Care Quality for Patients with Chronic Obstructive Pulmonary Disease in the Readmission Penalty Era

Incidence and Predictors of Long-Term Hypnotic Receipt among Patients with Chronic Obstructive Pulmonary Disease

Rationale: Many patients with chronic obstructive pulmonary disease (COPD) receive hypnotic prescriptions to mitigate insomnia symptoms. Although clinical practice guidelines advise short-term use, patients often receive these medications on a long-term basis. Because patients with COPD may be more susceptible to adverse effects of hypnotic medication, it is critical that we better understand the incidence and potential influences of this practice. Objectives: To characterize the incidence and predictors of guideline-discordant long-term receipt of hypnotic medications among patients with COPD. Methods: Using nationwide Veterans Health Administration data, we identified patients with clinically diagnosed COPD from 2010 to 2019 without prior hypnotic medication receipt in the previous 1 year. To identify individuals with new hypnotic agent use, we restricted this sample to those who received at least 30 total days of zolpidem, melatonin, trazodone, and/or doxepin within a 90-day period. We defined long-term hypnotic medication receipt as continued availability of one of these hypnotic medications for ≥30 days within the subsequent 90-day period. We then used a mixed-effects logistic regression model to assess patient and site-level associations with long-term receipt. Results: Among 4,262 patients with COPD and new hypnotic medication receipt, 55.6% (n = 2,371) continued to receive hypnotic medications on a long-term basis. Long-term receipt was positively associated with short-acting β-agonist receipt (for every 10% increase in days with short-acting β-agonist availability, odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05), maintenance inhaler prescriptions (monotherapy, OR, 1.35; 95% CI, 1.10-1.68; dual therapy, OR, 1.43; 95% CI, 1.20-1.70; triple therapy, OR, 1.54; 95% CI, 1.24-1.91), posttraumatic stress disorder (OR, 1.21; 95% CI, 1.02-1.44), major depressive disorder (OR, 1.24; 95% CI, 1.07-1.44), anxiety disorder (OR, 1.21; 95% CI, 1.03-1.44), and more frequent primary care visits (more than five visits in the past 12 mo, OR, 1.86; 95% CI, 1.19-2.90). Long-term receipt was negatively associated with initial receipt of melatonin (OR, 0.70; 95% CI, 0.55-0.91) and more than one pulmonary visit in the previous 12 months (OR, 0.74; 95% CI, 0.56-0.97). Conclusions: Despite guideline recommendations, long-term hypnotic medication receipt is common among patients with COPD. Future work to prevent long-term hypnotic prescriptions should consider the role that respiratory symptoms and mental health comorbidities may have in driving this practice.

Rural Residence Associated with Receipt of Recommended Postdischarge Chronic Obstructive Pulmonary Disease Care among a Cohort of U.S. Veterans

Rationale: Individuals with chronic obstructive pulmonary disease (COPD) in rural areas experience inequitable access to care. Objectives: To assess whether rural residence is associated with receipt of recommended postdischarge COPD care. Methods: We conducted a cohort study of all U.S. veterans discharged from a Veterans Affairs medical center after COPD hospitalization from 2010 to 2019. Rural residence was defined by rural-urban commuting area classification. Our primary outcome was the proportion of recommended care received within 90 days of hospital discharge, including smoking cessation therapy, appropriate management of supplemental oxygen, appropriate prescription of inhaled therapy, and pulmonary rehabilitation. We conducted multivariable linear regression between rural residence and the proportion of recommended care received, adjusting for age, sex, race, ethnicity, comorbidities, and primary care facility type. We tested multivariable linear probability models for each of the recommended therapies. Results: Of 67,649 patients, 7,370 (10.8%) resided in rural areas and 2,000 (3.0%) in highly rural areas. Overall, the proportion of recommended COPD treatments received was low (mean, 15.0%; standard deviation, 21.0%). Compared with urban residence, patients with rural and highly rural residence received fewer recommended COPD care treatments (rural estimate [adjusted percentage difference (95% confidence interval)], -1.1 [-1.6, -0.6]; highly rural estimate, -1.2 [-2.1, -0.3]). Rural and highly rural residence were associated with lower likelihood of receiving appropriate inhaled therapy escalation (rural estimate, -4.0 [-5.1, -3.0]; highly rural estimate, -3.0 [-5.0, -1.1]) and pulmonary rehabilitation referral (rural estimate, -1.2 [-1.6, -0.9]; highly rural estimate, -2.1 [-2.7, -1.4]) but a higher likelihood of receiving smoking cessation therapy (rural estimate, 5.4 [3.3, 7.5]; highly rural estimate, 7.2 [3.3, 11.2]). There was no significant difference in appropriate oxygen management (rural estimate, -1.0 [-2.8, 0.9]; highly rural estimate, 3.1 [-0.7, 6.9]). Conclusions: Patients across the rural-urban spectrum received few recommended postdischarge COPD treatments. Health systems approaches are needed to address widespread underuse of evidence-based COPD care.

