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Wijekulasuriya S, Sa Z, Badgery-Parker T, Long JC, Braithwaite J, Chapman DG, Levesque JF, Watson DE, Westbrook JI, Mitchell R. Factors affecting 12-month unplanned readmissions for chronic obstructive pulmonary disease patients: the effect of mental disorders in an Australian cohort. J Public Health (Oxf) 2024:fdae096. [PMID: 38860584 DOI: 10.1093/pubmed/fdae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/08/2024] [Accepted: 06/02/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Many individuals with chronic obstructive pulmonary disease (COPD) experience frequent hospitalization and readmissions, which is burdensome on the health system. This study aims to investigate factors associated with unplanned readmissions and mortality following a COPD-related hospitalization over a 12-month period in Australia, focusing on mental disorders and accounting for the acute phase of the COVID-19 pandemic. METHODS A retrospective cohort study using linked hospitalization and mortality records identified individuals aged ≥40 years who had at least one hospital admission with a principal diagnosis of COPD between 2014 and 2020 in New South Wales, Australia. A semi-competing risk analysis was conducted to examine factors associated with unplanned readmission and mortality. RESULTS Adults with a mental disorder diagnosis, specifically anxiety, had a higher risk of 12-month unplanned readmission. Individuals with anxiety and dementia also had a higher risk of mortality pre- and post-unplanned readmission. Individuals who were admitted during the acute phase of the COVID-19 pandemic period had lower risk of unplanned readmission, but higher risk of mortality without unplanned readmission. CONCLUSION Interventions aimed at reducing admissions should consider adults living with mental disorders such as anxiety or dementia to improve healthcare delivery and health outcomes for individuals living with COPD.
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Affiliation(s)
- Shalini Wijekulasuriya
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Zhisheng Sa
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
- NSW Biostatistics Training Program, NSW Ministry of Health, Sydney, NSW, 2065, Australia
| | - Tim Badgery-Parker
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - David G Chapman
- Respiratory Investigation Unit, Royal North Shore Hospital, Sydney, NSW, 2065, Australia
- Woolcock Institute of Medical Research, Macquarie University, Sydney, NSW, 2109, Australia
- School of Life Sciences, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Jean-Frédéric Levesque
- Agency for Clinical Innovation, Sydney, NSW, 2065, Australia
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Diane E Watson
- Bureau of Health Information, Sydney, NSW, 2065, Australia
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
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Roche N, Caron A, Emery C, Torreton E, Brisacier AC, Thissier F, Haushalter E, Tangre P, Grenier C, Raherison-Semjen C. [Medico-economic evaluation of the PRADO-BPCO post-exacerbation support program]. Rev Mal Respir 2024; 41:409-420. [PMID: 38824115 DOI: 10.1016/j.rmr.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/28/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION The "Programme d'Accompagnement du retour à Domicile" (PRADO) COPD is a home discharge support program dedicated to organizing care pathways following hospitalization for COPD exacerbation. This study aimed at assessing its medico-economic impact. METHODS This was a retrospective database study of patients included in the PRADO BPCO between 2017 and 2019. Data were extracted from the National Health Data System. A control group was built using propensity score matching. Morbi-mortality and costs (national health insurance perspective) were measured during the year following hospitalization. RESULTS While the proportion of patients with a care pathway complying with recommendations from the National Health Authority was higher in the PRADO group, there was no significant effect on mortality and 12-month rehospitalization. In the PRADO group, the rehospitalization rate was lower when the care pathway was optimal. Healthcare costs per patient were 670 € higher in the PRADO group. CONCLUSIONS The PRADO COPD improves quality of care but without decreasing rehospitalizations and mortality, although rehospitalizations did decrease among PRADO group patients benefiting from an optimal care pathway.
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Affiliation(s)
- N Roche
- Service de pneumologie, institut Cochin (UMR1016), hôpital Cochin, AP-HP, centre université Paris Cité, Paris, France; Inserm UMR1018, équipe d'épidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - A Caron
- Cemka, 43, boulevard du Maréchal-Joffre, 92340 Bourg-la-Reine, France.
| | - C Emery
- Cemka, 43, boulevard du Maréchal-Joffre, 92340 Bourg-la-Reine, France
| | - E Torreton
- Cemka, 43, boulevard du Maréchal-Joffre, 92340 Bourg-la-Reine, France
| | - A-C Brisacier
- Caisse nationale de l'Assurance Maladie, Direction des Assurés, 50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - F Thissier
- Caisse nationale de l'Assurance Maladie, Direction des Assurés, 50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - E Haushalter
- Caisse nationale de l'Assurance Maladie, Direction des Assurés, 50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - P Tangre
- Caisse nationale de l'Assurance Maladie, Direction des Assurés, 50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - C Grenier
- Caisse nationale de l'Assurance Maladie, Direction des Assurés, 50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France
| | - C Raherison-Semjen
- Service de pneumologie, centre hospitalier universitaire de la Guadeloupe, Guadeloupe, Martinique
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Yang H, Wang Z, Zhou Y, Gao Z, Xu J, Xiao S, Dai C, Wu F, Deng Z, Peng J, Ran P. Association between long-term ozone exposure and readmission for chronic obstructive pulmonary disease exacerbation. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2024; 348:123811. [PMID: 38531467 DOI: 10.1016/j.envpol.2024.123811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/28/2024]
Abstract
The relationship between long-term ozone (O₃) exposure and readmission for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) remains elusive. In this study, we collected individual-level information on AECOPD hospitalizations from a standardized electronic database in Guangzhou from January 1, 2014, to December 31, 2015. We calculated the annual mean O₃ concentration prior to the dates of the index hospitalization for AECOPD using patients' residential addresses. Employing Cox proportional hazards models, we assessed the association between long-term O₃ concentration and the risk of AECOPD readmission across several time frames (30 days, 90 days, 180 days, and 365 days). We estimated the disease and economic burden of AECOPD readmissions attributable to O₃ using a counterfactual approach. Of the 4574 patients included in the study, 1398 (30.6%) were readmitted during the study period, with 262 (5.7%) readmitted within 30 days. The annual mean O₃ concentration was 90.3 μg/m3 (standard deviation [SD] = 8.2 μg/m3). A 10-μg/m3 increase in long-term O₃ concentration resulted in a hazard ratio (HR) for AECOPD readmission within 30 days of 1.28 (95% confidence interval [CI], 1.09 to 1.49), with similar results for readmission within 90, 180, and 365 days. Older patients (aged 75 years or above) and males were more susceptible (HR, 1.33; 95% CI, 1.10-1.61 and HR, 1.29; 95% CI, 1.09-1.53, respectively). The population attributable fraction for 30-day readmission due to O₃ exposure was 29.0% (95% CI, 28.4%-30.0%), and the attributable mean cost per participant was 362.3 USD (354.5-370.2). Long-term exposure to elevated O₃ concentrations is associated with an increased risk of AECOPD readmission, contributing to a significant disease and economic burden.
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Affiliation(s)
- Huajing Yang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China; Guangzhou National Laboratory, Guangzhou, Guangdong, Postcode, China
| | - Zihui Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China
| | - Yumin Zhou
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China; Guangzhou National Laboratory, Guangzhou, Guangdong, Postcode, China
| | - Zhaosheng Gao
- Guangzhou Health Technology Appraisal and Talent Evaluation Center, Guangzhou Municipal Health Commission, Guangzhou, China
| | - Jing Xu
- Guangzhou Health Technology Appraisal and Talent Evaluation Center, Guangzhou Municipal Health Commission, Guangzhou, China
| | - Shan Xiao
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China; Department of Pulmonary and Critical Care Medicine, Shenzhen Longgang District Central Hospital, Shenzhen, China
| | - Cuiqiong Dai
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China
| | - Fan Wu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China; Guangzhou National Laboratory, Guangzhou, Guangdong, Postcode, China
| | - Zhishan Deng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China
| | - Jieqi Peng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China; Guangzhou National Laboratory, Guangzhou, Guangdong, Postcode, China
| | - Pixin Ran
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, Postcode, China; Guangzhou National Laboratory, Guangzhou, Guangdong, Postcode, China.
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Amin AN, Kartashov A, Ngai W, Steele K, Rosenthal N. Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:44-56. [PMID: 38390025 PMCID: PMC10883471 DOI: 10.36469/001c.92408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Abstract
Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.
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Affiliation(s)
| | - Alex Kartashov
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
| | | | | | - Ning Rosenthal
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
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Chow R, So OW, Im JHB, Chapman KR, Orchanian-Cheff A, Gershon AS, Wu R. Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review. Int J Chron Obstruct Pulmon Dis 2023; 18:2581-2617. [PMID: 38022828 PMCID: PMC10664718 DOI: 10.2147/copd.s418295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD. Methods A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035). Results In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility. Conclusion The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.
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Affiliation(s)
- Ronald Chow
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Olivia W So
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - James H B Im
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Kenneth R Chapman
- University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Andrea S Gershon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Robert Wu
- University Health Network, University of Toronto, Toronto, ON, Canada
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Kee YS, Wong CK, Abdul Aziz MA, Zakaria MI, Mohd Shaarif F, Ng KS, Liam CK, Pang YK, Khoo EM. 30-Day Readmission Rate of Patients with COPD and Its Associated Factors: A Retrospective Cohort Study from a Tertiary Care Hospital. Int J Chron Obstruct Pulmon Dis 2023; 18:2623-2631. [PMID: 38022826 PMCID: PMC10658934 DOI: 10.2147/copd.s429108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Readmission of chronic obstructive pulmonary disease (COPD) has been used as a measure of performance for COPD care. This study aimed to determine the rate of readmission of COPD in tertiary care hospital in Malaysia and its associated factors. Patients and Methods A retrospective cohort study was conducted at a tertiary care hospital in Malaysia from 1st January to 21st May 2019. Seventy admissions for COPD exacerbation involving 58 patients were analyzed. Results The majority of the patients were male (89.8%), had a mean age of 71.95 ± 7.24 years and a median smoking history of 40 (IQR = 25) pack-years, 84.5% were in GOLD group D and 91.4% had a mMRC grading of 2 or greater. Approximately 60.3% had upper or lower respiratory tract infection as the cause of exacerbation; one in five patients had uncompensated hypercapnic respiratory failure at presentation, and 27.6% needed mechanical ventilatory support. Approximately 43.1% of patients had a history of exacerbation that required hospitalisation in the past year. The mean blood eosinophil concentration was 0.38 ± 0.46 x109 cells/L. The 30-day readmission rate was 20.3%, revisit rate to the emergency room within 30 days after discharge was 3.4%, and in-hospital mortality rate was 1.7%. Among all characteristics, a higher baseline mMRC grade (p = 0.038) and history of exacerbation in the past 1 year (p < 0.001) were statistically associated with 30-day readmission. Conclusion The 30-day readmission rate for COPD exacerbation in a Malaysian tertiary hospital is similar to the rates in high-income countries. Exacerbation in the previous year and a higher baseline mMRC grading were significant risk factors for 30-day readmission in patients with COPD. Strategies of COPD management should concentrate on improvement of symptoms control by optimisation of pharmacotherapy, and early initiation of pulmonary rehabilitation, and structured integrated care programs to reduce readmission rates.
