Throughout the United States, more patients are being diagnosed with and treated for COPD than ever before, and many are unaware they even have the disease. COPD ranks as the third most frequent cause for readmission to hospitals within 30 days. Beginning in October 2015, Medicare reimbursement will be reduced for acute care hospitals whose rates for COPD readmission exceed a predetermined threshold. “The new Medicare reimbursement issue that withholds remuneration to hospitals for COPD exacerbation recidivism compels physicians to improve COPD care,” says Reynold A. Panettieri, Jr., MD. In light of the potential financial penalties from this decree, hospitals are committing substantial resources to developing systems and programs that are designed to mitigate readmissions.
It can be exceptionally challenging for clinicians to assure the stability of COPD after patients are discharged from hospitals. In order to prevent COPD-related rehospitalizations, clinicians need a clear understanding of the causes of patient decompensation that lead to readmission and then find ways to diminish these causes. Several factors have been shown to be predictive of readmission in clinical studies. These include prior hospital admission, oral corticosteroids, use of long-term oxygen therapy, poor health-related quality of life, and a lack of routine physical exercise.
Interventions to Prevent COPD Readmissions
In recent years, strategies for preventing readmissions in patients with COPD have been the focus of many clinical investigations. Many interventions have been explored, including face-to-face, post-discharge educational visits, patient education initiatives, and telephone follow-up. These interventions—and many others—have had varied success, but some common themes have emerged. For example, hospitals with more respiratory consultants and better organized care have lower mortality rates and shorter lengths of stay following admissions for exacerbations.
“COPD exacerbation recidivism is most likely to occur in patients with profound comorbidities or those with the most severe disease,” explains Dr. Panettieri. “Evidence now suggests that discharge of such patients to inpatient rehabilitation or to outpatient pulmonary rehabilitation may reduce readmission rates. In addition, clinicians should follow-up with patients within 2 weeks after they’re discharged with a COPD exacerbation to enhance airway disease management. This type of management includes educating patients on inhaler techniques and nutrition. Early follow-up can also inform clinicians on patients’ access to medications.”
Managing COPD Patients at Discharge
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides clinicians with discharge criteria for patients with COPD (Table 1). One of its chief recommendations is to start patients on long-acting bronchodilators, beta2-agonists, and/or anti-cholinergics with or without inhaled cortico-steroids in the hospital. The GOLD committee also provides a checklist of items to assess at discharge (Table 2) and at follow-up every 4 to 6 weeks after patients are discharged from the hospital (Table 3).
“COPD exacerbation recidivism is most likely to occur in patients with profound comorbidities or those with the most severe disease.”
After early follow-up, care at subsequent visits should be the same as it is for managing stable COPD patients, according to GOLD. This includes supervising smoking cessation, reviewing the effectiveness of each medication, and monitoring changes in spirometric parameters. Home visits by community nurses may also be of benefit for some patients when trying to reduce readmission. Written action plans can be helpful in shortening recovery time, especially for those deemed capable of effective self-management. For those who are hypoxemic during exacerbations, arterial blood gases and/or pulse oximetry should be evaluated before discharge and in the following 3 months. If patients remain hypoxemic, long-term supplemental oxygen therapy may be required.
Aiming to Prevent COPD Exacerbations
COPD exacerbations can often be prevented. Smoking cessation, influenza and pneumococcal vaccines, knowledge of current therapy (including inhaler techniques), and treatment with long-acting inhaled corticosteroids (with or without inhaled corticosteroids) and phosphodiesterase-4 inhibitors are all therapies that can reduce the number of exacerbations and hospitalizations. Early outpatient pulmonary rehabilitation after hospitalization for exacerbations is safe and can improve exercise capacity and health at 3 months.
Effective patient education and sustained reinforcement of these messages can result in favorable readmission outcomes. Common comorbidities associated with COPD, including heart disease, cancer, osteoporosis, depression and anxiety, and diabetes, should be addressed. Clinicians should also encourage patients to maintain physical activity and discuss issues with anxiety, depression, and social problems. Involving principal caregivers during patient education and training may further reduce risks for COPD readmissions.
Patient education and training needs to start in the hospital but must continue after discharge, Dr. Panettieri says. “Pulmonary rehabilitation, attention to comorbidities, and frequent follow-up with patients after discharge are potential approaches to decreasing exacerbation recidivism. At the same time, these strategies can enhance functional status and quality of life in COPD.”
Global Initiative for Chronic Obstructive Lung Disease (GOLD) Executive Summary. Updated 2013. Available at: http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf.
Elixhauser A, Au D, Podulka, J. Readmissions for chronic obstructive pulmonary disease, 2008. HCUP Statistical Brief #121. September 2011. AHRQ. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb121.pdf
Han MK, Martinez FJ. Pharmacotherapeutic approaches to preventing acute exacerbations of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2011;8:356-362.
Postma D, Anzueto A, Calverley P, et al. A new perspective on optimal care for patients with COPD. Prim Care Respir J. 2011;20:205-209. Available at: http://www.thepcrj.org/journ/vol20/20_2_205_209.pdf.
Anzueto A. Impact of exacerbations on COPD. Eur Respir Rev. 2010;19:113-118. Available at: http://err.ersjournals.com/content/19/116/113.full.
Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet. 2007;370(9589):786-796.