MRSA) infections, chronic obstructive pulmonary disease (COPD) and heart failure readmissions, surgical site infections and handwashing, bar coding, and the computerized physician order entry components of Leapfrog scoring. The checklist for each area served as a teaching tool for staff and a guideline for case review to ensure that standard work was routinely performed.

PRINCIPAL FINDINGS

The sprint teams showed dramatic results in the initial focus areas. From a baseline standardized infection ratio (SIR) of 1.141 for CLABSIs, the sprint team reduced the SIR to 0.885 in Year 1 of the program and to 0.687 in Year 2. For CAUTIs, the SIR decreased from a baseline of 1.391 in Year 1 to 0.720 in Year 2. C. diff. infections fell from 0.422 to 0.315 in Year 1 and to 0.260 in Year 2. While the MRSA SIR did not improve during the first year, the MRSA reduction sprint team showed success in Year 2 with a decrease in the SIR from 0.537 to 0.245. Readmission reduction sprint teams focused on heart failure, COPD, and total hip and knee complications. The teams also achieved positive results in reducing readmissions by following checklists and reviewing each readmission case for justification.

PRACTICAL APPLICATIONS

Rapid change can be safely and effectively implemented with multidisciplinary sprint teams. Developed with an evidence-based, case review approach, sprint team checklists can help to standardize processes for the review of any infections or readmissions that occur in the inpatient arena.

Development of Multivariable Prediction Models for the Identification of Patients Admitted to Hospital with an Exacerbation of COPD and the Prediction of Risk of Readmission: A Retrospective Cohort Study using Electronic Medical Record Data

BACKGROUND

Approximately 20% of patients who are discharged from hospital for an acute exacerbation of COPD (AECOPD) are readmitted within 30 days. To reduce this, it is important both to identify all individuals admitted with AECOPD and to predict those who are at higher risk for readmission.

OBJECTIVES

To develop two clinical prediction models using data available in electronic medical records: 1) identifying patients admitted with AECOPD and 2) predicting 30-day readmission in patients discharged after AECOPD.

METHODS

Two datasets were created using all admissions to General Internal Medicine from 2012 to 2018 at two hospitals: one cohort to identify AECOPD and a second cohort to predict 30-day readmissions. We fit and internally validated models with four algorithms.

RESULTS

Of the 64,609 admissions, 3,620 (5.6%) were diagnosed with an AECOPD. Of those discharged, 518 (15.4%) had a readmission to hospital within 30 days. For identification of patients with a diagnosis of an AECOPD, the top-performing models were LASSO and a four-variable regression model that consisted of specific medications ordered within the first 72 hours of admission. For 30-day readmission prediction, a two-variable regression model was the top performing model consisting of number of COPD admissions in the previous year and the number of non-COPD admissions in the previous year.

CONCLUSION

We generated clinical prediction models to identify AECOPDs during hospitalization and to predict 30-day readmissions after an acute exacerbation from a dataset derived from available EMR data. Further work is needed to improve and externally validate these models.

ERS International Congress 2022: highlights from the Respiratory Clinical Care and Physiology Assembly

It is a challenge to keep abreast of all the clinical and scientific advances in the field of respiratory medicine. This article contains an overview of the laboratory-based science, clinical trials and qualitative research that were presented during the 2022 European Respiratory Society International Congress within the sessions from the five groups of Assembly 1 (Respiratory Clinical Care and Physiology). Selected presentations are summarised from a wide range of topics: clinical problems, rehabilitation and chronic care, general practice and primary care, mobile/electronic health (m-health/e-health), clinical respiratory physiology, exercise and functional imaging.

Enhancing potential impact of hospital discharge interventions for patients with COPD: a qualitative systematic review

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) are frequently readmitted to hospital resulting in avoidable healthcare costs. Many different interventions designed to reduce hospital readmissions are reported with limited evidence for effectiveness. Greater insight into how interventions could be better designed to improve patient outcomes has been recommended.

AIM

To identify areas for optimisation within previously reported interventions provided to reduce COPD rehospitalisation to improve future intervention development.

METHODS

A systematic review was conducted by searching Medline, Embase, CINAHL, PsycINFO, and CENTRAL in June 2022. Inclusion criteria were interventions provided to patients with COPD in the transition from hospital to home or community. Exclusion criteria were lack of empirical qualitative results, reviews, drug trials, and protocols. Study quality was assessed using the Critical Appraisal Skills Programme tool and results were synthesised thematically.

RESULTS

A total of 2,962 studies were screened and nine studies included. Patients with COPD experience difficulties when transitioning from hospital to home. It is therefore important for interventions to facilitate a smooth transition process and give appropriate follow-up post-discharge. Additionally, interventions should be tailored for each patient, especially regarding information provided.

CONCLUSION

Very few studies specifically consider processes underpinning COPD discharge intervention implementation. There is a need to recognise that the transition itself creates problems, which require addressing, before introducing any new intervention. Patients report a preference for interventions to be individually adapted-in particular the provision of patient information. Whilst many intervention aspects were well received, feasibility testing may have enhanced acceptability. Patient and public involvement may address many of these concerns and greater use of process evaluations should enable researchers to learn from each other's experiences.

TRIAL REGISTRATION

The review was registered in PROSPERO with registration number CRD42022339523.