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Weissman GE, Silvestri JA, Lapite F, Mullen IS, Bishop NS, Kmiec T, Summer A, Sims MW, Ahya VN, Kangovi S, Klaiman TA, Szymczak JE, Hart JL. A Qualitative Study Identifying the Potential Risk Mechanisms Leading to Hospitalization for Patients With Chronic Lung Disease. CHEST PULMONARY 2024; 2:100060. [PMID: 39391571 PMCID: PMC11465817 DOI: 10.1016/j.chpulm.2024.100060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
BACKGROUND Care management programs for chronic lung disease attempt to reduce hospitalizations, yet have not reliably achieved this goal. A key limitation of many programs is that they target patients with characteristics associated with hospitalization risk, but do not specifically modify the mechanisms that lead to hospitalization. RESEARCH QUESTION What are the common mechanisms underlying known patient-level risk characteristics leading to hospitalizations for acute exacerbations of chronic lung disease? STUDY DESIGN AND METHODS We conducted a qualitative study of patients admitted to the University of Pennsylvania Health System with acute exacerbations of chronic lung disease between January and September 2019. We interviewed patients, their family caregivers, and their inpatient and outpatient clinicians about experiences leading up to the hospitalization. We analyzed the interview transcripts using triangulation and abductive analytic methods. RESULTS We conducted 69 interviews focused on the admission of 22 patients with a median age of 66 years (interquartile range, 60-70 years), of whom 16 patients (73%) were female and 14 patients (64%) were Black. We interviewed 22 patients, 14 caregivers, 19 inpatient clinicians, and 14 outpatient clinicians. We triangulated the available interview data for each patient admission and identified the underlying mechanisms of how several known patient characteristics associated with risk actually led to hospitalization. These mechanisms included limited capacity for home management of acute symptom changes, barriers to accessing care, chronic functional limitations, and comorbid behavioral health disorders. Importantly, many of the clinical, social, and behavioral mechanisms underlying hospitalizations were present for months or years before the symptoms that prompted inpatient care. INTERPRETATION Care management programs should be built to target specific clinical, social, and behavioral mechanisms that directly lead to hospitalization. Upstream interventions that reduce hospitalization risk are possible given that many contributory mechanisms are present for months or years before the onset of acute exacerbations.
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Affiliation(s)
- Gary E Weissman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Jasmine A Silvestri
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | | | - Isabelle S Mullen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nicholas S Bishop
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | - Tyler Kmiec
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | - Amy Summer
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | - Michael W Sims
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA
| | - Vivek N Ahya
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA
| | - Shreya Kangovi
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Community Health Workers, University of Pennsylvania, Philadelphia, PA
| | - Tamar A Klaiman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Julia E Szymczak
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Joanna L Hart
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
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