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Reducing COPD ReadmissionsReducing COPD Readmissions: Great Promise but Big Problems FREE TO VIEW

David M. Mannino, MD, FCCP; Byron Thomashow, MD, FCCP
Author and Funding Information

From the Department of Preventive Medicine and Environmental Health (Dr Mannino), University of Kentucky College of Public Health; and Department of Pulmonary and Critical Care Medicine (Dr Thomashow), Columbia University Medical Center, Columbia University.

CORRESPONDENCE TO: David M. Mannino, MD, FCCP, Department of Preventive Medicine and Environmental Health, University of Kentucky College of Public Health, 111 Washington Ave, Lexington, KY 40536; e-mail: dmannino@uky.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: Dr Mannino has served as a consultant for Boehringer Ingelheim GmbH; GlaxoSmithKline plc; AstraZeneca; Novartis AG; Merck Sharp & Dohme Corp; and Forest Laboratories, Inc and has received research grants from GlaxoSmithKline plc; Novartis AG; Boehringer Ingelheim GmbH; Forest Laboratories, Inc; and Pfizer Inc. He is also compensated by UpToDate, Inc, has served as an expert in tobacco-related cases, and is on the Board of the COPD Foundation. Dr Thomashow has served as a consultant for Boehringer Ingelheim GmbH and has served on advisory boards for GlaxoSmithKline plc; Novartis AG; Boehringer Ingelheim GmbH; Forest Laboratories, Inc; and Pfizer Inc. He is also the Chairman of the Board of the COPD Foundation.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1199-1201. doi:10.1378/chest.15-0380
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Published online

COPD is responsible for nearly 700,000 hospitalizations annually,1 and hospitalizations account for a large proportion of the annual direct medical costs of COPD.2 About 20% of patients hospitalized with COPD exacerbations are rehospitalized within 30 days of discharge,3 and these rehospitalizations are costly. One of the provisions in the Affordable Care Act targets reducing COPD rehospitalizations as a way to improve care and reduce costs.4 The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals if admissions for COPD exacerbations exceed a higher than expected all-cause 30-day rehospitalization rate.4

While several studies have been able to reduce overall rehospitalizations,5,6 none of these has been specific to COPD nor have they looked at interventions that might be critical in this population (eg, oxygen titration, nebulizer use, noninvasive ventilatory support). There are multiple factors contributing to readmissions, many of which are not specific to COPD. These include the severity of underlying disease, poor adherence to pharmacologic guidelines for therapy (by either providers or patients), poor adherence to nonpharmacologic guidelines (smoking, vaccinations, rehabilitation, nutrition), comorbidities, social issues, and posthospital syndrome.7-10 As only about 30% of readmissions are due to COPD, comorbid conditions appear to be a particularly important factor.11

In this issue of CHEST (see pages 1219 and 1227), two articles12,13 examine issues related to rehospitalization. Shah et al12 examine data from seven states to describe factors that lead to rehospitalizations following a COPD hospitalization. COPD only accounted for 27.6% of these rehospitalizations, highlighting the importance of comorbid conditions. Dual-insured patients (ie, poor patients with Medicaid coverage) were more likely to be readmitted, reinforcing the importance of social issues.

Importantly, this study confirmed that readmissions occur early, with one-half occurring within 2 weeks of discharge, confirming what others have seen.14 Thus, in planning a discharge strategy, arranging to see a patient 2 weeks postdischarge may fail by missing those most at risk.

The article by Jennings et al13 looked at an intervention to reduce rehospitalizations. They screened 1,225 patients to get 172 in the study; thus, their inclusion/exclusion criteria eliminated many patients who might benefit (and who would be included in the HRRP assessment). Jennings et al13 chose (for simplicity and cost issues) a limited discharge bundle: smoking intervention; screening for GI reflux, depression, and anxiety; teaching of inhaler technique; and a call at 48 h. They found no difference between the intervention group and the control group.

This negative study had some problems. For example, it is not clear how adherent patients were with follow-up and therapy (ie, was inhaler teaching done in a way that patients showed that they had successfully mastered technique? Did patients actually take the medications? What percentage of the 48-h calls actually got through to the patient?). That the “decision to initiate pharmacologic therapy was deferred to the primary team” is potentially problematic: Is it possible that those not readmitted were sent out on a more intensive pharmacologic regimen or were more compliant with that regimen?

