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Editorial |

Treat the Brain to Improve the Lungs?: Mental Illness as a Risk Factor for Readmission in COPD FREE TO VIEW

Abebaw Mengistu Yohannes, PhD, FCCP; Iracema Leroi, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Abebaw Mengistu Yohannes, PhD, FCCP, Department of Health Professions, Manchester Metropolitan University, 53 Bonsall Street, Manchester M15 6GX, England


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(4):887-888. doi:10.1016/j.chest.2015.08.022
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COPD is a major cause of increased morbidity, hospital readmission, mortality, and health-care use. In 2010, the direct cost of COPD in the United States was estimated to be in excess of $49 billion per year. Data from the United States inpatient nationwide sample from 2001 to 2012 revealed that hospitalization rates for common cardiovascular disorders, pneumonia, and lung cancer were reduced significantly, whereas for COPD the rehospitalization rate increased during the same period. The primary cause of hospitalization and emergency health-care admissions in patients with COPD is severe acute exacerbation, defined by increased dyspnea, increased cough, and purulent sputum present for at least 48 h. Readmission to short-term care for this group of patients is common and costly and is associated with impaired quality of life and increased burden to the caregiver. Furthermore, severe exacerbations that trigger hospital readmission may represent a life-threatening event and use of the ICU.

FOR RELATED ARTICLE SEE PAGE 905

The cause(s) of short-term hospital readmission in patients with COPD is often unclear but it is most likely multifactorial (Table 1). Snider and colleagues showed that oral nutritional supplementation was related to a significant reduction in the length of hospital stay and hospitalization cost, and in 30-day readmission in Medicare patients with COPD aged 65 years and older. Two previous uncontrolled retrospective studies, incorporating discharge letter management plans and outpatient follow-up by pulmonologists or primary care physicians after acute exacerbation of COPD also found a significant reduction in the rates of hospital readmission. Furthermore, those studies found that factors related to nonattendance to follow-up appointments with primary care physicians or pulmonologists by patients with COPD include older age, lower socioeconomic status, black race, and emergency admissions. Adding to these findings, Shah and colleagues demonstrated that patients with COPD who were readmitted within 30 days of discharge had longer hospital stays and significantly more comorbidities compared with patients with COPD who were not admitted. Unfortunately, to date, the type of comorbidities associated with COPD have not been well studied; however, this forms the subject of the study in this issue of CHEST reported by Singh and colleagues (see page 905), specifically with respect to the high rates of comorbidity of mental health problems and COPD. Mental health problems significantly complicate the already heavy burden of disease and acute exacerbations of COPD.

Table Graphic Jump Location
Table 1 Contributing Factors for Hospital Readmission in Patients With COPD

Singh and colleagues conducted an extensive study of acute care hospital admissions related to COPD that occurred between 2001 and 2011. All patients with COPD included in the study were aged 66 years or older and were enrolled in both Medicare parts A and B but were not part of a health maintenance organization. Findings revealed that the rates of comorbid mental health problems in the participants with COPD were as follows: 34% had depression, 43% had anxiety, 18% had psychosis, 30% misused alcohol, and 29% had misused substances. Furthermore, those with mental health problems had a higher risk for 30-day short-term hospital readmission compared with patients with COPD who did not have these disorders. Readmission was also associated with male sex, length of hospital stay, and ICU admission.

What do these findings mean to health-care professionals and providers? First, untreated or underrecognized mental health disorders clearly have a significant negative impact on patients with COPD. This includes being less able to cope with the burden of the disease and the demands of self-management of the illness process, as well as experiencing greater disruption in the usual routines of life, and having impaired social interactions and disrupted relationships. This then creates a strong argument for vigorous screening for mental health problems in patients who are admitted in the short term for exacerbations of COPD. Managing mental health problems associated with COPD should be an important part of the management plan for the short term as well as the discharge, including the recognition of mental health as a potentially modifiable target to reduce COPD-related readmissions. Second, Singh and colleagues should be congratulated for the painstaking work they have done in identifying the subgroup of patients with COPD who have a unique revolving door syndrome profile. These findings are particularly well-timed because US hospitals are now being penalized by the Centers for Medicare and Medicaid for excessive readmissions of patients with COPD., Thus, health-care professionals and providers should be working collaboratively and creatively to go beyond traditional discharge care planning and embrace new ways to manage the chronic condition. A key focus of this effort should be consideration of the comorbidities, which forecast poor prognosis of health-related outcomes.

