Low-Cost Program Slashes Readmission Rates for COPD

Pam Harrison

October 11, 2018

SAN ANTONIO — Rates of hospital readmission for acute exacerbations of chronic obstructive pulmonary disease (COPD) can be reduced significantly with a "discharge care bundle" that costs next to nothing to implement, new research shows.

Patient education and timely follow-up referrals are key, said senior author Chirag Shah, MD, from the Morristown Medical Center, Atlantic Health System, in New Jersey.

"This disease has a high burden of morbidity and mortality in the United States," he told Medscape Medical News. "Keeping people out of the hospital reduces the likelihood of death but, more important, it improves their quality of life."

The bundle "reduces healthcare costs and allows the hospital to use those resources for other things," he added. "I think that, ultimately, reimbursement will be a driving force for hospitals to want to keep COPD people out of the hospital."

The Centers for Medicare and Medicaid Services now limits payments to hospitals with high readmission rates for a number of conditions, and paramount among them is COPD.

Results from the study were presented by coauthor Moira Kendra, DNP, an acute care nurse practitioner, here at CHEST 2018. Lisa Landry was the respiratory therapist on the study.

The 150 patients admitted to the Morristown Medical Center with an acute exacerbation of COPD from April to September of 2016 served as the preintervention cohort. Implementation of the evidence-based care bundle was completed in March 2017. The patients admitted from April to September 2017 served as the postintervention cohort.

The cohorts were chosen from the same months to eliminate bias created by seasonal variations that affect COPD, Kendra explained.

The care bundle itself is not complicated.

Education began the moment the patient was admitted and continued daily. The signs and symptoms of an acute exacerbation of COPD were emphasized by members of the care team, and ways to better cope with difficulties encountered as patients transition from the hospital to home were discussed.

"Encouraging self-management was also a key factor in the success of this project," Kendra said. The need to seek early access to treatment to decrease was stressed.

The scheduling of pulmonary follow-up visit in the week after discharge was a "critically important" element in the discharge care bundle, she noted. And the team ensured that patients had a COPD action plan and that they knew how to use an inhaler correctly (which most did not).

Pre- vs Post-Bundle Care

Table. Readmission Rates After Hospital Discharge
Days After Discharge Preintervention, % Postintervention, % Difference, % P Value
30 32.7 22.2 10.5 .024
60 56.0 30.3 25.7 <.001
90 62.6 35.3 27.3 <.001

Implementation of the COPD care bundle did not increase the length of hospital stays, said Kendra.

The process is really straightforward. If the specific steps of the bundle are followed, the bundle can be implemented in any hospital. "That's what so exciting about it," Kendra told Medscape Medical News.

The cost of offering such a program to patients who require hospitalization for an acute exacerbation of COPD is negligible.

A dedicated nurse practitioner worked for 8 months to develop the pilot, but after that, the people already involved in the care of COPD patients, including a respiratory therapist, a nurse, and each patient's physician, took over.

"Moreover, 1 year out, our readmission rate — at 14.4% — is now lower than what it was at the end of our study, so this only gets better," Shah reported. And the number needed to "treat" is only four patients to reduce one readmission over 90 days of follow-up, he added.

"From an administrative hospital standpoint, this is a no-brainer," he said. "To use a nonpharmacologic intervention to help patients, that's huge. There are no side effects and patients are all willing to do it because there is no study drug — that's the beauty of this."

Reducing Readmission Rates

Brian Carlin, MD, from the University of Pittsburgh Medical Center, said that he was involved in a program that tasked members with reducing readmission rates, not only in COPD patients, but also in a number of other disease settings.

Although the Pittsburgh Regional Health Initiative required more dedicated personnel, the Morristown results are "very good," he told Medscape Medical News. "I'm encouraged so see more people doing this because this is what we need to see."

Many hospitals still do not have a program to offer COPD patients, "which is a shame," Carlin said. "You can do it, it makes sense, and we should not get paid to do a poor job."

The study authors have disclosed no relevant financial relationships. Carlin reports having served on advisory boards for AstraZeneca, GlaxoSmithKline, and Sunovion.

CHEST 2018: American College of Chest Physicians Annual Meeting: Abstract 16031. Presented October 9, 2018.

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