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Affiliation(s)
- Yan Shen Kee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chee Kuan Wong
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Mohd Idzwan Zakaria
- Academic Unit Trauma and Emergency, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Fatimah Mohd Shaarif
- Academic Unit Trauma and Emergency, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kee Seong Ng
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chong Kin Liam
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yong Kek Pang
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Halpin DMG. Clinical Management of COPD in the Real World: Can Studies Reveal Errors in Management and Pathways to Improve Patient Care? Pragmat Obs Res 2023; 14:51-61. [PMID: 37547630 PMCID: PMC10404047 DOI: 10.2147/por.s396830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023] Open
Abstract
Real world data comprise information on health care that is derived from multiple sources outside typical clinical research settings. This review focuses on what real world evidence tells us about problems with the diagnosis of chronic obstructive pulmonary disease (COPD), problems with the initial and follow-up pharmacological and non-pharmacological management, problems with the management of exacerbations and problems with palliative care. Data from real world studies show errors in the management of COPD with delays to diagnosis, lack of confirmation of the diagnosis with spirometry, lack of holistic assessment, lack of attention to smoking cessation, variable adherence to management guidelines, delayed implementation of appropriate interventions, under-recognition of patients at higher risk of adverse outcomes, high hospitalisation rates for exacerbations and poor implementation of palliative care. Understanding that these problems exist and considering how and why they occur is fundamental to developing solutions to improve the diagnosis and management of patients with COPD.
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Affiliation(s)
- David M G Halpin
- Department of Respiratory Medicine, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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Association between inpatient palliative care encounter and 30-day all-cause readmissions after index hospitalization for chronic obstructive pulmonary disease. Heart Lung 2023; 58:69-73. [PMID: 36410155 DOI: 10.1016/j.hrtlng.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/26/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies exist on the association between inpatient Palliative Care Encounter (iPCE) and 30-day rehospitalization among cancer and several non-cancer conditions but limited in persons with Chronic Obstructive Pulmonary Disease (COPD). OBJECTIVE To assess the association between an iPCE with the risk of 30-day rehospitalization after an index hospitalization for COPD. METHODS We conducted a cross-sectional analysis of the Nationwide Readmissions Database (2010-2014). Index hospitalizations were defined as persons ≥ 18 years of age, discharge destinations of either Home/Routine, Home with Home Care, or a Facility, and an index hospitalization with Diagnosis Related Group of COPD. The International Classification of Diseases, 9th revision codes were used to extract comorbidities and a Palliative Care Encounter (V66.7). RESULTS There were 3,163,889 index hospitalizations and iPCE occurred in 21,330 (0.67%). There were 558,059 (17.63%) with a 30-day rehospitalization. An iPCE was associated with a significantly lower adjusted odds of 30-day readmission (Odds Ratio [OR], 0.50; 95% Confidence Interval [CI], 0.46 to 0.54). By discharge destination, the odds of 30-day rehospitalization were for a discharged to a facility (OR, 0.37; 95% CI, 0.32 to 0.42), to home with home health (OR, 0.42; 95% CI, 0.37 to 0.47), and to home (OR, 0.98; 95% CI, 0.85 to 1.12) for those with relative to without iPCE. CONCLUSION Inpatient PCE was associated with a 50% lower relative odds of 30-day rehospitalization after an index hospitalization for COPD. This association varied by discharge destination being statistically significant among those with a discharge destination of a facility (63%) and home with home care (58%).
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Ruan H, Zhang H, Wang J, Zhao H, Han W, Li J. Readmission rate for acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis. Respir Med 2023; 206:107090. [PMID: 36528962 DOI: 10.1016/j.rmed.2022.107090] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/04/2022] [Accepted: 12/11/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Huanrong Ruan
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China
| | - Hailong Zhang
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China.
| | - Jiajia Wang
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China
| | - Hulei Zhao
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China
| | - Weihong Han
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China
| | - Jiansheng Li
- Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of PR China, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Henan University of Chinese Medicine, Zhengzhou, Henan, 450046, PR China; Department of Respiratory Diseases, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, 450003, PR China
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Kendra ME, Kakwani A, Uppala A, Mansukhani R, Pigott DK, Soubra M, Jacobson J, Cerrone F, Farrell M, Chiu S, Lieder K, Tonzola D, Shah CV, Cherian S. Impact of a COPD care bundle on hospital readmission rates. J Am Pharm Assoc (2003) 2023; 63:269-274. [PMID: 36335072 DOI: 10.1016/j.japh.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/16/2022] [Accepted: 10/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality worldwide and contributes considerably to morbidity and health care costs. In October 2014, the Centers for Medicare and Medicaid Services introduced financial penalties followed by bundled payments for care improvement initiatives in patients hospitalized with COPD. OBJECTIVES This study seeks to evaluate whether an evidence-based interprofessional COPD care bundle focused on inpatient, transitional, and outpatient care would reduce hospital readmission rates. METHODS A pre- and postintervention analysis comparing readmission rates after a hospitalization for COPD in subjects who received standard of care versus an interprofessional team-led COPD care bundle was conducted. The primary outcome was 30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-cause readmissions, escalation of pharmacotherapy, interprofessional interventions, and hospital length of stay. RESULTS A total of 189 subjects were included in the control arm and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%, P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P = 0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P < 0.001). Pharmacists consulted with 68.5% of subjects and assisted with access to outpatient medications in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P < 0.001) than the control arm. CONCLUSIONS An interprofessional team-led COPD care bundle resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90 days.
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11
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Lovis C, Zhang W, Visweswaran S, Raji M, Kuo YF. A Framework for Modeling and Interpreting Patient Subgroups Applied to Hospital Readmission: Visual Analytical Approach. JMIR Med Inform 2022; 10:e37239. [PMID: 35537203 PMCID: PMC9773032 DOI: 10.2196/37239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/06/2022] [Accepted: 05/02/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND A primary goal of precision medicine is to identify patient subgroups and infer their underlying disease processes with the aim of designing targeted interventions. Although several studies have identified patient subgroups, there is a considerable gap between the identification of patient subgroups and their modeling and interpretation for clinical applications. OBJECTIVE This study aimed to develop and evaluate a novel analytical framework for modeling and interpreting patient subgroups (MIPS) using a 3-step modeling approach: visual analytical modeling to automatically identify patient subgroups and their co-occurring comorbidities and determine their statistical significance and clinical interpretability; classification modeling to classify patients into subgroups and measure its accuracy; and prediction modeling to predict a patient's risk of an adverse outcome and compare its accuracy with and without patient subgroup information. METHODS The MIPS framework was developed using bipartite networks to identify patient subgroups based on frequently co-occurring high-risk comorbidities, multinomial logistic regression to classify patients into subgroups, and hierarchical logistic regression to predict the risk of an adverse outcome using subgroup membership compared with standard logistic regression without subgroup membership. The MIPS framework was evaluated for 3 hospital readmission conditions: chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and total hip arthroplasty/total knee arthroplasty (THA/TKA) (COPD: n=29,016; CHF: n=51,550; THA/TKA: n=16,498). For each condition, we extracted cases defined as patients readmitted within 30 days of hospital discharge. Controls were defined as patients not readmitted within 90 days of discharge, matched by age, sex, race, and Medicaid eligibility. RESULTS In each condition, the visual analytical model identified patient subgroups that were statistically significant (Q=0.17, 0.17, 0.31; P<.001, <.001, <.05), significantly replicated (Rand Index=0.92, 0.94, 0.89; P<.001, <.001, <.01), and clinically meaningful to clinicians. In each condition, the classification model had high accuracy in classifying patients into subgroups (mean accuracy=99.6%, 99.34%, 99.86%). In 2 conditions (COPD and THA/TKA), the hierarchical prediction model had a small but statistically significant improvement in discriminating between readmitted and not readmitted patients as measured by net reclassification improvement (0.059, 0.11) but not as measured by the C-statistic or integrated discrimination improvement. CONCLUSIONS Although the visual analytical models identified statistically and clinically significant patient subgroups, the results pinpoint the need to analyze subgroups at different levels of granularity for improving the interpretability of intra- and intercluster associations. The high accuracy of the classification models reflects the strong separation of patient subgroups, despite the size and density of the data sets. Finally, the small improvement in predictive accuracy suggests that comorbidities alone were not strong predictors of hospital readmission, and the need for more sophisticated subgroup modeling methods. Such advances could improve the interpretability and predictive accuracy of patient subgroup models for reducing the risk of hospital readmission, and beyond.
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Affiliation(s)
| | - Weibin Zhang
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, United States
| | - Shyam Visweswaran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mukaila Raji
- Division of Geriatric Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Yong-Fang Kuo
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX, United States
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12
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Truumees M, Kendra M, Tonzola D, Chiu S, Cerrone F, Zimmerman D, Mackwell C, Stevens C, Scannell K, Daley B, Markley D, Shah CV, Mansukhani R. The Impact of a Home Respiratory Therapist to Reduce 30-Day Readmission Rates for Exacerbation of COPD. Respir Care 2022; 67:631-637. [PMID: 34987079 PMCID: PMC9994190 DOI: 10.4187/respcare.08125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In 2015, the Centers for Medicare and Medicaid Services limited payments to hospitals with high readmission rates for patients admitted with COPD exacerbation. Decreasing readmissions in this patient population improves patient health and decreases health care utilization of resources. We hypothesized a COPD disease management program delivered by a respiratory therapist (RT) in the patient's home may reduce readmission rates for COPD exacerbation. METHODS We performed a pre/post interventional study comparing hospital readmissions for subjects with COPD exacerbation that received standard of care in the home versus an RT-led home COPD disease management program. Subjects discharged home from Atlantic Health System with COPD exacerbation were enrolled in the pre-intervention group. Subsequently, an evidence-based home COPD disease management program was implemented by an RT from At Home Medical in the home. The home COPD Disease Management Program was implemented from April 2017-September 2019, and this served as the post-intervention group. The primary end point was readmission rates at 30 d. Secondary end points included 60-d and 90-d readmission rates. RESULTS A total of 1,093 participants were included in the study, 658 in the pre-intervention cohort and 435 participants in the post-intervention group. Approximately 22.3% (n = 147) of subjects in the pre-intervention group was readmitted within 30 d of discharge compared to 12.2% (n = 53) in the post-intervention group (P < .001). A reduction in 60-d (33.9% vs 12.0%, P < .001) and 90-d all-cause readmissions (43.5% vs 13.1%, P < .001) was also seen. Participation in the COPD Disease Management Program was significantly associated with decreased 30-, 60-, and 90-d readmission rates adjusting for age, gender, race, ethnicity, and smoking status (odds ratio 0.48 [95% CI 0.33-0.70]; odds ratio 0.26 [95% CI 0.18-0.38]; odds ratio 0.20 [95% CI 0.14-0.27];P < .001, for all 3 readmission rates). CONCLUSIONS The COPD Disease Management Program is significantly associated with decreased readmission adjusting for demographics and smoking status.
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Affiliation(s)
- Monica Truumees
- Atlantic Health System/At Home Medical, Morris Plains, New Jersey
| | | | | | - Stephanie Chiu
- Atlantic Health Center of Research, Morristown, New Jersey
| | - Federico Cerrone
- Atlantic Medical Group/Pulmonary and Allergy Associates, Summit, New Jersey
| | | | | | | | | | | | - Daniel Markley
- Atlantic Medical Group/Pulmonary and Allergy Associates, Cedar Knolls, New Jersey
| | - Chirag V Shah
- Atlantic Medical Group/Pulmonary and Allergy Associates, Cedar Knolls, New Jersey
| | - Rupal Mansukhani
- Morristown Medical Center, Morristown, New Jersey; and Rutgers University, Piscataway, New Jersey.
