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      Impact of individualized care on readmissions after a hospitalization for acute exacerbation of COPD

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          Abstract

          Background

          Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) increase COPD morbidity and mortality and impose a great burden on health care systems. Early readmission following a hospitalization for AECOPD remains an important clinical problem. We examined how individualized comprehensive care influences readmissions following an index hospital admission for AECOPD.

          Methods

          We retrospectively reviewed data of patients admitted for AECOPD to two inner-city teaching hospitals to determine the impact of a comprehensive and individualized care management strategy on readmissions for AECOPD. The control group consisted of 271 patients whose index AECOPD occurred the year before the comprehensive program, and the experimental group consisted of 191 patients who received the comprehensive care. The primary outcome measure was the total number of readmissions in 30- and 90-day postindex hospitalizations. Secondary outcome measures included the length of time between the index admission and first readmission and all-cause mortality.

          Results

          The two groups were similar in terms of age, sex, forced expiratory volume in 1 second, body mass index (BMI), pack-years, and the number and types of comorbidities. Comprehensive care significantly reduced 90-day readmission rates in females ( P=0.0205, corrected for age, BMI, number of comorbidities, substance abuse, and mental illness) but not in males or in the whole group ( P>0.05). The average times between index admission and first readmission were not different between the two groups. Post hoc multivariate analysis showed that substance abuse ( P<0.01) increased 30- and 90-day readmissions (corrected for age, sex, BMI, number of comorbidities, and mental illness). The 90-day all-cause in-hospital mortality rates were significantly less in the care package group (2.67% versus 7.97%, P=0.0268).

          Conclusion

          Comprehensive individualized care for subjects admitted to hospital for AECOPD did not reduce 30- and 90-day readmission rates but did reduce 90-day total mortality. Interestingly, it reduced 90-day readmission rate in females. We speculate that an individualized care package could impact COPD morbidity and mortality after an acute exacerbation.

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          Most cited references 22

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          Predictors of rehospitalization and death after a severe exacerbation of COPD.

          Patients who survive a severe exacerbation of COPD are at high risk of rehospitalization for COPD and death. The objective of this study was to determine predictors of these events in a large cohort of Veterans Affairs (VA) patients. We identified 51,353 patients who were discharged after an exacerbation of COPD in the VA health-care system from 1999 to 2003, and determined the rates of rehospitalization for COPD and death from all causes. Potential risk factors were assessed with univariate and multivariate survival analysis. On average, the cohort was elderly (mean age, 69 years), predominately white (78% white, 13% black, 3% other, and 6% unknown), and male (97%), consistent with the underlying VA population. The risk of death was 21% at 1 year, and 55% at 5 years. Independent risk factors for death were age, male gender, prior hospitalizations, and comorbidities including weight loss and pulmonary hypertension; nonwhite race and other comorbidities (asthma, hypertension, and obesity) were associated with decreased mortality. The risk of rehospitalization for COPD was 25% at 1 year, and 44% at 5 years, and was increased by age, male gender, prior hospitalizations, and comorbidities including asthma and pulmonary hypertension. Hispanic ethnicity and other comorbidities (diabetes and hypertension) were associated with a decreased risk of rehospitalization. Age, male gender, prior hospitalizations, and certain comorbid conditions were risk factors for death and rehospitalization in patients discharged after a severe COPD exacerbation. Nonwhite race and other comorbidities were associated with decreased risk.
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            Barriers to pulmonary rehabilitation: characteristics that predict patient attendance and adherence.

            Pulmonary rehabilitation (PR) is efficacious in chronic obstructive pulmonary disease (COPD). As completion rates of PR are poor, we wished to assess predictors of attendance and adherence. We performed a retrospective analysis of 711 patients with COPD, who were invited to attend PR. Data were compared to allow predictors (gender, smoking status, attending partner, referral route, employment status, body mass index, forced expiratory volume in 1 s (FEV(1)), oxygen therapy (LTOT), oxygen saturations, chronic respiratory questionnaire (CRQ), shuttle walk distance, travel distance and time) of attendance (0 or >0 attendance) and adherence ( 63% attendance) to be identified. 31.8% of patients referred for PR did not attend and a further 29.1% were non-adherent. Predictors of non-attendance were female gender, current smoker, and living alone. Predictors of non-adherence were extremes of age, current smoking, LTOT use, FEV(1), CRQ score and travelling distance. Multiple logistic regression revealed that LTOT and living alone were independent predictors of poor attendance and current smoking, poor shuttle walking distance and hospitalisations were independent predictors of poor adherence. Smoking status, availability of social support and markers of disease severity were predictors of attendance and adherence to PR. Copyright © 2012 Elsevier Ltd. All rights reserved.
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              The cost of moderate and severe COPD exacerbations to the Canadian healthcare system.

              The cost of exacerbations in chronic obstructive pulmonary disease (COPD) has not been well studied. The aim of this study was to identify and quantify the (average) cost of moderate and severe exacerbations (ME and SE, respectively) from a Canadian perspective. Resources used during ME and SE were identified in a year long prospective, observational study (Resource Utilization Study In COPD (RUSIC)). The units of analysis were ME and SE. Unit costs (2006$CAN), based on provincial, hospital and published sources, were applied to resources. The overall cost per ME and SE were calculated. The population burden of exacerbations was also calculated. Among study participants (N=609, aged 68.6+/-9.4 years, 58.3% male) there were 790 exacerbations: 639 (80.9%) MEs and 151 (19.1%) SEs. Of the 790 exacerbations, 618 (78.2%), 245 (31.0%) and 151 (19.1%) included a visit to an outpatient clinic, emergency department (ED) or hospital, respectively. For ME, 85.9% and 13.1% involved visits to GPs and respirologists, respectively. Pharmacologic treatment changes in the outpatient setting involved antibiotics (63.1%) and corticosteroids (34.7%). The overall mean costs for outpatient and ED services for MEs were $126 (N=574) and $515 (N=105), respectively. The average overall cost of a ME was $641. For SEs, the average hospital stay was 10.0 days. The overall mean costs of outpatient, ED and hospitalization services for SE were $114 (N=44), $774 (N=140) and $8669 (N=151), respectively. The average overall cost of a SE was $9557. The economic burden associated with MEs and especially SEs, in Canada, is considerable and likely has a substantial impact on healthcare costs. The overall burden of exacerbations has been estimated in the range of $646 million to $736 million per annum.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                1176-9106
                1178-2005
                2016
                05 January 2016
                : 11
                : 61-71
                Affiliations
                [1 ]The Centre for Heart Lung Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
                [2 ]Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
                [3 ]Division of Respirology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
                Author notes
                Correspondence: Stephan F van Eeden, The Centre for Heart Lung Innovation, St Paul’s Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada, Tel +1 604 806 8346, Fax +1 604 806 8351, Email stephan.vaneeden@ 123456hli.ubc.ca
                Article
                copd-11-061
                10.2147/COPD.S93322
                4708191
                © 2016 Adamson et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

                Respiratory medicine

                female, mortality, substance abuse, readmissions, care package

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