Analysis of the effects of group progressive resistance training on inflammatory markers, cardiovascular fitness parameters, and respiratory function in elderly patients with chronic obstructive pulmonary disease

Background

To investigate the effects of implementing group progressive resistance training on Maximal Oxygen consumption (VO2max), Maximum Ventilation per minute (VEmax), Maximal Oxygen pulse (O2pulsemax), Maximum Heart Rate (HRmax), and Modified Medical Research Council dyspnea scale (mMRC) in elderly patients with chronic obstructive pulmonary disease.

Methods

A total number of 114 elderly patients with chronic obstructive pulmonary disease treated in the hospital from May 2022 to May 2024 were collected and divided into two groups based on different training methods. The conventional group (n=57) received routine rehabilitation training, while the organization group (n=57) received group progressive resistance training. Cardio - pulmonary Exercise Testing (CPET) parameters, serum inflammatory factors, lung function indicators, and mMRC score were compared between two groups before training, 2 weeks of training, and 4 weeks of training.

Results

Before training, there was no significant difference between the two groups regarding training compliance, CPET parameters, inflammatory factors, and mMRC score. After 2-4 weeks of training, both groups showed improvements in training frequency, intensity, autonomous training, and increases in VO2MAX, VEmax, O2pulsemax, and HRmax. However, the organization group had higher scores in these areas and lower levels of inflammatory factors (IL-8, IL-18, IL-6, IL-12) and mMRC scores compared to the conventional group, with statistically significant differences (P<0.05).

Conclusions

Group progressive resistance training can help improve the compliance of elderly patients with chronic obstructive pulmonary disease with training, reduce the body's inflammatory response, improve VO2MAX, VEmax, O2pulsemax, and HRmax levels, and alleviate breathing difficulties.

A Qualitative Study Identifying the Potential Risk Mechanisms Leading to Hospitalization for Patients With Chronic Lung Disease

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.

Evaluating Quality of Care for Patients with Asthma in the Readmission Penalty Era

Rationale: Asthma poses a significant burden for U.S. patients and health systems, yet inpatient care quality is understudied. National chronic obstructive lung disease (COPD) readmission policies may affect inpatient asthma care through hospital responses to these policies because of imprecise diagnosis and identification of patients with COPD and asthma. Objectives: Evaluate inpatient care quality for patients hospitalized with asthma and potential collateral effects of the Medicare COPD Hospital Readmissions Reduction Program (HRRP). Methods: This was a retrospective cohort study of patients aged 18-54 years hospitalized for asthma across 924 U.S. hospitals (Premier Healthcare Database). Results: Care quality for patients with asthma was evaluated before HRRP implementation (n = 20,820; January 2010-September 2014) and after HRRP implementation (n = 26,885; October 2014-December 2018) using adherence to inpatient care guidelines (recommended, nonrecommended, and "ideal care" [all recommended with no nonrecommended care]). Between 2010 and 2018, at least 80% of patients received recommended care annually. Recommended care decreased similarly (rate of 0.02%/mo) after versus before HRRP (P = 0.8). Nonrecommended care decreased more rapidly after HRRP (rate of 0.29%/mo) versus before HRRP (rate of 0.17%/mo; P < 0.001), with changes driven largely by decreased antibiotic prescribing. Ideal care increased more rapidly after HRRP (rate of 0.25%/mo) versus before HRRP (rate of 0.17%/mo; P = 0.02), with changes driven largely by nonrecommended care improvements. Conclusions: Post-HRRP trends suggest asthma care improved with increased rates of guideline concordance in nonrecommended and ideal care. Although federal policies (e.g., HRRP) may have had positive collateral effects, such as with asthma care, parallel care efforts, including antibiotic stewardship, likely contributed to these improvements.

