Recent study findings reveal which patients are more likely to be readmitted for COPD problems, and which readmission reduction strategies might work best.
Among the risk factors for 30-day hospital readmission for chronic obstructive pulmonary disease (COPD) are old age, male sex, longer hospital stay, prior hospitalizations, previous emergency department visits, leaving the hospital against medical advice, being discharged home with support services, and a more severe comorbidity.
In addition, patients of low socioeconomic status, those who are the most marginalized members of society, are also more likely to be readmitted than those patients who are prosperous and stable.
These are the findings of a population-based longitudinal cohort study conducted in Ontario, Canada.
All hospitalizations for COPD between 2004 and 2014 were assessed in 130,137 patients, of whom 15% had an unplanned readmission, with the median time to readmission being 12 days.
“Some of our results, such as prior hospitalizations and more severe comorbidity, are consistent with previous studies, so this is reassuring and makes us feel that we are on the right track,” says lead author Andrea Gershon, MD, a pulmonologist at Sunnybrook Health Sciences Centre in Toronto, Canada.
Study results were published as an abstract and presented in May at the American Thoracic Society 2017 International Conference in Washington, D.C.
“Unfortunately, socioeconomic factors that have been present for years and years are highly ingrained and not easy to address,” Gershon says. “Perhaps this is a signal to us that we need to start tackling these factors earlier, and not just after a patient’s first hospital admission.”
Ensuring that a patient adheres to their medication regimen is one strategy to reduce readmission. “Making medication affordable is important,” Gershon says. “Housing issues and unemployment are also issues that might need addressing.”
Smoking cessation is another factor that is more common in people of lower socioeconomic status.
“In our study, which took place in Canada where healthcare is universal, it is unlikely that the cost of health services or insurance was the reason for the disparity due to socioeconomic status that we saw,” Gershon says.
One of the predictors of readmission that was not very intuitive is specialist care. “This is probably due to specialists taking care of patients with the most severe disease,” Gershon says.
Next: Readmission red flags
WrightJean Wright, MD, vice president of innovation for Charlotte, North Carolina-based Carolinas Healthcare System, notes that “only 30% of the patients who return within 30 days do so for a reason related to their primary COPD-related condition. Another reason may be a comorbid condition like congestive health failure (CHF) or chest pain.”
Because these patients often have multi-comorbidity conditions, “keeping up with multiple medications, doctor's office appointments, and home care instructions is very difficult,” Wright says. “In fact, some of these patients have as many as 30 medications that they take in a 24-hour period. So it is not surprising that they cannot keep all these medications well managed.”
Carolinas Healthcare recently found that the risk factors for readmission were demographic, high utilization, and disease specific. “For example, not surprisingly, if you were over 80, you were high risk,” Wright says. Likewise, “if you frequented an ER, urgent care, or had a previous admission last year, you were high risk.”
The utilization measure might reflect the severity of the disease or lack of access to primary care, pulmonary care, or pulmonary rehabilitation, according to Wright. “Correlation does not conclude causality,” she says.
Wright says that support at the time of discharge, and follow up by telehealth for the first few days, “seems to make a difference in patients. We know getting back into their physician, particularly a pulmonologist, is a 'protective factor' against a readmission, but that must happen close to the index discharge to be of help to the patient. Those first few days at home are critical to them continuing their course of recovery and for their medication regime to become routine.”
Wright finds it interesting that male gender was a factor in the study. For other conditions at her institution, “we find a higher risk of readmission for men who live alone. Perhaps the role of the helpful spouse reminding them of medication, treatments and appointments is a critical factor in avoiding a readmission.”