In spite of the importance and timeliness of the report by Singh and colleagues, a note of caution is warranted. The findings reported were based on retrospective and administrative claim data. Furthermore, it was difficult to quantify the severity and therefore the exact prevalence of comorbid mental disorders and COPD, because appropriate diagnostic tools (eg, the Hospital Anxiety Depression Scale or Diagnostic Statistical Manual for Mental Disorders criteria) had not been applied. Nonetheless, the findings provide a key addition to the literature and clinical practice for strategies to reduce short-term hospital readmission rates for patients who have COPD, and we hope it sets the stage for further work in the area. Future intervention studies should examine whether combined pharmacological and nonpharmacological interventions may reduce hospital readmission in patients with acute exacerbation of COPD.

Supplementary Data

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2014 update.http://www.goldcopd.org/uploads/users/files/GOLD_Report2014_Feb07.pdf. Accessed July 23, 2015.
 
Dalal A.A. .Christensen L. .Liu F. .Riedel A.A. . Direct costs of chronic obstructive pulmonary disease among managed care patients. Int J Chron Obstruct Pulmon Dis. 2010;5:341-349 [PubMed]journal. [PubMed]
 
Ford E.S. . Hospital discharges from, readmissions and ED visits for COPD or bronchiectasis among US adults: findings from the nationwide inpatient sample 2001-2012 and Nationwide Emergency Department Sample 2006-2011. Chest. 2015;147:989-998 [PubMed]journal. [CrossRef] [PubMed]
 
Jencks S.F. .Williams M.V. .Coleman E.A. . Rehospitalizations among patients in the Medicare Fee-for-Service program. N Engl J Med. 2009;360:1418-1428 [PubMed]journal. [CrossRef] [PubMed]
 
Snider J.T. .Jena A.B. .Linthicium M.T. .et al Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmission among medicate patients with COPD. Chest. 2015;147:1477-1484 [PubMed]journal. [CrossRef] [PubMed]
 
Sharma G. .Kuo Y.F. .Freeman J.L. .Zhang D.D. .Goodwin J.S. . Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010;170:1664-1670 [PubMed]journal. [PubMed]
 
Gavish R. .Levy A. .Dekel O.K. .Karp E. .Maimon N. . The association between hospital readmission and pulmonologist follow-up visits in patients with COPD. Chest. 2015;148:375-381 [PubMed]journal. [CrossRef] [PubMed]
 
Shah T. .Churpek M.M. .Coca Perraillon M. .Konetzka R.T. . Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest. 2015;147:1219-1226 [PubMed]journal. [CrossRef] [PubMed]
 
Singh G. .Zhang W. .Kuo Y-F. .Sharma G. . Association of psychological disorders with 30-day readmission rates in patients with COPD. Chest. 2016;149:905-915 [PubMed]journal. [CrossRef] [PubMed]
 
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation: Payment Policies Related to Patient Status; Final Rule. 42 CFR Parts 412, 413, 414, 419, 424, 482, 485, and 489.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-Page-Items/FY-2014-IPPS-Final-Rule-CMS-1599-F-Regulations.html. Accessed August 5, 2015.
 
