Identifying Distinct Healthcare Pathways During Episodes of Chronic Obstructive Pulmonary Disease Exacerbations

Abstract

Healthcare pathways are important to measure because they are expected to affect outcomes. However, they are challenging to define because patients exhibit heterogeneity in their use of healthcare services. The objective of this study was to identify and describe healthcare pathways during episodes of chronic obstructive pulmonary disease (COPD) exacerbations.Linked administrative databases from Saskatchewan, Canada were used to identify a cohort of newly diagnosed COPD patients and their episodes of healthcare use for disease exacerbations. Latent class analysis (LCA) was used to classify the cohort into homogeneous pathways using indicators of respiratory-related hospitalizations, emergency department (ED) visits, general and specialist physician visits, and outpatient prescription drug dispensations. Multinomial logistic regression models tested patients’ demographic and disease characteristics associated with pathway group membership. The most frequent healthcare contact sequences in each pathway were described. Tests of mean costs across groups were conducted using a model-based approach with χ2 statistics.LCA identified 3 distinct pathways for patients with hospital- (n = 963) and ED-initiated (n = 364) episodes. For the former, pathway group 1 members followed complex pathways in which multiple healthcare services were repeatedly used and incurred substantially higher costs than patients in the other pathway groups. For patients with an ED-initiated episode, pathway group 1 members also had higher costs than other groups. Pathway groups differed with respect to patient demographic and disease characteristics. A minority of patients were discharged from ED or hospital, but did not have any follow-up care during the remainder of their episode.Patients who followed complex pathways could benefit from case management interventions to streamline their journeys through the healthcare system. The minority of patients whose pathways were not consistent with recommended follow-up care should be further investigated to fully align COPD treatment in the province with recommended care practices.

An economic evaluation of chronic obstructive pulmonary disease clinical pathway in Saskatchewan, Canada: Data-driven techniques to identify cost-effectiveness among patient subgroups

“…Individuals with COPD diagnosis were identified using the International Classification of Diseases, 10 th Revision, Canada (ICD-10-CA) codes J41, J42, J43 or J44 in the hospital discharge abstracts; whilst ICD-9 codes 491, 492 or 496 were used to identify individuals in the physician billing claims [ 27 ]. This case definitions has been used in previous studies [ 28 , 29 ]. COPD patients residing in Saskatoon were selected as controls because Saskatoon and Regina are the two main urban centers in Saskatchewan (population > 200,000 in each center), and together account for about half of the provincial population.…”

“…Costs were adjusted for inflation using the health and personal care (hospitalization, physician visits, ED visits) and the Medicinal and pharmaceutical products (prescription drugs dispensations) items of the Saskatchewan consumer price index [ 31 ] and expressed in 2019/20 constant Canadian dollars. The methods we used to estimate healthcare costs were applied in previous studies using Saskatchewan administrative health data [ 28 , 29 ]. All healthcare costs were calculated from the perspective of a single public payer (i.e., the Saskatchewan Ministry of Health), excluding individual out-of-pocket expenditures such as copayments.…”

“…ICD-10-CA codes J41, J42, J43, J44 were used to identify episodes of acute COPD exacerbations in inpatient hospital and ED records, whilst ICD-9 codes 491, 492, 496 were used to identify episodes of acute COPD exacerbations in physician visit records. These codes were validated and previously used to identify episodes of COPD exacerbations from administrative health data in Saskatchewan [ 29 ]. The ICD-10-CA codes must be in the most responsible diagnosis field, or a diagnosis of an acute lower respiratory tract infection in the most responsible diagnosis field and a diagnosis of other COPD (ICD-10-CA code J44) in the second diagnosis field.…”

The clinical journey of patients with a severe exacerbation of chronic obstructive pulmonary disease (COPD): from the ambulance to the emergency department to the hospital ward

“…The literature of COPD exacerbations is expanding rapidly and there are comprehensive national and international clinical guidelines including the COPD-X Plan and the GOLD Report (1,2). Whilst this literature is extensive, there are only a handful of studies and reviews which have linked aspects of the emergency healthcare pathway for exacerbations (3)(4)(5)(6)(7)(8).…”