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13
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Howard O, Thomas A, Henry H, Wallace J. Impact of a Pharmacist-led Outpatient Telemedicine Clinic on Chronic Obstructive Pulmonary Disease in a Veteran Population. J Am Pharm Assoc (2003) 2022; 62:1919-1924. [DOI: 10.1016/j.japh.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/25/2022] [Accepted: 06/21/2022] [Indexed: 11/29/2022]
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14
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Comorbid Anxiety and Depression, Though Underdiagnosed, Are Not Associated with High Rates of Low-Value Care in Patients with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 18:442-451. [PMID: 33306930 DOI: 10.1513/annalsats.201912-877oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with chronic obstructive pulmonary disease (COPD) and anxiety or depression experience more symptoms and exacerbations than patients without these comorbidities. Failure to provide beneficial COPD therapies to appropriate patients (underuse) and provision of potentially harmful therapies to patients without an appropriate indication (overuse) could contribute to respiratory symptoms and exacerbations. Anxiety and depression are known to affect the provision of health services for other comorbid conditions; therefore, underuse or overuse of therapies may explain the increased risk of severe symptoms among these patients.Objectives: To determine whether diagnosed anxiety and depression, as well as significant anxiety and depression symptoms, are associated with underuse and overuse of appropriate COPD therapies.Methods: We analyzed data from a multicenter prospective cohort study of 2,376 participants (smokers and control subjects) enrolled between 2010 and 2015. We identified two subgroups of participants, one at risk for inhaled corticosteroid (ICS) overuse and one at risk for long-acting bronchodilator (LABD) underuse based on the 2011 Global Initiative for Chronic Obstructive Lung Disease statement. Our primary outcomes were self-reported overuse and underuse. Our primary exposures of interest were self-reported anxiety and depression and significant anxiety and depression symptoms. We adopted a propensity-score method with inverse probability of treatment weighting adjusting for differences in prevalence of confounders and performed inverse probability of treatment weighting logistic regression to evaluate all associations between the exposures and outcomes.Results: Among the 1,783 study participants with COPD confirmed by spirometry, 667 (37.4%) did not have an indication for ICS use, whereas 985 (55.2%) had an indication for LABD use. Twenty-five percent (n = 167) of patients reported ICS use, and 72% (n = 709) denied LABD use in each subgroup, respectively. Neither self-reported anxiety and depression nor significant anxiety and depression symptoms were associated with overuse or underuse. At least 50% of patients in both subgroups with significant symptoms of anxiety or depression did not report a preexisting mental health diagnosis.Conclusions: Underuse of LABDs and overuse of ICSs are common but are not associated with comorbid anxiety or depression diagnosis or symptoms. Approximately one-third of individuals with COPD experience anxiety or depression, and most are undiagnosed. There are significant opportunities to improve disease-specific and patient-centered treatment for individuals with COPD.
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15
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Grossman Liu L, Rogers JR, Reeder R, Walsh CG, Kansagara D, Vawdrey DK, Salmasian H. Published models that predict hospital readmission: a critical appraisal. BMJ Open 2021; 11:e044964. [PMID: 34344671 PMCID: PMC8336235 DOI: 10.1136/bmjopen-2020-044964] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The number of readmission risk prediction models available has increased rapidly, and these models are used extensively for health decision-making. Unfortunately, readmission models can be subject to flaws in their development and validation, as well as limitations in their clinical usefulness. OBJECTIVE To critically appraise readmission models in the published literature using Delphi-based recommendations for their development and validation. METHODS We used the modified Delphi process to create Critical Appraisal of Models that Predict Readmission (CAMPR), which lists expert recommendations focused on development and validation of readmission models. Guided by CAMPR, two researchers independently appraised published readmission models in two recent systematic reviews and concurrently extracted data to generate reference lists of eligibility criteria and risk factors. RESULTS We found that published models (n=81) followed 6.8 recommendations (45%) on average. Many models had weaknesses in their development, including failure to internally validate (12%), failure to account for readmission at other institutions (93%), failure to account for missing data (68%), failure to discuss data preprocessing (67%) and failure to state the model's eligibility criteria (33%). CONCLUSIONS The high prevalence of weaknesses in model development identified in the published literature is concerning, as these weaknesses are known to compromise predictive validity. CAMPR may support researchers, clinicians and administrators to identify and prevent future weaknesses in model development.
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Affiliation(s)
- Lisa Grossman Liu
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - James R Rogers
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Rollin Reeder
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Colin G Walsh
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Department of Psychiatry, Vanderbilt University, Nashville, Tennessee, USA
| | - Devan Kansagara
- Department of Medicine, Oregon Health and Science University and VA Portland Health Care System, Portland, Oregon, USA
| | - David K Vawdrey
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
- Steele Institute for Health Innovation, Geisinger, Danville, Pennsylvania, USA
| | - Hojjat Salmasian
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Mass General Brigham, Somerville, Massachusetts, USA
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16
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Kim TW, Choi ES, Kim WJ, Jo HS. The Association with COPD Readmission Rate and Access to Medical Institutions in Elderly Patients. Int J Chron Obstruct Pulmon Dis 2021; 16:1599-1606. [PMID: 34113092 PMCID: PMC8184368 DOI: 10.2147/copd.s302631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/04/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Tae Wan Kim
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, South Korea
| | - Eun Sil Choi
- Gangwon Public Health Policy Institute, Chuncheon, South Korea
| | - Woo Jin Kim
- Department of Internal Medicine, Kangwon National University, Chuncheon, South Korea
| | - Heui Sug Jo
- Department of Health Policy & Management, Kangwon National University, Chuncheon, South Korea
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17
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Puebla Neira DA, Hsu ES, Kuo YF, Ottenbacher KJ, Sharma G. Readmissions Reduction Program: Mortality and Readmissions for Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2021; 203:437-446. [PMID: 32871097 DOI: 10.1164/rccm.202002-0310oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Rationale: Implementation of the Hospital Readmissions Reduction Program (HRRP) following discharge of patients with chronic obstructive pulmonary disease (COPD) has led to a reduction in 30-day readmissions with unknown effects on postdischarge mortality.Objectives: To examine the association of HRRP with 30-day hospital readmission and 30-day postdischarge mortality rate in patients after discharge from COPD hospitalization.Methods: Retrospective cohort study of readmission and mortality rates in a national cohort (N = 4,587,542) of admissions of Medicare fee-for-service beneficiaries 65 years or older with COPD from 2006 to 2017.Measurements and Main Results: Data were analyzed for three nonoverlapping periods based on implementation of the HRRP specific to COPD: 1) preannouncement (December 2006 to March 2010), 2) announcement (April 2010 to August 2014), and 3) implementation (October 2014 to November 2017). The 30-day readmission rate decreased from 20.54% in the preannouncement period (December 2006 to July 2008) to 18.74% in the implementation period (May 2016 to November 2017). The 30-day risk-standardized postdischarge mortality rates were 6.91%, 6.59%, and 7.30% for the preannouncement, announcement, and implementation periods, respectively. Generalized estimating equations analyses estimated an additional 1,196 deaths (October 2014 to April 2016) and 3,858 deaths (May 2016 to November 2017) during the HRRP implementation period.Conclusions: We found a reduction in 30-day all-cause readmission rate during the implementation period compared with the preannouncement phase. HRRP implementation was also associated with a significant increase in 30-day mortality after discharge from COPD hospitalization. Additional research is necessary to confirm our findings and understand the factors contributing to increased mortality in patients with COPD in the HRRP implementation period.
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Affiliation(s)
- Daniel A Puebla Neira
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine
| | | | - Yong-Fang Kuo
- Office of Biostatistics.,School of Health Professions, Division of Rehabilitation Sciences, and.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Kenneth J Ottenbacher
- School of Health Professions, Division of Rehabilitation Sciences, and.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Gulshan Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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18
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Hegewald MJ, Horne BD, Trudo F, Kreindler JL, Chung Y, Rea S, Blagev DP. Blood Eosinophil Count and Hospital Readmission in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:2629-2641. [PMID: 33122901 PMCID: PMC7591040 DOI: 10.2147/copd.s251115] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose This retrospective, observational cohort study investigated the association of blood eosinophil counts within 1 week of hospitalization for acute exacerbation of COPD (AECOPD) with subsequent risk of all-cause and COPD-related readmission from a large integrated health system. Patients and Methods Electronic medical records were extracted for index hospitalization for AECOPD at all Intermountain Healthcare hospitals. The primary outcome was the relationship of blood eosinophil count to 30-day all-cause readmission; secondary outcomes were 60-day, 90-day, and 12-month all-cause readmission, COPD-related readmission, and empiric derivation of the eosinophil count with the highest area under the curve (AUC) for predicting 30-day all-cause readmission. Results Of 2445 included patients, 1935 (79%) had a blood eosinophil count <300 cells/µL and 510 (21%) had a count ≥300 cells/µL. Using a 300-cells/μL threshold, there was no significant difference between high and low eosinophil groups in 30-day (odds ratio [OR]=1.05, 95% confidence interval [CI]=0.75–1.47) or 60-day (OR=1.15, 95% CI=0.88–1.51) all-cause readmissions. However, patients with greater (versus lesser) eosinophil counts had increased 90-day and 12-month all-cause readmissions (OR=1.35, 95% CI=1.06–1.72, and OR=1.32, 95% CI=1.07–1.62). COPD-related readmission rates were significantly greater for patients with greater (versus lesser) eosinophil counts at 30, 60, and 90 days and 12 months (OR range=1.52–1.97). A total of 70 cells/µL had the most discriminatory power to predict 30-day all-cause readmission (highest AUC). Conclusion Eosinophil counts in patients with COPD were not associated with a difference in 30-day all-cause readmissions. However, greater eosinophil counts were associated with increased risk of all-cause readmission at 90 days and 12 months and COPD-related readmission at 30, 60, and 90 days and 12 months. Patients with eosinophils <70 cells/μL had the lowest risk for 30-day all-cause readmission. Blood eosinophils in patients hospitalized with AECOPD may be a useful biomarker for the risk of hospital readmission.
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Affiliation(s)
- Matthew J Hegewald
- Pulmonary and Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Benjamin D Horne
- Intermountain Heart Institute at Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Frank Trudo
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - James L Kreindler
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - Yen Chung
- Health Economics Outcomes Research, AstraZeneca, Wilmington, DE, USA
| | - Susan Rea
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Denitza P Blagev
- Pulmonary and Critical Care Medicine Division, Intermountain Medical Center, Murray, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
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19
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Abstract
The role of noninvasive positive pressure ventilation (NIV) in severe chronic obstructive pulmonary disease (COPD) has been controversial. Over the past two decades, data primarily obtained from Europe have begun to define the clinical characteristics of patients likely to respond, the role of high-intensity NIV, and the potential best timing of initiating therapy. These approaches, however, have not been validated in the context of the U.S. healthcare delivery system. Use of NIV in severe COPD in the United States is limited by the practicalities of doing in-hospital titrations as well as a complex system of reimbursement. These systematic complexities, coupled with a still-emerging clinical trial database regarding the most effective means to deliver NIV, have led to persistent uncertainty regarding when in stable severe COPD treatment with NIV is actually appropriate. In this review, we propose an assessment algorithm and treatment plan that can be used in clinical practice in the United States, but we acknowledge that the absence of pivotal clinical trials largely precludes a robust evidence-based approach to this potentially valuable therapy.
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20
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Sorge R, DeBlieux P. Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians. J Emerg Med 2020; 59:643-659. [PMID: 32917442 DOI: 10.1016/j.jemermed.2020.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) impose a significant burden on patients and the emergency health care system. Patients with COPD who present to the emergency department (ED) often have comorbidities that can complicate their management. OBJECTIVE To discuss strategies for the management of acute exacerbations in the ED, from initial assessment through disposition, to enable effective patient care and minimize the risk of treatment failure and prevent hospital readmissions. DISCUSSION Establishing a correct diagnosis early on is critical; therefore, initial evaluations should be aimed at differentiating COPD exacerbations from other life-threatening conditions. Disposition decisions are based on the intensity of symptoms, presence of comorbidities, severity of the disease, and response to therapy. Patients who are appropriate for discharge from the ED should be prescribed evidence-based treatments and smoking cessation to prevent disease progression. A patient-centric discharge care plan should include medication reconciliation; bedside "teach-back," wherein patients demonstrate proper inhaler usage; and prompt follow-up. CONCLUSIONS An effective assessment, accurate diagnosis, and appropriate discharge plan for patients with AECOPD could improve treatment outcomes, reduce hospitalization, and decrease unplanned repeat visits to the ED.
