Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory condition associated airflow limitation and is a major cause of morbidity and mortality . As of 2021, COPD is the fourth leading cause of death in the United States . Hospitalizations, emergency department visits, and economic costs create a significant health care burden. In the United States, COPD results in over two million emergency department visits and 652,000 hospitalizations annually, with an associated economic cost approaching $50 billion .
COPD is the third most common cause of hospital readmission and approximately one in five patients hospitalized for COPD will have rehospitalization within 30 days [4,5]. Outside of the United States, 30-day and 90-day readmission rates have been reported as high as 24% and 43%, respectively . Hospital readmissions are costly and preventable. Health care facilities are now accountable for excess 30-day readmissions through the Hospital Readmissions Reduction Program for select conditions, including COPD. The Centers for Medicare and Medicaid Services limit payments to hospitals with high readmission rates via this program, providing a financial incentive for institutions to improve care coordination to reduce avoidable readmissions .
In order to reduce readmissions, delivery of guideline-directed care for maintenance and prevention is essential. To provide consistent care during hospitalization, care bundles can be utilized. The Institute of Healthcare Improvement defines care bundles as “a structured way of improving the processes of care and patients’ outcome” . These bundles standardize the care process and play an important role in management of chronic conditions, such as COPD . One study conducted by Laverty et al. evaluated a COPD care bundle that implemented smoking cessation assistance, pulmonary rehabilitation referral, patient education, inhaler technique assessment, and a follow-up appointment prior to discharge. This bundle was associated with a reduction in hospital readmission rate . Another study conducted by Ko et al. randomized patients discharged after an acute COPD exacerbation to receive a care bundle or usual care. The intervention consisted of a comprehensive, individualized care plan delivered by an interdisciplinary group, which included education from a respiratory nurse, pulmonary rehabilitation, three-monthly telephone calls by a respiratory nurse over one year, and follow-up at a respiratory clinic once every three months for one year. At one year, the adjusted relative risk of readmission was 0.668 (95% CI 0.449 to 0.995, p=0.047) for the patients receiving the care bundle compared to those who received usual care, indicating that the COPD program reduces hospital readmissions. Those receiving the intervention also had a shorter length of stay and greater improvements of symptoms and quality of life . Additionally, ensuring care coordination between inpatient and outpatient providers has been shown to not only reduce patient hospitalizations, but also improve patient quality of life .
Incorporation of supplemental elements into the COPD care bundle may also help optimize comprehensive patient care. For example, depression and anxiety are risk factors for COPD exacerbation and may have implications in COPD treatment compliance [13, 14]. Screening for and treating these ailments may have utility in a COPD care bundle. Nutritional support may also help target the extrapulmonary effects of COPD, such as the physical and metabolic adaptations. Studies have shown that patients with a body mass index (BMI) less than 20 kg/m2 have a higher risk of exacerbation than those with a higher BMI . Implementation of a dietary consult can help effectively manage the nutritional depletion seen in COPD and improve quality of life . Another supplemental intervention can include early mobilization, as it has been shown to reduce physical disability in older patients hospitalized with COPD and decrease length of stay [17, 18]. Lastly, ensuring medication affordability prior to discharge helps enhance transitions of care given the high cost and few available generic options. Medication cost is one of the most significant determinants of nonadherence in the COPD patient population . Confirming patients are discharged on inhalers covered by their health plan or helping to facilitate enrollment to patient assistance programs are additional interventions that can help improve overall care for patients with COPD.
To reduce healthcare burden and optimize patient care, sustainable interventions need to be established. Previous studies have evaluated the implementation of a limited number of interventions, many of which consist of smoking cessation, patient education, and follow up. Authors of this study designed an innovative, comprehensive COPD care bundle to be used during hospitalization and enhance care coordination. It was hypothesized this intervention would reduce readmission rates for patients hospitalized with COPD.
The purpose of this study was to evaluate the effect of the implementation of an innovative inpatient COPD care bundle on 30-day readmissions for patients admitted with a COPD exacerbation. The primary objective of this study was to measure the 30-day readmission rates in patients who received the care bundle versus those who received standard of care. Secondary outcomes evaluated 60- and 90-day readmission rates and length of stay.