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2019 HSR&D/QUERI National Conference Abstract

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1043 — Redesigning healthcare delivery to improve quality-of-life and hospital readmission after COPD exacerbation: a pragmatic clinical trial

Lead/Presenter: David Au,  COIN - Seattle/Denver
All Authors: Au DH (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA), Collins, MP (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA), Berger, D (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA) Carvalho, P (Boise VA Medical Center, Boise, ID) Nelson, KM (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA) Reinke, LF (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA) Goodman, RB (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA) Adamson, R (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA) Rise, P (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA) Epler, EM (Center of Innovation for Veteran-Centered and Value-Drive Care, VA Puget Sound Health Care System, Seattle, WA) Weppner, WG (Boise VA Medical Center, Boise, ID)

Objectives:
Hospital readmission after chronic obstructive pulmonary disease (COPD) exacerbations is common and contributes to decrements in health-related quality-of-life. We designed a pragmatic intervention to address care gaps during transitions of care, driven by geographic, temporal and other access challenges. We tested whether this intervention improved readmission and health-related quality-of-life.

Methods:
Population: Primary care clinicians and their patients discharged after COPD exacerbation from the VA Puget Sound Health Care System and Boise VA Medical Center. Design: Stepped-wedge clinical trial. Intervention: After discharge, a team of primary care, pulmonary, and pharmacy clinicians reviewed patients' medical records and care recommendations focused on guideline concordance for COPD and co-morbid disease treatment, accounting for context of patient care. We communicated recommendations to primary care teams using proactive e-consults. Timed to coincide with the post-discharge clinic follow-up, we entered recommendations as unsigned orders on behalf of providers which could be accepted, modified or declined. Outcomes: The primary outcomes were the Clinical COPD Questionnaire (CCQ) collected six weeks after discharge and all-cause 180-day readmission/death. Analytic approach: Mixed-effects linear and logistic regression. We adjusted for imbalances in patient characteristics.

Results:
We randomized 369 (98.1%) providers and 352 of their patients discharged from hospital after a COPD exacerbation. 191 (54.3%) patients contributed to the control period and 161 (45.7%) to the intervention. For intervention patients, we made a total of 753 total recommendations. 425 recommendations were entered as pre-completed orders and 330 (77%) were accepted. We conducted unadjusted and adjusted analyses. Intervention patients experienced non-significant reduction in 180-day mortality or readmission (aOR 0.78 (95% CI, 0.46 to 1.30)). Patients in the intervention reported clinically meaningful improved quality-of-life (CCQ -0.52 (95% CI, -0.92 to -0.11) (MID for CCQ 0.38)). Results were robust to adjustment. Providers reported being satisfied with the intervention across multiple dimensions.

Implications:
A pragmatic intervention involving a proactive, targeted population health approach addresses a number of healthcare delivery challenges improved patients' quality-of-life after discharge for COPD exacerbation.

Impacts:
In context of the Mission Act, VA can improve quality and access to specialty services by reorganizing approach to care using existing resources, with minimal increased burden to providers and the healthcare system