Effectiveness of a Bundled Payments for Care Improvement Program for Chronic Obstructive Pulmonary Disease

BACKGROUND

The Medicare Bundled Payments for Care Improvement (BPCI) program reimburses 90-day care episodes post-hospitalization. COPD is a leading cause of early readmissions making it a target for value-based payment reform.

OBJECTIVE

Evaluate the financial impact of a COPD BPCI program.

DESIGN, PARTICIPANTS, INTERVENTIONS

A single-site retrospective observational study evaluated the impact of an evidence-based transitions of care program on episode costs and readmission rates, comparing patients hospitalized for COPD exacerbations who received versus those who did not receive the intervention.

MAIN MEASURES

Mean episode costs and readmissions.

KEY RESULTS

Between October 2015 and September 2018, 132 received and 161 did not receive the program, respectively. Mean episode costs were below target for six out of eleven quarters for the intervention group, as opposed to only one out of twelve quarters for the control group. Overall, there were non-significant mean savings of $2551 (95% CI: - $811 to $5795) in episode costs relative to target costs for the intervention group, though results varied by index admission diagnosis-related group (DRG); there were additional costs of $4184 per episode for the least-complicated cohort (DRG 192), but savings of $1897 and $1753 for the most complicated index admissions (DRGs 191 and 190, respectively). A significant mean decrease of 0.24 readmissions per episode was observed in 90-day readmission rates for intervention relative to control. Readmissions and hospital discharges to skilled nursing facilities were factors of higher costs (mean increases of $9098 and $17,095 per episode respectively).

CONCLUSIONS

Our COPD BPCI program had a non-significant cost-saving effect, although sample size limited study power. The differential impact of the intervention by DRG suggests that targeting interventions to more clinically complex patients could increase the financial impact of the program. Further evaluations are needed to determine if our BPCI program decreased care variation and improved quality of care.

PRIMARY SOURCE OF FUNDING

This research was supported by NIH NIA grant #5T35AG029795-12.

Patterns of care in the management of high-risk COPD in the US (2011-2019): an observational study for the CONQUEST quality improvement program

Background

In this study, we compare management of patients with high-risk chronic obstructive pulmonary disease (COPD) in the United States to national and international guidelines and quality standards, including the COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST).

Methods

Patients were identified from the DARTNet Practice Performance Registry and categorized into three high-risk cohorts in each year from 2011 to 2019: newly diagnosed (≤12 months after diagnosis), already diagnosed, and patients with potential undiagnosed COPD. Patients were considered high-risk if they had a history of exacerbations or likely exacerbations (respiratory consult with prescribed medication). Descriptive statistics for 2019 are reported, along with annual trends.

Findings

In 2019, 10% (n = 16,610/167,197) of patients met high-risk criteria. Evidence of spirometry for diagnosis was low; in 2019, 81% (n = 1228/1523) of patients newly diagnosed at high-risk had no record of spirometry/peak expiratory flow in the 12 months pre- or post-diagnosis and 43% (n = 651/1523) had no record of COPD symptom review. Among those newly and already diagnosed at high-risk, 52% (n = 4830/9350) had no evidence of COPD medication.

Interpretation

Findings suggest inconsistent adherence to evidence-based guidelines, and opportunities to improve identification, documentation of services, assessment, therapeutic intervention, and follow-up of patients with COPD.

Funding

This study was conducted by the Observational and Pragmatic Research Institute (OPRI) Pte Ltd and was partially funded by Optimum Patient Care Global and AstraZeneca Ltd. No funding was received by the Observational & Pragmatic Research Institute Pte Ltd (OPRI) for its contribution.