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Affiliation(s)
- Randy Sorge
- Department of Medicine, Section of Emergency Medicine, Louisiana State University Health Sciences Center, University Medical Center, New Orleans, Louisiana
| | - Peter DeBlieux
- Department of Medicine, Section of Emergency Medicine, Louisiana State University Health Sciences Center, University Medical Center, New Orleans, Louisiana
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21
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Adler D, Cavalot G, Brochard L. Comorbidities and Readmissions in Survivors of Acute Hypercapnic Respiratory Failure. Semin Respir Crit Care Med 2020; 41:806-816. [PMID: 32746468 DOI: 10.1055/s-0040-1710074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Dan Adler
- Division of Lung Diseases, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva Medical School, Geneva, Switzerland
| | - Giulia Cavalot
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Division of Internal Medicine, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
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22
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Predictors for 30-Day and 90-Day Hospital Readmission Among Patients With Opioid Use Disorder. J Addict Med 2020; 13:306-313. [PMID: 30633044 DOI: 10.1097/adm.0000000000000499] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify the incidence, characteristics, and predictors for 30 and 90-day readmission among acutely hospitalized patients with opioid use disorder (OUD). METHODS This retrospective, cohort study evaluated consecutive adults with OUD admitted to an academic medical center over a 5-year period (10/1/11 to 9/30/16). Multivariable logistic regression was used to determine independent predictors for 30 and 90-day readmissions based on pertinent admission, hospital, and discharge variables collected via chart review and found to be different (with a P < 0.10) on univariate analysis. RESULTS Among the 470 adults (mean age 43.1 ± 12.8 years, past heroin use 77.9%; admission opioid agonist therapy use [buprenorphine 22.6%; methadone 27.0%]; medical [vs surgical] admission 75.3%, floor [vs ICU] admission 93.0%, in-hospital mortality 0.9%), 85 (18.2%) and 151 (32.1%) were readmitted within 30 and 90 days, respectively. Among the 90-day readmitted patients, median time to first readmission was 26 days. Buprenorphine use (vs no use) at index hospital admission was independently associated with reduced 30-day (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.24-0.93) and 90-day (OR 0.57, 95% CI 0.34-0.96) readmission; prior heroin (vs prescription opioid) use was associated with reduced 90-day readmission (OR 0.59, 95% CI 0.37-0.94) and length of hospital stay was associated with both greater 30-day (OR 1.02, 95% CI 1.01-1.05) and 90-day (OR 1.04, 95% CI 1.01-1.06) readmission rates. CONCLUSIONS Among patients with OUD taking buprenorphine at the time of hospital admission, 30-day and 90-day hospital readmission was reduced by 53% and 43%, respectively.
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AlHafidh OZ, Sidhu JS, Virk J, Patel N, Patel Z, Gayam V, Altuhafy D, Mukhtar O, Pata R, Shrestha B, Quist J, Enriquez D, Schmidt F. Incidence, Predictors, Causes, and Cost of 30-Day Hospital Readmission in Chronic Obstructive Pulmonary Disease Patients Undergoing Bronchoscopy. Cureus 2020; 12:e8607. [PMID: 32550091 PMCID: PMC7294856 DOI: 10.7759/cureus.8607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Chronic obstructive pulmonary disease (COPD) has a significant disease burden and is among the leading causes of hospital readmissions, adding a significant burden on healthcare resources. The association between 30-day readmission in a COPD patient undergoing bronchoscopy and a wide range of modifiable potential risk factors, after adjusting for sociodemographic and clinical factors, has been assessed, and comparison has been made with COPD patients not undergoing bronchoscopy. Methods We conducted a comprehensive analysis of the 2016 Nationwide Readmission Database (NRD) of 30-day all-cause readmission among COPD patients undergoing bronchoscopy. A Cox’s proportional hazards model was used to obtain independent relative risks of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy. Our primary outcome was the 30-day all-cause readmission rate in both groups. Other secondary outcomes of interest were the 10 most common reasons for readmission, resource utilization, independent predictors of readmission, and relative proportion of comorbidities between the index admission (IA) and the readmission in both groups. Results The overall rate of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy was 17.32% and 15.87%, respectively. The final multivariate model in the bronchoscopy group showed that the variables found to be an independent predictor of readmission were: pulmonary hypertension (hazard ratio [HR] 2.35; 95% confidence interval [CI] 1.26-4.25; P < .01), adrenal insufficiency (HR 4.47; 95% CI 1.44-13.85; P = .01) and discharge to rehab status. Independent predictor variables of admission in Group B were gender (women < men; HR 0.91; 95% CI 0.88-0.93; P < .01), and type of insurance (Medicaid > Medicare > private insurance). For all patients undergoing bronchoscopy, the mean length of stay (LOS) for IA was 11.91 ± 20.21 days, and LOS for readmission was 5.87 ± 5.48 days. The mean total cost of IA for patients undergoing bronchoscopy was much higher than that of readmission ($26,916 vs. $12,374, respectively). The entire LOS for readmission was 1,265 days, with a total cost of $2.66 million. For patients not undergoing bronchoscopy during the IA, mean LOS for IA was 4.26 ± 4.27 days, and mean LOS for readmission was 5.39 ± 5.51 days, which was longer than the IA in Group B but still shorter than LOS for readmission in Group A (patients undergoing bronchoscopy). The mean total cost of readmission was higher than the IA ($8,137 for IA vs. $10,893 for readmission). The total LOS in this group of patients was 313,287 days, with the total cost of readmission at $628 million. Conclusions Patients undergoing bronchoscopy have a slightly higher rate of 30-day readmissions as compared to patients not undergoing bronchoscopy, and the LOS is also slightly higher in this group during subsequent readmissions as compared to readmission in patients not undergoing bronchoscopy in IA. The readmission rate in COPD patients is impacted by a variety of social, personal, and medical factors. Patients with multiple medical comorbidities have a higher risk of readmission. In our understanding, bronchoscopy in a patient with acute exacerbation of COPD should be reserved for selected patients, and the rationale should be clarified, as it affects the overall LOS and healthcare expenditure.
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Alqahtani JS, Njoku CM, Bereznicki B, Wimmer BC, Peterson GM, Kinsman L, Aldabayan YS, Alrajeh AM, Aldhahir AM, Mandal S, Hurst JR. Risk factors for all-cause hospital readmission following exacerbation of COPD: a systematic review and meta-analysis. Eur Respir Rev 2020; 29:29/156/190166. [PMID: 32499306 DOI: 10.1183/16000617.0166-2019] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/18/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Readmission rates following hospitalisation for COPD exacerbations are unacceptably high, and the contributing factors are poorly understood. Our objective was to summarise and evaluate the factors associated with 30- and 90-day all-cause readmission following hospitalisation for an exacerbation of COPD. METHODS We systematically searched electronic databases from inception to 5 November 2019. Data were extracted by two independent authors in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale. We synthesised a narrative from eligible studies and conducted a meta-analysis where this was possible using a random-effects model. RESULTS In total, 3533 abstracts were screened and 208 full-text manuscripts were reviewed. A total of 32 papers met the inclusion criteria, and 14 studies were included in the meta-analysis. The readmission rate ranged from 8.8-26.0% at 30 days and from 17.5-39.0% at 90 days. Our narrative synthesis showed that comorbidities, previous exacerbations and hospitalisations, and increased length of initial hospital stay were the major risk factors for readmission at 30 and 90 days. Pooled adjusted odds ratios (95% confidence intervals) revealed that heart failure (1.29 (1.22-1.37)), renal failure (1.26 (1.19-1.33)), depression (1.19 (1.05-1.34)) and alcohol use (1.11 (1.07-1.16)) were all associated with an increased risk of 30-day all-cause readmission, whereas being female was a protective factor (0.91 (0.88-0.94)). CONCLUSIONS Comorbidities, previous exacerbations and hospitalisation, and increased length of stay were significant risk factors for 30- and 90-day all-cause readmission after an index hospitalisation with an exacerbation of COPD.
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Affiliation(s)
- Jaber S Alqahtani
- UCL Respiratory, University College London, London, UK .,Dept of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Chidiamara M Njoku
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Bonnie Bereznicki
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Barbara C Wimmer
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Gregory M Peterson
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Leigh Kinsman
- School of Nursing and Midwifery, University of Newcastle, Port Macquarie, Australia
| | - Yousef S Aldabayan
- UCL Respiratory, University College London, London, UK.,Dept of Respiratory Care, King Faisal University, Al Ahsa, Saudi Arabia
| | - Ahmed M Alrajeh
- UCL Respiratory, University College London, London, UK.,Dept of Respiratory Care, King Faisal University, Al Ahsa, Saudi Arabia
| | - Abdulelah M Aldhahir
- UCL Respiratory, University College London, London, UK.,Respiratory Care Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Swapna Mandal
- UCL Respiratory, University College London, London, UK.,Royal Free London NHS Foundation Trust, London, UK
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
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Goto T, Yoshida K, Faridi MK, Camargo CA, Hasegawa K. Contribution of social factors to readmissions within 30 days after hospitalization for COPD exacerbation. BMC Pulm Med 2020; 20:107. [PMID: 32349715 PMCID: PMC7191726 DOI: 10.1186/s12890-020-1136-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/06/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND To investigate whether, in patients hospitalized for COPD, the addition of social factors improves the predictive ability for the risk of overall 30-day readmissions, early readmissions (within 7 days after discharge), and late readmissions (8-30 days after discharge). METHODS Patients (aged ≥40 years) hospitalized for COPD were identified in the Medicare Current Beneficiary Survey from 2006 through 2012. With the use of 1000 bootstrap resampling from the original cohort (training-set), two prediction models were derived: 1) the reference model including age, comorbidities, and mechanical ventilation use, and 2) the optimized model including social factors (e.g., educational level, marital status) in addition to the covariates in the reference model. Prediction performance was examined separately for 30-day, early, and late readmissions. RESULTS Following 905 index hospitalizations for COPD, 18.5% were readmitted within 30 days. In the test-set, for overall 30-day readmissions, the discrimination ability between reference and optimized models did not change materially (C-statistic, 0.57 vs. 0.58). By contrast, for early readmissions, the optimized model had significantly improved discrimination (C-statistic, 0.57 vs. 0.63; integrated discrimination improvement [IDI], 0.018 [95%CI, 0.003-0.032]) and reclassification (continuous net reclassification index [NRI], 0.298 [95%CI 0.060-0.537]). Likewise, for late readmissions, the optimized model also had significantly improved discrimination (C-statistic, 0.65 vs. 0.68; IDI, 0.026 [95%CI 0.009-0.042]) and reclassification (continuous NRI, 0.243 [95%CI 0.028-0.459]). CONCLUSIONS In a nationally-representative sample of Medicare beneficiaries hospitalized for COPD, we found that the addition of social factors improved the predictive ability for readmissions when early and late readmissions were examined separately.
