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Correspondence |

The Effect of Clinical and Physiological Instability at Discharge Following Hospitalization for Acute Exacerbation of COPD on Early Readmission: A Cohort Study FREE TO VIEW

Roni Nasser, MD; Danny Epstein, MD; Rawan Azzam, BSc; Itai Gofman, MD; Walid Saliba, MD, MPH; Emilia Hardak, MD; Zaher S. Azzam, MD; Gidon Berger, MD
Author and Funding Information

Drs Nasser and Epstein contributed equally to this letter.

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aDepartment of Internal Medicine “B”, Rambam Health Care Campus, Haifa, Israel

bDivision of Pulmonary Medicine, Rambam Health Care Campus, Haifa, Israel

cRappaport's Faculty of Medicine, The Technion Institute, Haifa, Israel

dDepartment of Community Medicine and Epidemiology, Carmel Medical Center, Clalit Health Services, Haifa, Israel

CORRESPONDENCE TO: Danny Epstein, MD, Department of Internal Medicine “B”, Ramabam Health Care Campus, HaAliya HaShniya St 8, Haifa, 3109601, Israel


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(5):1192-1194. doi:10.1016/j.chest.2017.01.028
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Acute exacerbations of COPD (AECOPD) are of major importance with respect to prolonged detrimental effects on patients, accelerated disease progression, and high health-care costs., Among patients hospitalized for AECOPD, 20% and 35% require rehospitalization within 30 and 90 days, respectively., These hospitalizations increase patient mortality and morbidity and the economic burden of COPD., Although reduction of early readmissions has become a policy target in many developed countries, little is known regarding standards that can be applied to the timing and nature of discharge.

Systematic assessment of clinical and physiological stability, as well as follow-up arrangements and initiation of long-acting bronchodilators, are proposed as discharge criteria by the Global Initiative for Chronic Obstructive Lung Disease. Unfortunately, these criteria are largely based only on consensus and limited evidence.

To evaluate the adherence to these discharge criteria and to examine whether it is predictive of readmission, we retrospectively screened 1,157 hospitalizations for AECOPD at Rambam Health Care Campus between January 1, 2011 and December 31, 2013. The study was approved by the institution's Institutional Review Board (reference 0447-14).

The degree of adherence to the discharge criteria recommended by the Global Initiative for Chronic Obstructive Lung Disease was 66%, 62%, 56%, and 50% for blood gas stability, clinical stability, completion of follow-up arrangements, and discharge with a recommendation for long-acting bronchodilators, respectively. Clinical stability at discharge was associated with lower readmission rates at 30 days: 18.3% vs 13.73% (P = .03). Abnormal or unstable levels of Pco2 at discharge were associated with higher readmission rates: 13.57% vs 19.03% at 30 days (P = .019) and 20.78% vs 27.35% (P = .01) at 60 days (Fig 1). Using Cox regression for adjusting different risk factors for readmission, we found a positive correlation between clinical and gas stability and 30- and 60-day readmission rates as well as a positive correlation between completion of follow-up arrangements and 60-day readmission rates (Fig 2). A subgroup analysis of patients naive to any long-acting COPD treatment showed that initiation of such treatment is associated with significantly (P = .004) lower readmission rates at 60 days: 10.11% vs 22.6%.

Figure Jump LinkFigure 1 Clinical and physiological stability and readmission rates. A, Kaplan-Meier plot of time to first readmission within 30 days after hospitalization due to acute exacerbations of COPD (AECOPD) according to clinical stability at discharge. B, Kaplan-Meier plot of time to first readmission within 30 days after hospitalization due to AECOPD according to physiological stability at discharge. C, Kaplan-Meier plot of time to first readmission within 30 days following hospitalization due to AECOPD according to physiological and clinical stability at discharge. D, Forest plot showing ORs for readmission within 30 days after discharge according to physiological and clinical stability at discharge.Grahic Jump Location

Figure Jump LinkFigure 2 Forest plot showing ORs of different risk factors associated with readmission within 30 and 60 days after discharge.Grahic Jump Location

Our findings provide evidence for the significance of the discharge criteria after hospitalization for AECOPD and emphasize the importance of meticulous assessment before decisions about discharge are made. The discharge criteria are hospital-level factors and may thus be modified by health systems to reduce early readmissions and hence decrease morbidity and the economic burden of COPD.

Quint J.K. .Donaldson G.C. .Hurst J.R. .Goldring J.J.P. .Seemungal T.R. .Wedzicha J.A. . Predictive accuracy of patient-reported exacerbation frequency in COPD. Eur Respir J. 2011;37:501-507 [PubMed]journal. [CrossRef] [PubMed]
 
Shah T. .Press V.G. .Huisingh-Scheetz M. .White S.R. . COPD readmissions: addressing COPD in the era of value-based healthcare. Chest. 2016;150:916-926 [PubMed]journal. [CrossRef] [PubMed]
 
Hartl S. .Lopez-Campos J.L. .Pozo-Rodriguez F. .et al Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit. Eur Respir J. 2016;47:113-121 [PubMed]journal. [CrossRef] [PubMed]
 
Shah T. .Churpek M.M. .Perraillon M.C. .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]
 
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015.http://www.goldcopd.org. Date last accessed: October 25, 2015. Date last updated: 2015.
 

Figures

Figure Jump LinkFigure 1 Clinical and physiological stability and readmission rates. A, Kaplan-Meier plot of time to first readmission within 30 days after hospitalization due to acute exacerbations of COPD (AECOPD) according to clinical stability at discharge. B, Kaplan-Meier plot of time to first readmission within 30 days after hospitalization due to AECOPD according to physiological stability at discharge. C, Kaplan-Meier plot of time to first readmission within 30 days following hospitalization due to AECOPD according to physiological and clinical stability at discharge. D, Forest plot showing ORs for readmission within 30 days after discharge according to physiological and clinical stability at discharge.Grahic Jump Location
Figure Jump LinkFigure 2 Forest plot showing ORs of different risk factors associated with readmission within 30 and 60 days after discharge.Grahic Jump Location

Tables

References

Quint J.K. .Donaldson G.C. .Hurst J.R. .Goldring J.J.P. .Seemungal T.R. .Wedzicha J.A. . Predictive accuracy of patient-reported exacerbation frequency in COPD. Eur Respir J. 2011;37:501-507 [PubMed]journal. [CrossRef] [PubMed]
 
Shah T. .Press V.G. .Huisingh-Scheetz M. .White S.R. . COPD readmissions: addressing COPD in the era of value-based healthcare. Chest. 2016;150:916-926 [PubMed]journal. [CrossRef] [PubMed]
 
Hartl S. .Lopez-Campos J.L. .Pozo-Rodriguez F. .et al Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit. Eur Respir J. 2016;47:113-121 [PubMed]journal. [CrossRef] [PubMed]
 
Shah T. .Churpek M.M. .Perraillon M.C. .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]
 
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015.http://www.goldcopd.org. Date last accessed: October 25, 2015. Date last updated: 2015.
 
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