Effect of a Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Hospitalized Patients With Chronic Obstructive Pulmonary Disease

Abstract

IMPORTANCE Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life.OBJECTIVE To evaluate a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers. DESIGN, SETTING, AND PARTICIPANTSThis single-site randomized clinical trial was conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016. INTERVENTIONSThe intervention (n = 120) was a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by COPD nurses (nurses with special training on supporting patients with COPD using standardized tools). Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care. MAIN OUTCOMES AND MEASURESThe primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful). RESULTS Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; females, 61.7%), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 63.1 (19.9) in the intervention group and 62.6 (19.3) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 0.72 (95% CI, 0.45-0.97) in the intervention group vs 1.40 (95% CI, 1.01-1.79) in the usual care group (difference, 0.68 [95% CI, 0.22 to 1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was −1.53 in the intervention and +5.44 in the usual care group (adjusted difference, −6.69 [95% CI, −12.97 to −0.40]; P = .04). During the study period, there were 15 deaths (intervention: 7; usual care: 8) and 337 hospitalizations (intervention: 135; usual care: 202). CONCLUSIONS AND RELEVANCEIn a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly fewer COPD-related hospitalizations and emergency department visits and better health-related quality of life at 6 months after discharge. Further research is needed to evaluate this intervention in other settings.

Coordinated‐Transitional Care for Veterans with Heart Failure and Chronic Lung Disease

“…Where possible, incorporation of a home visit component has clear advantages, especially for the most complex . Some programs follow patients for longer than 30 days postdischarge that helps improve chronic disease management . C‐TraC is a complement to these programs, making high‐quality transitional care available to patients out of the range of home visits or who are in resource‐poor healthcare systems.…”

“…5,6,19 Some programs follow patients for longer than 30 days postdischarge that helps improve chronic disease management. 6,19,20 C-TraC is a complement to these programs, making high-quality transitional care available to patients out of the range of home visits or who are in resource-poor healthcare systems. Of note, only 27% of patients in our program required the full follow-up, suggesting the major benefit of the intervention was in the first few weeks.…”

Evaluation of a Multicomponent Care Transitions Program for High‐Risk Hospitalized Older Adults

“…Fifth, our attempts to enroll a broad‐based high‐risk patient population may have limited our ability to provide specialized expertise on specific high‐risk conditions. Programs that focus on one condition, such as chronic pulmonary disease and delirium, have been shown to be effective in reducing readmissions . Thus, for some conditions, condition‐specific programs may be more effective than a program targeted to a broader group of hospitalized high‐risk geriatric patients.…”

“…Programs that focus on one condition, such as chronic pulmonary disease and delirium, have been shown to be effective in reducing readmissions. 43,44 Thus, for some conditions, condition-specific programs may be more effective than a program targeted to a broader group of hospitalized high-risk geriatric patients. Disease-specific programs may not, however, be optimal in the SNF setting because of the multiple and nonspecific nature of acute changes in condition that result in hospital transfers.…”

Comorbidities and Readmissions in Survivors of Acute Hypercapnic Respiratory Failure

“…105 In a recent randomized clinical trial, a 3-month program combining transitional care and longterm self-management support not only failed to show a reduction in COPD readmissions at 6 months but showed significantly greater COPD-related hospitalizations and emergency department visits in the intervention group, without an improvement in quality of life. 106 Studies on care bundles to reduce early readmissions have shown the same variability of results. In a randomized controlled trial, Linden and Butterworth did not show any significant reduction in 30-day readmissions with a hospital-based transitional care program.…”