Hospital admissions for chronic obstructive pulmonary disease (COPD) exacerbations are common among Veterans. From a patient perspective, exacerbations cause significant decrements in health-related quality-of-life. For VA, exacerbations drive health care expenditures with as many as half of patients requiring readmission within 6 months. Most patients discharged after COPD do not receive care that is known to improve health outcomes for COPD. VA needs to redesign care delivery systems, including improving the reach of specialty medicine with greatest expertise to engage in the treatment of patients within Patient Aligned Care Teams (PACT). VA's current system reflects a fee-for-service model where specialists wait for patient referrals and do not assume responsibility for the health of a population of patients. Specialists also are geographically concentrated at major medical centers that are culturally and physically separated from the patient's medical home. Determining how to deploy existing specialties using a PACT-Veteran-centric approach is important to improve access, timeliness, and quality-of-care.
We designed a pragmatic intervention that sought to: 1) utilize population health methods to identify vulnerable/high-risk patients, 2) support primary care teams in the care of patients recently discharged with a COPD exacerbation, 3) integrate proactive collaborative care with specialty care, primary care and pharmacy services, 4) deliver care within the context of existing services and ongoing care, 5) leverage VA IT and virtual care platforms to facilitate improved care delivery, and 6) minimize workload and preserve autonomy for primary care. We examined if this intervention would: 1) decrease hospital readmission and mortality after hospital discharge for COPD exacerbation, and 2) improve patient quality-of-life as measured by the Clinical COPD Questionnaire (CCQ).
Setting: We identified patients from the VA Puget Sound and the Boise Health Care Systems that included 2 tertiary facilities and their accompanying 10 community based outpatient clinics.
Population: We recruited primary care clinicians and their patients who were discharged with COPD exacerbations. We performed daily interrogation of the VA Corporate Data Warehouse (CDW) to identify patients who were discharged for COPD.
Design: We used a stepped-wedge design; a variant of a provider-level clustered randomized trial. Each step was designed to balance patients/providers into 30 unique groups. Every month, one group was randomly assigned to step/cross over from control to intervention.
Intervention: For patients whose provider was in the intervention arm, a team of study clinicians reviewed: discharge summaries; primary care, pulmonary, sleep study, emergency room, procedures, imaging, social work, and post-discharge follow-up call notes; consults; and advanced directives. The study team developed recommendations for post-discharge care according to COPD guidelines and key co-morbidities. Recommendations focused on diagnostic testing, medications, therapies/referrals, and/or follow-up around COPD care and co-morbid disease treatment. Timed to coincide with the post-discharge clinic follow-up, rationale of recommendations were delivered via e-consult notes. We entered all recommendations as unsigned orders on behalf of PACT. The PACT provider could accept, modify, or decline any or all recommendations. In select situations, we made recommendations that could be considered but were not entered as orders based on patient context.
Outcomes: The primary patient reported outcome (CCQ) was collected at six weeks after discharge via mailed survey and telephone. The second primary outcome was readmission/death assessed at 180 days post-hospital discharge. Secondary outcomes included the VR-12 (SF-12 modified for Veteran population) physical component score (PCS) and satisfaction using a modified Survey of Healthcare Experiences of Patients (SHEP). Based on qualitative interviews from a prior Office of Specially Care Transformation provider satisfaction evaluation, we developed and administered a 10-item provider satisfaction survey for the intervention. We conducted qualitative interviews with a sample of enrolled providers to learn about their perspective of the program.
Analytic approach: We used mixed-effects linear regression or logistic regression as appropriate for the outcome of interest. Models were adjusted for within-provider clustering, temporal trend, number of days exposed to systemic corticosteroids, and number of COPD exacerbations in the prior year not requiring readmission. Rubin's rules were used to pool inference from multiply-imputed data sets that addressed missingness in CCQ Total Score.
Of the 376 primary care providers eligible, we enrolled 369 (98.1%). Over the course of the 30-month intervention period, we identified 362 potential patient participants, of whom 352 (97.2%) met eligibility criteria. Of these patients, 191 (54.3%) participated in the control period and 161 (45.7%) in the intervention. On average, patients were well balanced across sociodemographic and co-existing conditions except for days exposed to systemic corticosteroid and number of COPD exacerbations in prior year not requiring admission, which were adjusted for in final analyses.
We made a total of 753 total recommendations. Of the 425 recommendations entered as orders, 328 (77.2%) were endorsed by PACT providers. These recommendations focused on diagnostic, pharmacologic, and non-pharmacologic care, including behavioral health engagement. Of the 333 recommendations that were not entered as orders, 64 (19.2%) were endorsed by PACT.
The unadjusted rate of 180-day mortality or readmission was 36.6% in the intervention group compared to 44.0% in the control group. The intervention had a non-statistically significant decrease in 180-day readmission/mortality (adjusted OR 0.78 (95% CI, 0.46 to 1.30)). Patients in the intervention reported better quality-of-life that was clinically meaningful and statically significant (unadjusted mean CCQ Total Score Control: 3.50 (SD 1.22) vs Intervention: 2.97 (SD 1.20)). After adjustment and accounting for missing values (52.7% missing), the between-group difference was -0.52 (95% CI, -0.92 to -0.11). The statistical significance and magnitude of the CCQ Total Score difference persisted when using complete-case analyses. Overall post-discharge COPD quality-of-care was higher among patients who participated in the intervention group. Of the intervention participants, clinical review suggested that 27.5% did not meet the clinical definition of a COPD exacerbation. Providers were generally satisfied with the intervention across multiple dimensions including effect on workload, respecting the role of PACT, and improving quality-of-care. We found no significant differences between patient groups with respect to satisfaction (modified SHEP) or generic health status (unadjusted mean VR-12 PCS Control: 29.92 (SD 12.22) vs Intervention: 33.25 (SD 11.94). After adjustment and accounting for missing values (57.4%), the between-group difference was 3.22 (95% CI, -1.21 to 7.65)).
A pragmatic intervention that redesigned healthcare delivery leveraging the VA's integrated healthcare and informatics system to deliver proactive, virtually delivered, specialist supported recommendations within PACT setting improved quality-of-life after COPD exacerbations. Care recommendations were consistently endorsed by PACT providers and improved overall quality-of-care for patients with COPD.
- Au DH, Berger D, Carvalho P, Collins MP, Goodman R, Gunnink E, McDowell J, Moss B, Nelson KM, Plumley R, Reinke LF, Weppner W, Woo D, Feemster LM. COPD Hospital Readmissions Penalties: Do Patients Discharged with COPD diagnoses have COPD? Poster session presented at: American Thoracic Society Annual International Conference; 2015 May 20; Denver, CO.