Chronic Obstructive Pulmonary Disease Discharge Research Articles

Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations.

Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.

Enhancing potential impact of hospital discharge interventions for patients with COPD: a qualitative systematic review

BackgroundPatients with chronic obstructive pulmonary disease (COPD) are frequently readmitted to hospital resulting in avoidable healthcare costs. Many different interventions designed to reduce hospital readmissions are reported with limited evidence for effectiveness. Greater insight into how interventions could be better designed to improve patient outcomes has been recommended.AimTo identify areas for optimisation within previously reported interventions provided to reduce COPD rehospitalisation to improve future intervention development.MethodsA systematic review was conducted by searching Medline, Embase, CINAHL, PsycINFO, and CENTRAL in June 2022. Inclusion criteria were interventions provided to patients with COPD in the transition from hospital to home or community. Exclusion criteria were lack of empirical qualitative results, reviews, drug trials, and protocols. Study quality was assessed using the Critical Appraisal Skills Programme tool and results were synthesised thematically.ResultsA total of 2,962 studies were screened and nine studies included. Patients with COPD experience difficulties when transitioning from hospital to home. It is therefore important for interventions to facilitate a smooth transition process and give appropriate follow-up post-discharge. Additionally, interventions should be tailored for each patient, especially regarding information provided.ConclusionVery few studies specifically consider processes underpinning COPD discharge intervention implementation. There is a need to recognise that the transition itself creates problems, which require addressing, before introducing any new intervention. Patients report a preference for interventions to be individually adapted—in particular the provision of patient information. Whilst many intervention aspects were well received, feasibility testing may have enhanced acceptability. Patient and public involvement may address many of these concerns and greater use of process evaluations should enable researchers to learn from each other’s experiences.Trial registrationThe review was registered in PROSPERO with registration number CRD42022339523.

Health System Approach to Improve Chronic Obstructive Pulmonary Disease Care after Hospital Discharge: Stepped-Wedge Clinical Trial.

Rationale: Patients discharged from the hospital for chronic obstructive pulmonary disease (COPD) exacerbation have impaired quality of life and frequent readmission and death. Clinical trials to reduce readmission demonstrate inconsistent results, including some demonstrating potential harms. Objectives: We tested whether a pragmatic proactive interdisciplinary and virtual review of patients discharged after hospitalization for COPD exacerbation would improve quality of life, using the Clinical COPD Questionnaire, and reduce all-cause 180-day readmission and/or mortality. Methods: We performed a stepped-wedge clinical trial. We enrolled primary care providers and their patients after hospital discharge for COPD at two Department of Veterans Affairs medical centers and 10 outpatient clinics. A multidisciplinary team reviewed health records and developed treatment recommendations delivered to primary care providers via E-consult. We facilitated uptake by entering recommendations as unsigned orders that could be accepted, modified, or canceled. Providers and patients made all final treatment decisions. Measurements and Main Results: We enrolled 365 primary care providers. Over a 30-month period, 352 patients met eligibility criteria, with 191 (54.3%) patients participating in the control and 161 (45.7%) in the intervention. The intervention led to clinically significant better Clinical COPD Questionnaire scores (-0.47; 95% confidence interval [CI], -0.85 to -0.09; 52.6% missing) but did not reduce 180-day readmission and/or mortality (adjusted odds ratio, 0.83; 95% CI, 0.49 to 1.38), in part because of wide CIs. Among the 161 patients in the intervention group, we entered 519 recommendations as unsigned orders, of which 401 (77.3%) were endorsed. Conclusions: A pragmatic health system-level intervention that delivered proactive specialty supported care improved quality of life but did not reduce 180-day readmission or death. Clinical trial registered with www.clinicaltrials.gov (NCT02021955).

Association of weather, air pollutants, and seasonal influenza with chronic obstructive pulmonary disease hospitalization risks

The influences of weather and air pollutants on chronic obstructive pulmonary disease (COPD) have been well-studied. However, the heterogeneous effects of different influenza viral infections, air pollution and weather on COPD admissions and re-admissions have not been thoroughly examined. In this study, we aimed to elucidate the relationships between meteorological variables, air pollutants, seasonal influenza, and hospital admissions and re-admissions due to COPD in Hong Kong, a non-industrial influenza epicenter. A total number of 507703 hospital admissions (i.e., index admissions) and 301728 re-admission episodes (i.e., episodes within 30 days after the previous discharge) for COPD over 14 years (1998–2011) were obtained from all public hospitals. The aggregated weekly numbers were matched with meteorological records and outdoor air pollutant concentrations. Type-specific and all-type influenza-like illness positive (ILI+) rates were used as proxies for influenza activity. Generalized additive models were used in conjunction with distributed-lag non-linear models to estimate the associations of interest. According to the results, high concentrations of fine particulate matter, oxidant gases, and cold weather were strong independent risk factors of COPD outcomes. The cumulative adjusted relative risks exhibited a monotone increasing trend except for ILI+ B, and the numbers were statistically significant over the entire observed range of ILI+ total and ILI+ A/H3N2 when the reference rate was zero. COPD hospitalization risk from influenza infection was higher in the elderly than that in the general population. In conclusion, our results suggest that health administrators should impose clean air policies, such as strengthening emissions control on petrol vehicles, to reduce pollution from oxidant gases and particulates. An extension of the influenza vaccination program for patients with COPD may need to be encouraged: for example, vaccination may be included in hospital discharge planning, particularly before the winter epidemic.