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Affiliation(s)
- Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA, 02114-1101, USA.
| | - Kazuki Yoshida
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mohammad Kamal Faridi
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA, 02114-1101, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA, 02114-1101, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA, 02114-1101, USA.,Harvard Medical School, Boston, MA, USA
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26
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Affiliation(s)
- Valerie G Press
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
- Corresponding Author: Valerie G. Press, MD, MPH; E-mail: ; Telephone: 773-702-5170; Twitter: @vgpress13
| | - Brian J Miller
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC
- University of North Carolina Kenan-Flagler Business School, Chapel Hill, North Carolina
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Buhr RG, Jackson NJ, Dubinett SM, Kominski GF, Mangione CM, Ong MK. Factors Associated with Differential Readmission Diagnoses Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease. J Hosp Med 2020; 15:219-227. [PMID: 32118572 PMCID: PMC7153488 DOI: 10.12788/jhm.3367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Readmissions after exacerbations of chronic obstructive pulmonary disease (COPD) are penalized under the Hospital Readmissions Reduction Program (HRRP). Understanding attributable diagnoses at readmission would improve readmission reduction strategies. OBJECTIVES Determine factors that portend 30-day readmissions attributable to COPD versus non-COPD diagnoses among patients discharged following COPD exacerbations. DESIGN, SETTING, AND PARTICIPANTS We analyzed COPD discharges in the Nationwide Readmissions Database from 2010 to 2016 using inclusion and readmission definitions in HRRP. MAIN OUTCOMES AND MEASURES We evaluated readmission odds for COPD versus non-COPD returns using a multilevel, multinomial logistic regression model. Patient-level covariates included age, sex, community characteristics, payer, discharge disposition, and Elixhauser Comorbidity Index. Hospital-level covariates included hospital ownership, teaching status, volume of annual discharges, and proportion of Medicaid patients. RESULTS Of 1,622,983 (a weighted effective sample of 3,743,164) eligible COPD hospitalizations, 17.25% were readmitted within 30 days (7.69% for COPD and 9.56% for other diagnoses). Sepsis, heart failure, and respiratory infections were the most common non-COPD return diagnoses. Patients readmitted for COPD were younger with fewer comorbidities than patients readmitted for non-COPD. COPD returns were more prevalent the first two days after discharge than non-COPD returns. Comorbidity was a stronger driver for non-COPD (odds ratio [OR] 1.19) than COPD (OR 1.04) readmissions. CONCLUSION Thirty-day readmissions following COPD exacerbations are common, and 55% of them are attributable to non-COPD diagnoses at the time of return. Higher burden of comorbidity is observed among non-COPD than COPD rehospitalizations. Readmission reduction efforts should focus intensively on factors beyond COPD disease management to reduce readmissions considerably by aggressively attempting to mitigate comorbid conditions.
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Affiliation(s)
- Russell G Buhr
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- Corresponding Author: Russell G. Buhr, MD, PhD; E-mail: ; Telephone: 310-267-2614; Twitter: @rgbMDPhD
| | - Nicholas J Jackson
- Department of Medicine Statistics Core, University of California, Los Angeles, California
| | - Steven M Dubinett
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Gerald F Kominski
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Center for Health Policy Research, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
| | - Carol M Mangione
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael K Ong
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, California
- Medical Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California
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Axson EL, Ragutheeswaran K, Sundaram V, Bloom CI, Bottle A, Cowie MR, Quint JK. Hospitalisation and mortality in patients with comorbid COPD and heart failure: a systematic review and meta-analysis. Respir Res 2020; 21:54. [PMID: 32059680 PMCID: PMC7023777 DOI: 10.1186/s12931-020-1312-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/04/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Discrepancy exists amongst studies investigating the effect of comorbid heart failure (HF) on the morbidity and mortality of chronic obstructive pulmonary disease (COPD) patients. METHODS MEDLINE and Embase were searched using a pre-specified search strategy for studies comparing hospitalisation, rehospitalisation, and mortality of COPD patients with and without HF. Studies must have reported crude and/or adjusted rate ratios, risk ratios, odds ratios (OR), or hazard ratios (HR). RESULTS Twenty-eight publications, reporting 55 effect estimates, were identified that compared COPD patients with HF with those without HF. One study reported on all-cause hospitalisation (1 rate ratio). Two studies reported on COPD-related hospitalisation (1 rate ratio, 2 OR). One study reported on COPD- or cardiovascular-related hospitalisation (4 HR). One study reported on 90-day all-cause rehospitalisation (1 risk ratio). One study reported on 3-year all-cause rehospitalisation (2 HR). Four studies reported on 30-day COPD-related rehospitalisation (1 risk ratio; 5 OR). Two studies reported on 1-year COPD-related rehospitalisation (1 risk ratio; 1 HR). One study reported on 3-year COPD-related rehospitalisation (2 HR). Eighteen studies reported on all-cause mortality (1 risk ratio; 4 OR; 24 HR). Five studies reported on all-cause inpatient mortality (1 risk ratio; 4 OR). Meta-analyses of hospitalisation and rehospitalisation were not possible due to insufficient data for all individual effect measures. Meta-analysis of studies requiring spirometry for the diagnosis of COPD found that risk of all-cause mortality was 1.61 (pooled HR; 95%CI: 1.38, 1.83) higher in patients with HF than in those without HF. CONCLUSIONS In this systematic review, we investigated the effect of HF comorbidity on hospitalisation and mortality of COPD patients. There is substantial evidence that HF comorbidity increases COPD-related rehospitalisation and all-cause mortality of COPD patients. The effect of HF comorbidity may differ depending on COPD phenotype, HF type, or HF severity and should be the topic of future research.
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Affiliation(s)
- Eleanor L Axson
- National Heart and Lung Institute, Imperial College London, G05 Emmanuel Kaye Building, Manresa Road, London, SW3 6LR, UK.
| | - Kishan Ragutheeswaran
- National Heart and Lung Institute, Imperial College London, G05 Emmanuel Kaye Building, Manresa Road, London, SW3 6LR, UK
| | - Varun Sundaram
- National Heart and Lung Institute, Imperial College London, G05 Emmanuel Kaye Building, Manresa Road, London, SW3 6LR, UK
| | - Chloe I Bloom
- National Heart and Lung Institute, Imperial College London, G05 Emmanuel Kaye Building, Manresa Road, London, SW3 6LR, UK
| | - Alex Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin R Cowie
- National Heart and Lung Institute, Imperial College London, G05 Emmanuel Kaye Building, Manresa Road, London, SW3 6LR, UK
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, G05 Emmanuel Kaye Building, Manresa Road, London, SW3 6LR, UK
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Lin SY, Xue H, Deng Y, Chukmaitov A. Multi-morbidities are Not a Driving Factor for an Increase of COPD-Related 30-Day Readmission Risk. Int J Chron Obstruct Pulmon Dis 2020; 15:143-154. [PMID: 32021153 PMCID: PMC6970247 DOI: 10.2147/copd.s230072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/19/2019] [Indexed: 12/04/2022] Open
Abstract
Background and Objective Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. COPD is expensive to treat, whereas the quality of care is difficult to evaluate due to the high prevalence of multi-morbidity among COPD patients. In the US, the Hospital Readmissions Reduction Program (HRRP) was initiated by the Centers for Medicare and Medicaid Services to penalize hospitals for excessive 30-day readmission rates for six diseases, including COPD. This study examines the difference in 30-day readmission risk between COPD patients with and without comorbidities. Methods In this retrospective cohort study, we used Cox regression to estimate the hazard ratio of 30-day readmission rates for COPD patients who had no comorbidity and those who had one, two or three, or four or more comorbidities. We controlled for individual, hospital and geographic factors. Data came from three sources: Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), Area Health Resources Files (AHRF) and the American Hospital Association’s (AHA's) annual survey database for the year of 2013. Results COPD patients with comorbidities were less likely to be readmitted within 30 days relative to patients without comorbidities (aHR from 0.84 to 0.87, p < 0.05). In a stratified analysis, female patients with one comorbidity had a lower risk of 30-day readmission compared to female patients without comorbidity (aHR = 0.80, p < 0.05). Patients with public insurance who had comorbidities were less likely to be readmitted within 30 days in comparison with those who had no comorbidity (aHR from 0.79 to 0.84, p < 0.05). Conclusion COPD patients with comorbidities had a lower risk of 30-day readmission compared with patients without comorbidity. Future research could use a different study design to identify the effectiveness of the HRRP.
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Affiliation(s)
- Shuo-Yu Lin
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Hong Xue
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Askar Chukmaitov
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Coleman JM, Gates KL, Kalhan R. Home Noninvasive Ventilation for Patients With Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. JAMA 2020; 323:421-422. [PMID: 32016294 DOI: 10.1001/jama.2019.22484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John M Coleman
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Khalilah L Gates
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ravi Kalhan
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Bowles KH, Murtaugh CM, Jordan L, Barrón Y, Mikkelsen ME, Whitehouse CR, Chase JAD, Ryvicker M, Feldman PH. Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors. J Am Med Dir Assoc 2019; 21:84-90.e2. [PMID: 31837933 DOI: 10.1016/j.jamda.2019.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/30/2019] [Accepted: 11/03/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To profile the characteristics of growing numbers of sepsis survivors receiving home healthcare (HHC) by type of sepsis before, during, and after a sepsis hospitalization and identify characteristics significantly associated with 7-day readmission. DESIGN Cross-sectional descriptive study. Data sources included the Outcome and Assessment Information Set (OASIS) and Medicare administrative and claims data. SETTING AND PARTICIPANTS National sample of Medicare beneficiaries hospitalized for sepsis who were discharged to HHC between July 1, 2013 and June 30, 2014 (N = 165,228). METHODS We used an indicator distinguishing among 3 types of sepsis: explicitly coded sepsis diagnosis without organ dysfunction; severe sepsis with organ dysfunction; and septic shock. We compared these subgroups' demographic, clinical and functional characteristics, comorbidities, risk factors for rehospitalization, characteristics of the index hospital stay, and predicted 7-day hospital readmission. RESULTS The majority (80.7%) had severe sepsis, 5.7% had septic shock, and 13.6% had sepsis without acute organ system dysfunction. The medical diagnoses recorded at HHC admission identified sepsis or blood infection only 7% of the time, potentially creating difficulty identifying the sepsis survivor in HHC. Among sepsis types, septic shock survivors had the greatest illness burden profile. This study describes 12 key variables, each of which individually raises the relative 7-day readmission risk by as much as 60%. Increased risk of 7-day rehospitalization was found among those with septic shock, 3 or more previous inpatient stays, index hospital length of stay of >8 days, dyspnea, >6 functional dependencies, and other risk factors. CONCLUSIONS AND IMPLICATIONS Implications for practice include using our findings to identify sepsis survivors who are at risk for early readmission. Assessment for these factors may profile the at-risk patient, thereby triggering the call for additional acute care intervention such as delayed discharge, or post-acute intervention such as early home visit and outpatient follow-up.