There are many factors contributing to readmissions that were not addressed in this study. There was no referral to rehabilitation in the discharge bundle, but it is possible that this occurred in some patients outside of the bundle. The bundle did not include a home-care visit or an early doctor visit. As noted, most hospital readmissions occur for causes other than COPD, but this analysis just focused on readmissions for COPD. A more extensive discharge bundle designed and evaluated by Hopkinson et al15 had much more positive results, and the “negative” results of the study by Jennings et al13 should not dissuade clinicians, hospitals, and researchers from developing potentially more effective discharge bundles.

Decreasing rehospitalizations among patients discharged after a COPD hospitalization is a worthy goal that could both improve the health of the patients and save resources. This is the great promise noted in our title. As we noted, there are also, however, big problems. There are really no clear data on what actually prevents rehospitalizations following a COPD discharge. Indeed, a systematic review of interventions to reduce rehospitalization after a COPD exacerbation hospitalization found no studies targeting 30-day readmissions,16 and only one, to our knowledge, randomized trial in this country—a Veterans Administration study, which reported that a comprehensive care management program for COPD, which included patient education and scheduled proactive calls, resulted in greater COPD-related hospitalizations and mortality for patients in the intervention group.17 This lack of data leaves hospitals with little guidance regarding approaches to reduce readmissions among patients with COPD.

With comorbidity and social factors being main drivers of rehospitalizations, prevention strategies may have to look well beyond the traditional factors addressed. For example, being hospitalized for any condition can result in impaired sleep, high levels of stress, deconditioning, and poor nutrition. Thus, one strategy to decrease rehospitalization is to change the actual hospitalization process itself by incorporating early rehabilitation, more patient-friendly medication strategies, and improved nutrition.

An ominous sign, however, is that the current HRRP may have unintended consequences by penalizing some of the hospitals that are serving the highest risk patients. Results of a recent Commonwealth Fund analysis found that safety-net hospitals, those that take care of predominately the poor, are 30% more likely to have 30-day hospital readmission rates above the national average, compared with non-safety-net hospitals, and will, therefore, be disproportionately impacted by the HRRP.18 Shah et al12 showed that poorer patients (as noted by being covered by Medicaid) are more likely to be rehospitalized. This is likely due to factors well beyond the control of the hospitals, physicians, and patients. Determining a path forward that improves patient care and protects the most vulnerable will be critical as HRRP is implemented.

References

Ford ES, Croft JB, Mannino DM, Wheaton AG, Zhang X, Giles WH. COPD surveillance—United States, 1999-2011. Chest. 2013;144(1):284-305. [CrossRef] [PubMed]
 
Ford ES, Murphy LB, Khavjou O, Giles WH, Holt JB, Croft JB. Total and state-specific medical and absenteeism costs of COPD among adults aged ≥ 18 years in the United States for 2010 and projections through 2020. Chest. 2015;147(1):31-45. [CrossRef] [PubMed]
 
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. [CrossRef] [PubMed]
 
US Congress. House Committee on Ways and Means, Committee on Energy and Commerce, Committee on Education and Labor. Compilation of Patient Protection and Affordable Care Act: As Amended Through November 1, 2010, Including Patient Protection and Affordable Care Act Health-Related Portions of the Health Care and Education Reconciliation Act of 2010. Washington, DC: US Government Printing Office; 2010.
 
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187. [CrossRef] [PubMed]
 
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828. [CrossRef] [PubMed]
 
Roberts CM, Lopez-Campos JL, Pozo-Rodriguez F, Hartl S; European COPD Audit team. European hospital adherence to GOLD recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions. Thorax. 2013;68(12):1169-1171. [CrossRef] [PubMed]
 
Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-102. [CrossRef] [PubMed]
 
Nishi SP, Wang Y, Kuo YF, Goodwin JS, Sharma G. Spirometry use among older adults with chronic obstructive pulmonary disease: 1999-2008. Ann Am Thorac Soc. 2013;10(6):565-573. [CrossRef] [PubMed]
 
Gaurav K, Vaid U, Sexauer W, Kavuru MS. Readmissions after hospital discharge with acute exacerbation of COPD: are we missing something? Hosp Pract (1995). 2014;42(2):58-69. [CrossRef] [PubMed]
 
Baker CL, Zou KH, Su J. Risk assessment of readmissions following an initial COPD-related hospitalization. Int J Chron Obstruct Pulmon Dis. 2013;8:551-559. [PubMed]
 
Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest. 2015;147(5):1219-1226.
 
