Is Bundled Care Effective in Pulmonary Medicine?

The Study

Worldwide prevalence of chronic obstructive pulmonary disease (COPD) is increasing, yet, to date, physicians have limited means for slowing the progression of this common respiratory condition characterized by airflow obstruction during expiration.^[1] Acute exacerbation of COPD (AECOPD) is diagnosed when patients have a change in respiratory symptoms, such as cough, dyspnea, or sputum production. AECOPD is associated with significant morbidity and is a major target for intervention by the medical system. Recent guidelines published by the American College of Chest Physicians highlight the importance of diagnosis, treatment, and prevention.^[2]

The Bundled Payments for Care Improvement (BCPI) initiative was created by the Center for Medicare & Medicaid Services (CMS) Innovation Center.^[3,4] The Innovation Center was designed to test alternative payment models that improve efficiency and reduce the cost of delivering care. Rather than paying per procedure, intervention, or diagnosis, BCPI pays a target price for an episode of care. Because AECOPD is common and guidelines outline proven methods for reducing recurrence, it is an ideal candidate for testing BCPI.

Researchers from the University of Alabama (UAB) recently published data on their experience with BCPI and AECOPD.^[5] The bundled care provided for hospitalization for AECOPD included the following: 5 days of antibiotics and corticosteroids; educational material; tobacco cessation counseling; follow-up in a COPD clinic within 2 weeks; and case-based referrals (as appropriate) to pulmonary rehabilitation, home health, palliative care, and hospice. Periodic phone calls were also placed to the patient to gauge clinical status and push early intervention as needed.

The BCPI initiative for AECOPD started at UAB in 2014. The authors compared outcomes for that year with those for patients treated for AECOPD in 2012 (historical controls). The primary outcome was that all-cause 30-day readmission rate and secondary outcomes included the following: all-cause 90-day readmission rate, 30- and 90-day AECOPD readmission rate, and 30- and 90-day costs. The authors report that UAB incurred an upfront cost of approximately $250,000 to hire a full-time nurse practitioner and nurse, an additional part-time nurse, and the costs of telephone calls, printed materials, and physician effort.^[5]

What they found is depressing at first glance: no significant change in the primary outcome or any of the secondary outcomes. Cost savings were evident but they didn't compensate for the investment in excess personnel, paper printing, telephone calls, and "physician effort." Strike another blow for the opponents of CMS, the Affordable Care Act, comparative efficacy research, and alternative payment models that originate with the federal government, right?

Viewpoint

Well, maybe not. Let's take a closer look at the numbers. I'll start by taking issue with their cost analysis. In 2012 (historical control year) and 2014 (BCPI intervention year), UAB averaged 109 and 78 admissions for AECOPD, respectively. So, to manage 78 admissions per year, they needed one-and-a-half to two-and-a-half mid-level employees (nurses and nurse practitioners)? Having run two pulmonary services at two separate tertiary, academic medical centers, I would estimate that this task should occupy one mid-level nurse practitioner for only a portion of the given shift. At most. Even accounting for the extra BCPI initiatives, this individual's involvement should decrease physician effort, not increase it. Last, printing flyers costs little, and education and telephone calls can be automated at minimal expense.^[6] In short, I think cost efficacy is underestimated in their analysis.

With respect to outcomes, the authors acknowledge that they were significantly underpowered in their ability to detect a difference in readmission rates. In fact, they estimate that they'd need closer to 1800 patients to detect a 5% reduction. Because 78 AECOPD admissions per year is a reasonable estimate for what most tertiary care hospitals caring for Medicare patients will see, the authors argue that most won't obtain meaningful cost savings with BCPI. But the study did show savings by diagnosis, and total cost was below the CMS target rate, so individual hospitals wouldn't need to reduce readmission by 5% in order to see savings. The upfront personnel costs mentioned above would still be a problem, but health systems with larger patient pools could leverage individual personnel to care for patients across hospitals.

Table 2 of the study shows that the BCPI group received a greater number of AECOPD admission-related services. Tobacco cessation, pulmonary rehabilitation, and vaccination are all indicated following AECOPD, according to recent guidelines.^[2,7] The increase in durable medical equipment services, presumably related to oxygen prescription, likely accounted for a significant proportion of the costs incurred per diagnosis. Given recent evidence,^[8,9] future programs could reduce costs by eliminating this from the bundle unless patients qualify for 24-7 use. In summary, BCPI successfully increased "guideline-appropriate" care. This is a good thing.

The results of their Cox-regression are presented in table 2 as well. Although they failed to show a statistically significant difference between groups (unadjusted hazards ratio 0.70 [95% confidence interval, 0.45-1.07; P = .101]), the curves reveal an increasing separation that starts fairly early. It's easy to imagine that a slightly larger sample size, and perhaps a higher overall readmission rate, would provide the numbers needed to show significance.

The authors do bring up a number of important concerns. COPD is a "complex medical condition," and patients often have multiple comorbid diseases.^[7] Is it reasonable to expect bundled care that targets COPD to affect all-cause readmission rates? Perhaps not. Patients in the BCPI group also had longer hospital stays. Could providers be gaming the system to reduce readmissions by prolonging hospitalization? If so, it's not necessarily a bad thing, assuming it works. Still, top-down interventions often create unintended consequences, so the extended stays are worrisome.

In summary, I'd view this study as part of an ongoing discussion about providing evidence-based, cost-effective, and high-quality care. The fact that so many patients in both arms went without proven, guideline-recommended interventions speaks for itself. It's also a familiar story.^[10,11] For those providers who resent being held to standards that differ from their own internal barometer for quality, I'd recommend getting with the program.

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