Feemester L.C. .Au D.H. . Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014;189:634-639 [PubMed]journal. [CrossRef] [PubMed]
 
Zigmond A.S. .Snaith R.P. . The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361-370 [PubMed]journal. [CrossRef] [PubMed]
 
First M.B. .Spitzer L. .Robert L. .Gibbon M. .Williams J.B.W. . Structural Clinical Interview for DSM-IV-TR Axis I. Disorders Research version, patient edition (SCID-I/P).  2002;:- [PubMed] Biometrics Research, New York State Psychiatric Institute New York, NYjournal
 
Yohannes A.M. .Alexopoulos G.S. . Pharmacological treatment of depression in older patients with chronic obstructive pulmonary disease: impact on the course of the disease and health outcomes. Drugs Aging. 2014;31:483-492 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 Contributing Factors for Hospital Readmission in Patients With COPD

References

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2014 update.http://www.goldcopd.org/uploads/users/files/GOLD_Report2014_Feb07.pdf. Accessed July 23, 2015.
 
Dalal A.A. .Christensen L. .Liu F. .Riedel A.A. . Direct costs of chronic obstructive pulmonary disease among managed care patients. Int J Chron Obstruct Pulmon Dis. 2010;5:341-349 [PubMed]journal. [PubMed]
 
Ford E.S. . Hospital discharges from, readmissions and ED visits for COPD or bronchiectasis among US adults: findings from the nationwide inpatient sample 2001-2012 and Nationwide Emergency Department Sample 2006-2011. Chest. 2015;147:989-998 [PubMed]journal. [CrossRef] [PubMed]
 
Jencks S.F. .Williams M.V. .Coleman E.A. . Rehospitalizations among patients in the Medicare Fee-for-Service program. N Engl J Med. 2009;360:1418-1428 [PubMed]journal. [CrossRef] [PubMed]
 
Snider J.T. .Jena A.B. .Linthicium M.T. .et al Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmission among medicate patients with COPD. Chest. 2015;147:1477-1484 [PubMed]journal. [CrossRef] [PubMed]
 
Sharma G. .Kuo Y.F. .Freeman J.L. .Zhang D.D. .Goodwin J.S. . Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010;170:1664-1670 [PubMed]journal. [PubMed]
 
Gavish R. .Levy A. .Dekel O.K. .Karp E. .Maimon N. . The association between hospital readmission and pulmonologist follow-up visits in patients with COPD. Chest. 2015;148:375-381 [PubMed]journal. [CrossRef] [PubMed]
 
Shah T. .Churpek M.M. .Coca Perraillon M. .Konetzka R.T. . Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest. 2015;147:1219-1226 [PubMed]journal. [CrossRef] [PubMed]
 
Singh G. .Zhang W. .Kuo Y-F. .Sharma G. . Association of psychological disorders with 30-day readmission rates in patients with COPD. Chest. 2016;149:905-915 [PubMed]journal. [CrossRef] [PubMed]
 
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation: Payment Policies Related to Patient Status; Final Rule. 42 CFR Parts 412, 413, 414, 419, 424, 482, 485, and 489.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-Page-Items/FY-2014-IPPS-Final-Rule-CMS-1599-F-Regulations.html. Accessed August 5, 2015.
 
Feemester L.C. .Au D.H. . Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014;189:634-639 [PubMed]journal. [CrossRef] [PubMed]
 
Zigmond A.S. .Snaith R.P. . The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67:361-370 [PubMed]journal. [CrossRef] [PubMed]
 
First M.B. .Spitzer L. .Robert L. .Gibbon M. .Williams J.B.W. . Structural Clinical Interview for DSM-IV-TR Axis I. Disorders Research version, patient edition (SCID-I/P).  2002;:- [PubMed] Biometrics Research, New York State Psychiatric Institute New York, NYjournal
 
Yohannes A.M. .Alexopoulos G.S. . Pharmacological treatment of depression in older patients with chronic obstructive pulmonary disease: impact on the course of the disease and health outcomes. Drugs Aging. 2014;31:483-492 [PubMed]journal. [CrossRef] [PubMed]
 
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