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Affiliation(s)
- Kathryn H Bowles
- University of Pennsylvania School of Nursing, Philadelphia, PA; Center for Home Care Policy & Research Visiting Nurse Service of New York, New York, NY.
| | | | - Lizeyka Jordan
- Center for Home Care Policy & Research Visiting Nurse Service of New York, New York, NY
| | - Yolanda Barrón
- Center for Home Care Policy & Research Visiting Nurse Service of New York, New York, NY
| | - Mark E Mikkelsen
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | | | - Jo-Ana D Chase
- University of Missouri, Sinclair School of Nursing, Columbia, MO
| | - Miriam Ryvicker
- Center for Home Care Policy & Research Visiting Nurse Service of New York, New York, NY
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Goto T, Jo T, Matsui H, Fushimi K, Hayashi H, Yasunaga H. Machine Learning-Based Prediction Models for 30-Day Readmission after Hospitalization for Chronic Obstructive Pulmonary Disease. COPD 2019; 16:338-343. [PMID: 31709851 DOI: 10.1080/15412555.2019.1688278] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
While machine learning approaches can enhance prediction ability, little is known about their ability to predict 30-day readmission after hospitalization for Chronic Obstructive Pulmonary Disease (COPD). We identified patients aged ≥40 years with unplanned hospitalization due to COPD in the Diagnosis Procedure Combination database, an administrative claims database in Japan, from 2011 through 2016 (index hospitalizations). COPD was defined by ICD-10-CM diagnostic codes, according to Centers for Medicare and Medicaid Services (CMS) readmission measures. The primary outcome was any readmission within 30 days after index hospitalization. In the training set (randomly-selected 70% of sample), patient characteristics and inpatient care data were used as predictors to derive a conventional logistic regression model and two machine learning models (lasso regression and deep neural network). In the test set (remaining 30% of sample), the prediction performances of the machine learning models were examined by comparison with the reference model based on CMS readmission measures. Among 44,929 index hospitalizations for COPD, 3413 (7%) were readmitted within 30 days after discharge. The reference model had the lowest discrimination ability (C-statistic: 0.57 [95% confidence interval (CI) 0.56-0.59]). The two machine learning models had moderate, significantly higher discrimination ability (C-statistic: lasso regression, 0.61 [95% CI 0.59-0.61], p = 0.004; deep neural network, 0.61 [95% CI 0.59-0.63], p = 0.007). Tube feeding duration, blood transfusion, thoracentesis use, and male sex were important predictors. In this study using nationwide administrative data in Japan, machine learning models improved the prediction of 30-day readmission after COPD hospitalization compared with a conventional model.
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Affiliation(s)
- Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.,Graduate School of Medical Sciences, The University of Fukui, Fukui, Japan
| | - Taisuke Jo
- Department of Health Services Research, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Hayashi
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Keshishian A, Xie L, Dembek C, Yuce H. Reduction in Hospital Readmission Rates Among Medicare Beneficiaries With Chronic Obstructive Pulmonary Disease: A Real-world Outcomes Study of Nebulized Bronchodilators. Clin Ther 2019; 41:2283-2296. [DOI: 10.1016/j.clinthera.2019.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 11/15/2022]
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Miró Ò, Takagi K, Gayat E, Llorens P, Martín-Sánchez FJ, Jacob J, Herrero-Puente P, Gil V, Wussler DN, Richard F, López-Grima ML, Gil C, Garrido JM, Pérez-Durá MJ, Alquézar A, Alonso H, Tost J, Lucas Invernón FJ, Mueller C, Mebazaa A. CORT-AHF Study: Effect on Outcomes of Systemic Corticosteroid Therapy During Early Management Acute Heart Failure. JACC-HEART FAILURE 2019; 7:834-845. [PMID: 31521676 DOI: 10.1016/j.jchf.2019.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study investigated whether systemic corticosteroids (new onset) administered to patients with acute heart failure (AHF) have any association with outcomes, with differentiated analyses for patients with and without chronic obstructive pulmonary disease (COPD) as a comorbidity. BACKGROUND Patients with undiagnosed dyspnea frequently receive corticosteroids in emergency departments while determining a final diagnosis, but their effect on the outcomes of patients with AHF without overt COPD exacerbation is unknown. METHODS We selected patients with AHF from the EAHFE (Epidemiology of Acute Heart Failure in the Emergency Departments) registry, recording key data (new-onset corticosteroid therapy, COPD condition). Patients with and without COPD were analyzed separately. We calculated unadjusted and adjusted ratios for corticosteroid-treated compared with corticosteroid-untreated patients for 2 coprimary endpoints: 90-day all-cause mortality (from index episode) and 90-day post-discharge combined endpoint (all-cause mortality or readmission for AHF), with intermediate time-point estimations. Other secondary endpoints were calculated, and some sensitive and stratified analyses were performed. RESULTS We analyzed 11,356 patients: 8,635 without COPD (841 corticosteroid-treated, 9.7%) and 2,721 with COPD (753 corticosteroid-treated, 27.7%). There were several differences between treated and untreated patients, essentially because corticosteroid-treated patients were sicker. Although unadjusted outcomes were worse in corticosteroid-treated patients, especially in patients without COPD, these differences disappeared after adjustment: hazard ratios for 90-day mortality (without/with COPD) were 0.91 (95% confidence interval (CI): 0.76 to 1.10)/0.99 (95% CI: 0.78 to 1.26), and 1.09 (95% CI: 0.93 to 1.28)/1.02 (95% CI: 0.86 to 1.21) for the post-discharge combined endpoint. Analyses of intermediate time-point coprimary endpoints and secondary outcomes rendered similar estimations. Sensitivity and stratified analysis did not significantly modify these results. CONCLUSIONS There is no evidence of harm related to the new onset of systemic corticosteroid therapy during an episode of AHF, either in patients with or without concomitant COPD.
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Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clinic, Institut d'Investigació Biomèdica August Pi i Sunyer, Barcelona, Catalonia, Spain, University of Barcelona, Barcelona, Catalonia, Spain.
| | - Koji Takagi
- Cardiology and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital, Kawasaki, Japan; INSERM UMR-S 942, Paris, France
| | - Etienne Gayat
- INSERM UMR-S 942, Paris, France; Department of Anaesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | - Pere Llorens
- Emergency Department, Short-Stay Unit and Home Hospitalization, Hospital General de Alicante, Alicante, Spain
| | - Francisco J Martín-Sánchez
- Emergency Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Catalonia, Spain
| | | | - Víctor Gil
- Emergency Department, Hospital Clinic, Institut d'Investigació Biomèdica August Pi i Sunyer, Barcelona, Catalonia, Spain, University of Barcelona, Barcelona, Catalonia, Spain
| | - Desiree N Wussler
- Cardiology Department, University Hospital Basel, Basel, Switzerland
| | - Fernando Richard
- Emergency Department, Hospital Universitario de Burgos, Burgos, Spain
| | | | - Cristina Gil
- Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | - José M Garrido
- Emergency Department, Hospital Virgen de la Macarena, Seville, Spain
| | | | - Aitor Alquézar
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
| | - Héctor Alonso
- Emergency Department, Hospital Marqués de Valdecilla, Santander, Spain
| | - Josep Tost
- Emergency Department, Hospital de Terrassa, Catalonia, Spain
| | | | - Christian Mueller
- Cardiology Department, University Hospital Basel, Basel, Switzerland
| | - Alexandre Mebazaa
- INSERM UMR-S 942, Paris, France; Department of Anaesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
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Is It Time to Move on from Identifying Risk Factors for 30-Day Chronic Obstructive Pulmonary Disease Readmission? A Call for Risk Prediction Tools. Ann Am Thorac Soc 2019; 15:801-803. [PMID: 29957037 DOI: 10.1513/annalsats.201804-246ed] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Stellefson M, Paige SR, Alber JM, Chaney BH, Chaney D, Apperson A, Mohan A. Association Between Health Literacy, Electronic Health Literacy, Disease-Specific Knowledge, and Health-Related Quality of Life Among Adults With Chronic Obstructive Pulmonary Disease: Cross-Sectional Study. J Med Internet Res 2019; 21:e12165. [PMID: 31172962 PMCID: PMC6592488 DOI: 10.2196/12165] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 02/01/2019] [Accepted: 04/12/2019] [Indexed: 12/11/2022] Open
Abstract
Background Despite the relatively high prevalence of low health literacy among individuals living with chronic obstructive pulmonary disease (COPD), limited empirical attention has been paid to the cognitive and health literacy–related skills that can uniquely influence patients’ health-related quality of life (HRQoL) outcomes. Objective The aim of this study was to examine how health literacy, electronic health (eHealth) literacy, and COPD knowledge are associated with both generic and lung-specific HRQoL in people living with COPD. Methods Adults from the COPD Foundation’s National Research Registry (n=174) completed a cross-sectional Web-based survey that assessed sociodemographic characteristics, comorbidity status, COPD knowledge, health literacy, eHealth literacy, and generic/lung-specific HRQoL. Hierarchical linear regression models were tested to examine the roles of health literacy and eHealth literacy on generic (model 1) and lung-specific (model 2) HRQoL, after accounting for socioeconomic and comorbidity covariates. Spearman rank correlations examined associations between ordinal HRQoL items and statistically significant hierarchical predictor variables. Results After adjusting for confounding factors, health literacy, eHealth literacy, and COPD knowledge accounted for an additional 9% of variance in generic HRQoL (total adjusted R2=21%; F9,164=6.09, P<.001). Health literacy (b=.08, SE 0.02, 95% CI 0.04-0.12) was the only predictor positively associated with generic HRQoL (P<.001). Adding health literacy, eHealth literacy, and COPD knowledge as predictors explained an additional 7.40% of variance in lung-specific HRQoL (total adjusted R2=26.4%; F8,161=8.59, P<.001). Following adjustment for covariates, both health literacy (b=2.63, SE 0.84, 95% CI 0.96-4.29, P<.001) and eHealth literacy (b=1.41, SE 0.67, 95% CI 0.09-2.73, P<.001) were positively associated with lung-specific HRQoL. Health literacy was positively associated with most lung-specific HRQoL indicators (ie, cough frequency, chest tightness, activity limitation at home, confidence leaving home, sleep quality, and energy level), whereas eHealth literacy was positively associated with 5 of 8 (60%) lung-specific HRQoL indicators. Upon controlling for confounders, COPD knowledge (b=−.56, SE 0.29, 95% CI −1.22 to −0.004, P<.05) was inversely associated with lung-specific HRQoL. Conclusions Health literacy, but not eHealth literacy, was positively associated with generic HRQoL. However, both health literacy and eHealth literacy were positively associated with lung-specific HRQoL, with higher COPD knowledge indicative of lower lung-specific HRQoL. These results confirm the importance of considering health and eHealth literacy levels when designing patient education programs for people living with COPD. Future research should explore the impact of delivering interventions aimed at improving eHealth and health literacy among patients with COPD, particularly when disease self-management goals are to enhance HRQoL.
