Does pay-for-performance improve patient outcomes in acute exacerbation of COPD admissions?

Abstract

BackgroundThe COPD Best Practice Tariff (BPT) is a pay-for-performance scheme in England that incentivises review by a respiratory specialist within 24 hours of admission and completion of a list of key care components prior to discharge, known as a discharge bundle, for patients admitted with acute exacerbation of COPD (AECOPD). We investigated whether the two components of the COPD BPT were associated with lower 30-day mortality and readmission in people discharged following AECOPD.MethodsLongitudinal study of national audit data containing details of AECOPD admissions in England and Wales between 01 February 2017 and 13 September 2017. Data were linked with national admissions and mortality data. Mixed-effects logistic regression, using a random intercept for hospital to adjust for clustering of patients, was used to determine the relationship between the COPD BPT criteria (combined and separately) and 30-day mortality and readmission. Models were adjusted for age, sex, socioeconomic status, length of stay, smoking status, Charlson comorbidity index, mental illness and requirement for oxygen or noninvasive ventilation during admission.Results28 345 patients discharged from hospital following AECOPD were included. 37% of admissions conformed to the two COPD BPT criteria. No relationship was observed between BPT conforming admissions and 30-day mortality (OR: 1.09 (95% CI 0.92 to 1.29)) or readmissions (OR: 0.96 (95% CI 0.90 to 1.02)). No relationship was observed between either of the individual COPD BPT components and 30-day mortality or readmissions. However, a specialist review at any time during admission was associated with lower inpatient mortality (OR: 0.69 (95% CI 0.58 to 0.81)).ConclusionCompletion of the combined COPD BPT criteria does not appear associated with a reduction in 30-day mortality or readmission. However, specialist review was associated with reduced inpatient mortality. While it is difficult to argue that discharge bundles do not improve care, this analysis questions whether the pay-for-performance model improves mortality or readmissions.

Optimizing COPD Acute Care Patient Outcomes Using a Standardized Transition Bundle and Care Coordinator

“…Financial incentives often are seen as being an important element in changing clinical practice. 49 A recent study found that pay-for-performance as part of a health-care system initiative in England resulted in higher uptake in discharge bundle use compared with the current study (53% vs 19% in the current study); however, this discharge bundle was not associated with reduced readmission rates or mortality. 49 Further study in this area is warranted.…”

Advances in chronic obstructive pulmonary disease: management of exacerbations

“…The remains unexplained variation in care for COPD exacerbations, and national audit programmes such as the UK National Asthma and COPD Audit Programme can be used to benchmark care [15]. There is evidence that care is improved when patients with COPD are reviewed by a COPD specialist from the multi-disciplinary team during their admission [16].…”

Implementation of the Care Bundle for the Management of Chronic Obstructive Pulmonary Disease with/without Heart Failure

“…As defined by the Institute for Healthcare Improvement, a care bundle is “a small set of evidence based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually” [ 100 ]. Care bundles have been demonstrated to improve the outcomes of COPD, especially when a respiratory specialist is involved [ 101 , 102 ].…”