Interventions to Reduce Rehospitalizations after Chronic Obstructive Pulmonary Disease Exacerbations. A Systematic Review

Abstract

Rationale: Approximately 20% of patients hospitalized for COPD exacerbations in the United States will be readmitted within 30 days. The Centers for Medicare and Medicaid Services has recently proposed to revise the Hospital Readmissions Reduction Program to financially penalize hospitals with high all-cause 30-day rehospitalization rates after a hospitalization for COPD exacerbation on or after October 1, 2014.Objectives: To report the results of a systematic review of randomized clinical trials evaluating interventions to reduce the rehospitalizations after COPD exacerbations.Methods: Multiple electronic databases were systematically searched to identify relevant studies published between January 1966 and June 2013. Titles, abstracts, and, subsequently, full-text articles were assessed for eligibility. Each study was appraised using predefined criteria.Measurements and Main Results: Among 913 titles and abstracts screened, 5 studies (1,393 participants) met eligibility criteria. All studies had a primary outcome of rehospitalization at 6 or 12 months. No study examined 30-day rehospitalization as the primary outcome. Each study tested a different set of interventions. Two studies (one conducted in Canada and one conducted in Spain and Belgium) showed a decrease in all-cause rehospitalization over 12 months in the intervention group versus comparator group (mean number of hospitalizations per patient, 1.0 vs. 1.8; P = 0.01; percent hospitalized, 45 vs. 67%; P = 0.028; respectively). The only study conducted in the United States found a greater than twofold higher risk of mortality in the intervention group (17 vs. 7%, P = 0.003) but no significant difference in rehospitalizations. It was unclear which set of interventions was effective or harmful. Conclusions:The evidence base is inadequate to recommend specific interventions to reduce rehospitalizations in this population and does not justify penalizing hospitals for high 30-day rehospitalization rates after COPD exacerbations.

Association of Psychological Disorders With 30-Day Readmission Rates in Patients With COPD

“…Hospitals with a disproportionate share of patients with these disorders will be more likely to have higher rates of readmission and risk getting penalized, even though most of these conditions are nonmodifiable. 64 Because of scarce evidence in literature to support any interventions to reduce readmissions in patients with COPD, [65][66][67][68] hospitals and health-care providers need more guidance to reduce readmission in patients with COPD, and it may not be practical to penalize hospitals for higher 30-day readmission rates. Clearly, more studies are needed in this area.…”

Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study

“…The proportion of readmissions that could be prevented with better care depends largely on the definition of 'preventable' and the population in question, but it is considerable; in their June 2007 report to the US Congress, the Medical Payment Advisory Commission estimated that 75% of Medicare readmissions are potentially preventable. 82 Much has been written about strategies for reducing readmissions in patients with chronic conditions such as HF and COPD, such as continuity of care and better co-operation with community teams, 83,84 medication reconciliation, 84 self-management, 85 health education, telemonitoring, 83 pulmonary rehabilitation, 86,87 and care bundles, 88 although the evidence base in terms of randomised controlled trials for reducing COPD readmissions is disputed 89 and a multifactorial approach is needed. 84 We also note that our analysis found that mortality and readmission were more likely at hospitals with fewer doctors per bed and that readmission was also more likely at smaller hospitals.…”

Understanding Why Patients With COPD Get Readmitted

“…4 In contrast, a specifi c randomized study of a US hospital intervention to evaluate the eff ect on the 30-day COPD readmission rate has yet to be conducted, and there is little evaluation of the cost of such interventions. 5 Th us, hospitals have little guid-…”