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Affiliation(s)
- Michael Stellefson
- Department of Health Education and Promotion, East Carolina University, Greenville, NC, United States
| | - Samantha R Paige
- STEM Translational Communication Center, College of Journalism and Communications, University of Florida, Gainesville, FL, United States
| | - Julia M Alber
- Department of Kinesiology and Public Health, College of Science & Mathematics, California Polytechnic State University, San Luis Obispo, CA, United States
| | - Beth H Chaney
- Department of Health Education and Promotion, East Carolina University, Greenville, NC, United States
| | - Don Chaney
- Department of Health Education and Promotion, East Carolina University, Greenville, NC, United States
| | - Avery Apperson
- Department of Health Education and Promotion, East Carolina University, Greenville, NC, United States
| | - Arjun Mohan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University Brody School of Medicine, Greenville, NC, United States
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Ferrone M, Masciantonio MG, Malus N, Stitt L, O'Callahan T, Roberts Z, Johnson L, Samson J, Durocher L, Ferrari M, Reilly M, Griffiths K, Licskai CJ. The impact of integrated disease management in high-risk COPD patients in primary care. NPJ Prim Care Respir Med 2019; 29:8. [PMID: 30923313 PMCID: PMC6438975 DOI: 10.1038/s41533-019-0119-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 02/26/2019] [Indexed: 12/23/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD) have a reduced quality of life (QoL) and exacerbations that drive health service utilization (HSU). A majority of patients with COPD are managed in primary care. Our objective was to evaluate an integrated disease management, self-management, and structured follow-up intervention (IDM) for high-risk patients with COPD in primary care. This was a one-year multi-center randomized controlled trial. High-risk, exacerbation-prone COPD patients were randomized to IDM provided by a certified respiratory educator and physician, or usual physician care. IDM received case management, self-management education, and skills training. The primary outcome, COPD-related QoL, was measured using the COPD Assessment Test (CAT). Of 180 patients randomized from 8 sites, 81.1% completed the study. Patients were 53.6% women, mean age 68.2 years, post-bronchodilator FEV1 52.8% predicted, and 77.4% were Global Initiative for Obstructive Lung Disease Stage D. QoL-CAT scores improved in IDM patients, 22.6 to 14.8, and worsened in usual care, 19.3 to 22.0, adjusted difference 9.3 (p < 0.001). Secondary outcomes including the Clinical COPD Questionnaire, Bristol Knowledge Questionnaire, and FEV1 demonstrated differential improvements in favor of IDM of 1.29 (p < 0.001), 29.6% (p < 0.001), and 100 mL, respectively (p = 0.016). Compared to usual care, significantly fewer IDM patients had a severe exacerbation, −48.9% (p < 0.001), required an urgent primary care visit for COPD, −30.2% (p < 0.001), or had an emergency department visit, −23.6% (p = 0.001). We conclude that IDM self-management and structured follow-up substantially improved QoL, knowledge, FEV1, reduced severe exacerbations, and HSU, in a high-risk primary care COPD population. Clinicaltrials.gov NCT02343055. Patients enrolled on a chronic lung disease care program involving education and self-management report improved quality of life (QoL). People with severe forms of chronic obstructive pulmonary disease (COPD) often require urgent treatment for exacerbations and struggle with poor QoL. Christopher Licskai at Western University in Ontario, Canada, and co-workers trialed a one-year integrated disease management (IDM) program and compared it with standard care in 168 patients with severe COPD in primary care. The IDM involved regular collaboration with health professionals, guidance on best practice with medications, and personalized action plans. All participants completed the COPD Assessment Test, which indicated that IDM patients’ QoL scores improved during treatment, while QoL of those in standard care worsened over time. Significantly fewer IDM patients had severe exacerbations or the need for urgent medical care.
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Affiliation(s)
- Madonna Ferrone
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada.,Hotel-Dieu Grace Healthcare, Windsor, ON, Canada
| | - Marcello G Masciantonio
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada.,Western University, London Health Sciences Centre, London, ON, Canada
| | - Natalie Malus
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada.,Western University, London Health Sciences Centre, London, ON, Canada
| | - Larry Stitt
- Lawson Health Research Institute, London, ON, Canada
| | | | - Zofe Roberts
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
| | - Laura Johnson
- Chatham Kent Family Health Team, Chatham, ON, Canada
| | - Jim Samson
- Leamington Family Health Team, Leamington, ON, Canada
| | - Lisa Durocher
- Leamington Family Health Team, Leamington, ON, Canada
| | | | | | | | - Christopher J Licskai
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada. .,Western University, London Health Sciences Centre, London, ON, Canada. .,Lawson Health Research Institute, London, ON, Canada.
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Shay A, Fulton JS, O'Malley P. Mobility and Functional Status Among Hospitalized COPD Patients. Clin Nurs Res 2019; 29:13-20. [PMID: 30854876 DOI: 10.1177/1054773819836202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Older adults with chronic obstructive pulmonary disease (COPD) are at known risk for deconditioning and functional decline during hospitalization. The purpose of this study was to examine correlations between in-hospital mobility activities and functional status indicators in hospitalized older adults with COPD. A predictive correlational, secondary analysis design using multivariate analyses assessed the relationship between mobility events and functional status indicators in patients with COPD (n = 111) and non-COPD (n = 190) diagnoses. Ambulation to the bathroom, ambulation outside the room, and number of days to first out-of-bed activity predicted discharge to home versus extended care facility (ECF; p ≤ .05); days to first out-of-bed activity and out-of-room ambulation predicted reduced length of stay (LOS; p ≤ .05); no variables predicted 30-day readmission. COPD patients experienced more nonweight-bearing activity and longer lengths of stay than non-COPD patients. Specific early weight-bearing activities were associated with positive functional status-related outcomes in hospitalized COPD patients.
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Affiliation(s)
- Amy Shay
- Indiana University, Indianapolis, USA
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Insights about the economic impact of chronic obstructive pulmonary disease readmissions post implementation of the hospital readmission reduction program. Curr Opin Pulm Med 2019; 24:138-146. [PMID: 29210750 DOI: 10.1097/mcp.0000000000000454] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) affects over 12 million adults in the United States and is the third leading cause of 30-day readmissions. COPD is costly with almost $50 billion in direct costs annually. Total COPD costs can be up to double the identified direct costs because of comorbid disease and numerous indirect costs such as absenteeism. Acute exacerbations of COPD (AECOPD) are responsible for up to 70% of COPD-related healthcare costs; hospital readmissions alone account for over $15 billion annually. In this review, we aim to describe insights about the economic impact of COPD readmissions based on articles published over the last 18 months. RECENT FINDINGS Interventions aimed at reducing readmission, particularly those using interdisciplinary teams with bundled care interventions, were uniformly successful at improving the quality of care provided and demonstrating improved process measures. However, success at reducing readmissions and cost savings based on these interventions varied across the studies. SUMMARY The literature to date points to factors and conditions that may place patients at higher risk of readmissions and may lead to higher costs. Interventions aimed at reducing readmissions after index admissions for AECOPD have demonstrated variable results. Most interventions did not reflect cost-based analyses.
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Cousse S, Gillibert A, Salaün M, Thiberville L, Cuvelier A, Patout M. Efficacy of a home discharge care bundle after acute exacerbation of COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:289-296. [PMID: 30774326 PMCID: PMC6349078 DOI: 10.2147/copd.s178147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose Acute exacerbations of COPD (AECOPD) are frequent and associated with a poor prognosis. A home discharge care bundle, the PRADO-BPCO program, has been set up by the French National Health System in order to reduce readmission rate after hospitalization for AECOPD. This program includes early consultations by the general practitioner, a nurse, and a physiotherapist after discharge. The aim of our study was to evaluate the effect of the PRADO-BPCO program on the 28-days readmission rate of COPD patients after hospitalization for AECOPD. Patients and methods This was a retrospective cohort study including all patients admitted for AECOPD in our center between November 2015 and January 2017. The readmission or death rate at 28 days after hospitalization for AECOPD was compared between patients included in the PRADO-BPCO program and patients with standard care after discharge. Inclusion in the program was decided by the physician in charge of the patient. Results A total of 62 patients were included in the PRADO-BPCO group and 202 in the control group. At baseline, patients in the PRADO group had a more severe COPD disease and more severe exacerbations than the control group and mean inpatient stay was shorter in the PRADO group: 8.6±4.3 vs 10.4±7.4 days (P=0.034). Readmission or death rate at 28 days was similar between groups: 10 (16.1%) in the PRADO group vs 30 (14.9%) in the control group (P=0.81). Ninety-days readmission or death rate and overall survival were similar in the two groups. Conclusion In our center, despite more severe COPD and a shorter hospitalization time, the PRADO-BPCO program failed to prove a benefit on the 28 days readmission or death rate when compared with standard care.
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Affiliation(s)
- Stéphanie Cousse
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France,
| | - André Gillibert
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Mathieu Salaün
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France, .,Normandy University, UNIROUEN, CIC INSERM 1404, Rouen, France
| | - Luc Thiberville
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France, .,Normandy University, UNIROUEN, CIC INSERM 1404, Rouen, France
| | - Antoine Cuvelier
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France, .,Normandy University, UNIROUEN, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France,
| | - Maxime Patout
- Pulmonary, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France, .,Normandy University, UNIROUEN, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France,
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Adherence of Elderly Patients with Cardiovascular Disease to Statins and the Risk of Exacerbation of Chronic Obstructive Pulmonary Disease: Evidence from an Italian Real-World Investigation. Drugs Aging 2018; 35:1099-1108. [DOI: 10.1007/s40266-018-0600-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Crisafulli E, Barbeta E, Ielpo A, Torres A. Management of severe acute exacerbations of COPD: an updated narrative review. Multidiscip Respir Med 2018; 13:36. [PMID: 30302247 PMCID: PMC6167788 DOI: 10.1186/s40248-018-0149-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023] Open
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital. Main body In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD. Conclusion Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.
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Affiliation(s)
- Ernesto Crisafulli
- 1Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Enric Barbeta
- 2Pneumology Department, Clinic Institute of Thorax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Antonella Ielpo
- 1Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Antoni Torres
- 2Pneumology Department, Clinic Institute of Thorax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Goto T, Shimada YJ, Faridi MK, Camargo CA, Hasegawa K. Incidence of Acute Cardiovascular Event After Acute Exacerbation of COPD. J Gen Intern Med 2018; 33:1461-1468. [PMID: 29948806 PMCID: PMC6108996 DOI: 10.1007/s11606-018-4518-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 04/12/2018] [Accepted: 05/24/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a lack of comprehensive view of the association between acute exacerbation of COPD (AECOPD) and the risk of acute cardiovascular events. OBJECTIVE To determine the association of AECOPD with 30-day and 1-year incidences of acute cardiovascular event. DESIGN Self-controlled case series analysis using population-based datasets from three US states from 2005 through 2011. PARTICIPANTS Patients aged ≥ 40 years with AECOPD. MAIN MEASURES The primary outcome was a composite of an ED visit or hospitalization for acute cardiovascular events, including acute myocardial infarction, heart failure, atrial fibrillation, pulmonary embolism, and stroke. We compared the incidence of each patient's acute cardiovascular event during the first 30-day period before the index AECOPD (30-day reference period) in comparison with that during the 30-day period after the index AECOPD. Likewise, with the 1-year period before the index AECOPD as reference, we also estimated incidence rate ratios (IRRs) for each patient's outcomes during 1-year period after the index AECOPD. KEY RESULTS Overall, there were 362,867 patients with an ED visit or hospitalization for AECOPD. Compared with the 30-day reference period, the incidence of acute cardiovascular event in the 30-day period after the AECOPD was significantly higher (IRR, 1.34; 95%CI, 1.30-1.39; P < 0.001). Likewise, compared with the 1-year reference period, the incidence during the 1-year period after the AECOPD was also higher (IRR, 1.20; 95%CI, 1.18-1.22; P < 0.001). For each of acute cardiovascular conditions, the associations remained significant (all P < 0.05). CONCLUSIONS AECOPD was associated with increased 30-day and 1-year incidences of acute cardiovascular event.
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Affiliation(s)
- Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Yuichi J Shimada
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Jacobs DM, Noyes K, Zhao J, Gibson W, Murphy TF, Sethi S, Ochs-Balcom HM. Early Hospital Readmissions after an Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the Nationwide Readmissions Database. Ann Am Thorac Soc 2018; 15:837-845. [PMID: 29611719 PMCID: PMC6207114 DOI: 10.1513/annalsats.201712-913oc] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 03/27/2018] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Understanding the causes and factors related to readmission for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) within a nationwide database including all payers and ages can provide valuable input for the development of generalizable readmission reduction strategies. OBJECTIVES To determine the rates, causes, and predictors for early (3-, 7-, and 30-d) readmission in patients hospitalized with AECOPD in the United States using the Nationwide Readmission Database after the initiation of the Hospital Readmissions Reduction Program, but before its expansion to COPD. METHODS We conducted an analysis of the Nationwide Readmission Database from 2013 to 2014. Index admissions and readmissions for an AECOPD were defined consistent with Hospital Readmissions Reduction Program guidelines. We investigated the percentage of 30-day readmissions occurring each day after discharge and the most common readmission diagnoses at different time periods after hospitalization. The relationship between predictors (categorized as patient, clinical, and hospital factors) and early readmission were evaluated using a hierarchical two-level logistic model. To examine covariate effects on early-day readmission, predictors for 3-, 7-, and 30-day readmissions were modeled separately. RESULTS There were 202,300 30-day readmissions after 1,055,830 index AECOPD admissions, a rate of 19.2%. The highest readmission rates (4.2-5.5%) were within the first 72 hours of discharge, and 58% of readmissions were within the first 15 days. Respiratory-based diseases were the most common reasons for readmission (52.4%), and COPD was the most common diagnosis (28.4%). Readmission diagnoses were similar at different time periods after discharge. Early readmission was associated with patient (Medicaid payer status, lower household income, and higher comorbidity burden) and clinical factors (longer length of stay and discharge to a skilled nursing facility). Predictors did not vary substantially by time of readmission after discharge within the 30-day window. CONCLUSIONS Thirty-day readmissions after an AECOPD remain a major healthcare burden, and are characterized by a similar spectrum of readmission diagnoses. Predictors associated with readmission include both patient and clinical factors. Development of a COPD-specific risk stratification algorithm based on these factors may be necessary to better predict patients with AECOPD at high risk of early readmission.