Jennings JH, Thavarajah K, Mendez MP, Eichenhorn M, Kvale P, Yessayan L. Predischarge bundle for patients with acute exacerbations of COPD to reduce readmissions and ED visits: a randomized, controlled trial. Chest. 2015;147(5):1227-1234.
 
Sharif R, Parekh TM, Pierson KS, Kuo YF, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2014;11(5):685-694. [CrossRef] [PubMed]
 
Hopkinson NS, Englebretsen C, Cooley N, et al. Designing and implementing a COPD discharge care bundle. Thorax. 2012;67(1):90-92. [CrossRef] [PubMed]
 
Prieto-Centurion V, Markos MA, Ramey NI, et al. Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations. A systematic review. Ann Am Thorac Soc. 2014;11(3):417-424. [CrossRef] [PubMed]
 
Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012;156(10):673-683. [CrossRef] [PubMed]
 
Berenson J, Shih A. Higher readmissions at safety-net hospitals and potential policy solutions. Issue Brief (Commonw Fund). 2012;34:1-16. [PubMed]
 

Figures

Tables

References

Ford ES, Croft JB, Mannino DM, Wheaton AG, Zhang X, Giles WH. COPD surveillance—United States, 1999-2011. Chest. 2013;144(1):284-305. [CrossRef] [PubMed]
 
Ford ES, Murphy LB, Khavjou O, Giles WH, Holt JB, Croft JB. Total and state-specific medical and absenteeism costs of COPD among adults aged ≥ 18 years in the United States for 2010 and projections through 2020. Chest. 2015;147(1):31-45. [CrossRef] [PubMed]
 
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. [CrossRef] [PubMed]
 
US Congress. House Committee on Ways and Means, Committee on Energy and Commerce, Committee on Education and Labor. Compilation of Patient Protection and Affordable Care Act: As Amended Through November 1, 2010, Including Patient Protection and Affordable Care Act Health-Related Portions of the Health Care and Education Reconciliation Act of 2010. Washington, DC: US Government Printing Office; 2010.
 
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187. [CrossRef] [PubMed]
 
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828. [CrossRef] [PubMed]
 
Roberts CM, Lopez-Campos JL, Pozo-Rodriguez F, Hartl S; European COPD Audit team. European hospital adherence to GOLD recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions. Thorax. 2013;68(12):1169-1171. [CrossRef] [PubMed]
 
Krumholz HM. Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-102. [CrossRef] [PubMed]
 
Nishi SP, Wang Y, Kuo YF, Goodwin JS, Sharma G. Spirometry use among older adults with chronic obstructive pulmonary disease: 1999-2008. Ann Am Thorac Soc. 2013;10(6):565-573. [CrossRef] [PubMed]
 
Gaurav K, Vaid U, Sexauer W, Kavuru MS. Readmissions after hospital discharge with acute exacerbation of COPD: are we missing something? Hosp Pract (1995). 2014;42(2):58-69. [CrossRef] [PubMed]
 
Baker CL, Zou KH, Su J. Risk assessment of readmissions following an initial COPD-related hospitalization. Int J Chron Obstruct Pulmon Dis. 2013;8:551-559. [PubMed]
 
Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest. 2015;147(5):1219-1226.
 
Jennings JH, Thavarajah K, Mendez MP, Eichenhorn M, Kvale P, Yessayan L. Predischarge bundle for patients with acute exacerbations of COPD to reduce readmissions and ED visits: a randomized, controlled trial. Chest. 2015;147(5):1227-1234.
 
Sharif R, Parekh TM, Pierson KS, Kuo YF, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2014;11(5):685-694. [CrossRef] [PubMed]
 
Hopkinson NS, Englebretsen C, Cooley N, et al. Designing and implementing a COPD discharge care bundle. Thorax. 2012;67(1):90-92. [CrossRef] [PubMed]
 
Prieto-Centurion V, Markos MA, Ramey NI, et al. Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations. A systematic review. Ann Am Thorac Soc. 2014;11(3):417-424. [CrossRef] [PubMed]
 
Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012;156(10):673-683. [CrossRef] [PubMed]
 
Berenson J, Shih A. Higher readmissions at safety-net hospitals and potential policy solutions. Issue Brief (Commonw Fund). 2012;34:1-16. [PubMed]
 
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