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Affiliation(s)
- David M. Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences
| | - Katia Noyes
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions
| | - Jiwei Zhao
- Department of Biostatistics, School of Public Health and Health Professions, and
| | - Walter Gibson
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences
| | - Timothy F. Murphy
- Department of Medicine, Clinical and Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Sanjay Sethi
- Department of Medicine, Clinical and Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Heather M. Ochs-Balcom
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions
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Bottle A, Honeyford K, Chowdhury F, Bell D, Aylin P. Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [PMID: 30044581 DOI: 10.3310/hsdr06260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundHeart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete.ObjectivesTo model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions.DesignObservational study.SettingEnglish NHS.ParticipantsAll patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.InterventionsNone.Main outcome measuresOne-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD.Data sourcesPatient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information.ResultsOne-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were 19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factors predicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long) index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS and comorbidities also predicted readmission. Of the practice and hospital factors we considered, only more doctors per 10 beds [odds ratio (OR) 0.95 per doctor;p < 0.001] was significant for both cohorts for mortality, with staff recommending to friends and family (OR 0.80 per unit increase;p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP;p = 0.004) important for COPD. For readmission, only hospital size [OR per 100 beds = 2.16, 95% confidence interval (CI) 1.34 to 3.48 for HF, and 2.27, 95% CI 1.40 to 3.66 for COPD] and doctors per 10 beds (OR 0.98;p < 0.001) were significantly associated. Some factors, such as comorbidities, varied in importance depending on the readmission diagnosis. ED visits were common after the index discharge, with 75% resulting in admission. Many predictors of admission at this visit were as for readmission minus comorbidities and plus attendance outside the day shift and numbers of admissions that hour. Hospital-level rates for ED attendance varied much more than those for readmission, but the omega statistics favoured them as a performance indicator.LimitationsData lacked direct information on disease severity and ED attendance reasons; NHS surveys were not specific to HF or COPD patients; and some data sets were aggregated.ConclusionsFollowing an index admission for HF or COPD, older age, prior missed outpatient appointments, LOS and many comorbidities predict both mortality and readmission. Of the aggregated practice and hospital information, only doctors per bed and numbers of hospital beds were strongly associated with either outcome (both negatively). The 30-day ED visits and diagnosis-specific readmission rates seem to be useful performance indicators.Future workHospital variations in ED visits could be investigated using existing data despite coding limitations. Primary care management could be explored using individual-level linked databases.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Alex Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Kate Honeyford
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Faiza Chowdhury
- Department of Acute Medicine, Chelsea and Westminster Hospital, Imperial College London, London, UK
- National Institute for Health Research under the Collaborations for Leadership in Applied Health Research and Care Programme North West London, Imperial College London, London, UK
| | - Derek Bell
- Department of Acute Medicine, Chelsea and Westminster Hospital, Imperial College London, London, UK
- National Institute for Health Research under the Collaborations for Leadership in Applied Health Research and Care Programme North West London, Imperial College London, London, UK
- Royal College of Physicians, Edinburgh, UK
| | - Paul Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
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Underner M, Cuvelier A, Peiffer G, Perriot J, Jaafari N. Influence de l’anxiété et de la dépression sur les exacerbations au cours de la BPCO. Rev Mal Respir 2018; 35:604-625. [PMID: 29937312 DOI: 10.1016/j.rmr.2018.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/13/2018] [Indexed: 02/05/2023]
Affiliation(s)
- M Underner
- Unité de recherche clinique, centre hospitalier Henri-Laborit, université de Poitiers, 370, avenue Jacques-Cœur CS 10587, 86021 Poitiers cedex, France.
| | - A Cuvelier
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, centre hospitalier universitaire de Rouen, 76031 Rouen, France; Université de Rouen-Normandie, UPRES EA3830 groupe de recherche sur le handicap ventilatoire (GRHV), Institut de recherche et d'innovation biomédicale (IRIB), 76000 Rouen, France
| | - G Peiffer
- Service de pneumologie, centre hospitalier régional Metz-Thionville, 57038 Metz, France
| | - J Perriot
- Dispensaire Émile-Roux, centre de tabacologie, 63100 Clermont-Ferrand, France
| | - N Jaafari
- Unité de recherche clinique, centre hospitalier Henri-Laborit, université de Poitiers, 370, avenue Jacques-Cœur CS 10587, 86021 Poitiers cedex, France
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Swanson JO, Vogt V, Sundmacher L, Hagen TP, Moger TA. Continuity of care and its effect on readmissions for COPD patients: A comparative study of Norway and Germany. Health Policy 2018; 122:737-745. [PMID: 29933893 DOI: 10.1016/j.healthpol.2018.05.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/02/2018] [Accepted: 05/21/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Jayson O Swanson
- Department of Health Economics and Health Management, Institute of Health and Society, University of Oslo, PO Box 1089 Blindern, NO-0317 Oslo, Norway.
| | - Verena Vogt
- Berlin Centre of Health Economics Research (BerlinHECOR), Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, Berlin, 10623, Germany.
| | - Leonie Sundmacher
- Department of Health Services Management, Ludwig-Maximilians-Universität, Schackstraße 4, München, 80539, Germany.
| | - Terje P Hagen
- Department of Health Economics and Health Management, Institute of Health and Society, University of Oslo, PO Box 1089 Blindern, NO-0317 Oslo, Norway.
| | - Tron Anders Moger
- Department of Health Economics and Health Management, Institute of Health and Society, University of Oslo, PO Box 1089 Blindern, NO-0317 Oslo, Norway.
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Jiang X, Xiao H, Segal R, Mobley WC, Park H. Trends in Readmission Rates, Hospital Charges, and Mortality for Patients With Chronic Obstructive Pulmonary Disease (COPD) in Florida From 2009 to 2014. Clin Ther 2018; 40:613-626.e1. [PMID: 29609879 DOI: 10.1016/j.clinthera.2018.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/23/2018] [Accepted: 03/11/2018] [Indexed: 01/04/2023]
Abstract
PURPOSE Chronic obstructive pulmonary disease (COPD) is a leading and costly cause of readmissions to the hospital, with one of the highest rates reported in Florida. From 2009 to 2014, strategies such as readmission reduction programs, as well as updated guidelines for COPD management, were instituted to reduce readmission rates for patients with COPD. Thus, the question has been raised whether COPD-related 30-day hospital readmission rates in Florida have decreased and whether COPD-related readmission costs during this period have changed. In addition, we examined trends in length of stay, hospital charges, and in-hospital mortality associated with COPD, as well as identified patient-level risk factors associated with 30-day readmissions. METHODS A retrospective analysis of adult patients (≥18 years of age) with COPD was conducted by using the Healthcare Cost and Utilization Project Florida State Inpatient Database, 2009 to 2014. Weighted least squares regression was used to assess trends in the COPD readmission rate on a yearly basis, as well as other outcomes of interest. A multivariable logistic regression was used to identify patient characteristics that were associated with 30-day COPD readmissions. FINDINGS Overall, 268,084 adults were identified as having COPD. Between 2009 and 2014, more than half of patients aged 65-84 years, most were white, 55% were female, and 73% had Medicare. The unadjusted rate for COPD-related 30-day readmissions did not change (8.04% to 7.85%; P = 0.434). However, the mean total charge for 30-day COPD-related readmissions was significantly higher in 2014 ($40,611) compared with that in 2009 ($36,714) (P = 0.011). The overall unadjusted in-hospital mortality of COPD-related hospitalizations significantly decreased from 1.83% in 2009 to 1.34% in 2014 (P < 0.001). In a multivariable logistic regression model, patients with COPD were 2% less likely to be readmitted to the hospital for each additional year (odds ratio [OR], 0.98 [95% confidence interval (CI), 0.97-0.99]). Factors associated with significantly higher odds of COPD-related readmission were: older age (45 ≤ age ≤ 64 years; OR, 1.91 [95% CI, 1.70-2.14]), being male (OR, 1.14 [95% CI, 1.10-1.17]), and being a Medicaid beneficiary (OR, 1.28 [95% CI, 1.21-1.35]). IMPLICATIONS Although the adjusted odds of COPD readmissions slightly decreased, as did the length of stay and all-cause in-patient mortality, the financial burden increased substantially. Future strategies to further reduce readmissions of patients with COPD and curb financial burden in Florida are needed.
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Affiliation(s)
- Xinyi Jiang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Hong Xiao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Richard Segal
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - William Cary Mobley
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida.
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49
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Readmission Due to Exacerbation of COPD: Associated Factors. Lung 2018; 196:185-193. [DOI: 10.1007/s00408-018-0093-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
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50
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Hakim MA, Garden FL, Jennings MD, Dobler CC. Performance of the LACE index to predict 30-day hospital readmissions in patients with chronic obstructive pulmonary disease. Clin Epidemiol 2017; 10:51-59. [PMID: 29343987 PMCID: PMC5751805 DOI: 10.2147/clep.s149574] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and objective Patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (COPD) have a high 30-day hospital readmission rate, which has a large impact on the health care system and patients’ quality of life. The use of a prediction model to quantify a patient’s risk of readmission may assist in directing interventions to patients who will benefit most. The objective of this study was to calculate the rate of 30-day readmissions and evaluate the accuracy of the LACE index (length of stay, acuity of admission, co-morbidities, and emergency department visits within the last 6 months) for 30-day readmissions in a general hospital population of COPD patients. Methods All patients admitted with a principal diagnosis of COPD to Liverpool Hospital, a tertiary hospital in Sydney, Australia, between 2006 and 2016 were included in the study. A LACE index score was calculated for each patient and assessed using receiver operator characteristic curves. Results During the study period, 2,662 patients had 5,979 hospitalizations for COPD. Four percent of patients died in hospital and 25% were readmitted within 30 days; 56% of all 30-day readmissions were again due to COPD. The most common reasons for readmission, following COPD, were heart failure, pneumonia, and chest pain. The LACE index had moderate discriminative ability to predict 30-day readmission (C-statistic =0.63). Conclusion The 30-day hospital readmission rate was 25% following hospitalization for COPD in an Australian tertiary hospital and as such comparable to international published rates. The LACE index only had moderate discriminative ability to predict 30-day readmission in patients hospitalized for COPD.
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Affiliation(s)
- Maryam A Hakim
- Department of Respiratory Medicine, Liverpool Hospital.,South Western Sydney Clinical School, University of New South Wales
| | - Frances L Garden
- South Western Sydney Clinical School, University of New South Wales.,Ingham Institute for Applied Medical Research
| | | | - Claudia C Dobler
- Department of Respiratory Medicine, Liverpool Hospital.,South Western Sydney Clinical School, University of New South Wales.,Ingham Institute for Applied Medical Research.,Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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