The Effects of a Video Intervention on Posthospitalization Pulmonary Rehabilitation Uptake. A Randomized Controlled Trial.

Rationale: Pulmonary rehabilitation (PR) after hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life and reduces readmissions. However, posthospitalization PR uptake is low. To date, no trials of interventions to increase uptake have been conducted.Objectives: To study the effect of a codesigned education video as an adjunct to usual care on posthospitalization PR uptake.Methods: The present study was an assessor- and statistician-blinded randomized controlled trial with nested, qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including PR information leaflet) or usual care plus the codesigned education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, FEV1 % predicted, frailty, transport availability, and previous PR experience.Measurements and Main Results: The primary outcome was PR uptake within 28 days of hospital discharge. A total of 200 patients were recruited, and 196 were randomized (51% female, median FEV1% predicted, 36 [interquartile range, 27–48]). PR uptake was 41% and 34% in the usual care and intervention groups, respectively (P = 0.37), with no differences in secondary (PR referral and completion) or safety (readmissions and death) endpoints. A total of 6 of the 15 participants interviewed could not recall receiving the video.Conclusions: A codesigned education video delivered at hospital discharge did not improve posthospitalization PR uptake, referral, or completion.

Models of care across the continuum of exacerbations for patients with chronic obstructive pulmonary disease.

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality, and treatments require a multidisciplinary approach to address patient needs. This review considers different models of care across the continuum of exacerbations (1) chronic care and self-management interventions with the action plan, (2) domiciliary care for severe exacerbation and the impact on readmission prevention and (3) the discharge care bundle for management beyond the acute exacerbation episode. Self-management strategies include written action plans and coaching with patient and family support. Self-management interventions facilitate the delivery of good care, can reduce exacerbations associated with admission, be cost-effective and improve quality of life. Hospitalization as a complication of exacerbation is not always unavoidable. Domiciliary care has been proposed as a solution to replace part, and perhaps even all, of the patient’s in-hospital stay, and to reduce hospital bed days, readmission rates and costs; low-risk patients can be identified using risk stratification tools. A COPD discharge bundle is another potentially important approach that can be considered to improve the management of COPD exacerbations complicated by hospital admission; it comprised treatments that have demonstrated efficacy, such as smoking cessation, personalized pharmacotherapy and non-pharmacotherapy such as pulmonary rehabilitation. COPD bundles may also improve the transition of care from the hospital to the community following exacerbation and may reduce readmission rates. Future models of care should be personalized – providing patient education aiming at behaviour changes, identifying and treating co-morbidities, and including outcomes that measure quality of care rather than focusing only on readmission quantity within 30 days.

Care Bundles after Discharging Patients with Chronic Obstructive Pulmonary Disease Exacerbation from the Emergency Department.

Chronic obstructive pulmonary disease (COPD) is the second leading cause of emergency department (ED) admissions to hospital, and nearly a third of patients with acute exacerbation (AE) of COPD are re-admitted to hospital within 28 days after discharge. It has been suggested that nearly a third of COPD admissions could be avoided through the implementation of evidence-based care interventions. A COPD discharge bundle is a set of evidence-based practices, aimed at improving patient outcomes after discharge from AE COPD; body of evidence supports the usefulness of discharge care bundles after AE of COPD, although there is a lack of consensus of what interventions should be implemented. On the other hand, the implementation of those interventions also involves different challenges. Important care gaps remain regarding discharge care bundles for patients with acute exacerbation of COPD discharged from EDs There is an urgent need for investigations to guide future implementation of care bundles for those patients discharged from EDs.

Risk Trajectories of Readmission and Death in the First Year after Hospitalization for Chronic Obstructive Pulmonary Disease.

Characterization of the dynamic nature of posthospital risk in chronic obstructive pulmonary disease (COPD) is needed to provide counseling and plan clinical services. To analyze risk of readmission and death after discharge for COPD among Medicare beneficiaries aged 65 years and older and to determine the association between ventilator support and risk trajectory. We computed daily absolute risks of hospital readmission and death for 1 year after discharge for COPD, stratified by ventilator support. We determined the time required for risks to decline by 50% from maximum daily values after discharge and for daily risks to plateau. We compared risks with those found in the general elderly population. Among 2,340,637 hospitalizations, the readmission rate at 1 year was 64.2%, including 63.5%, 66.0%, and 64.1% among those receiving invasive, noninvasive, and no ventilation, respectively. Among 1,283,069 hospitalizations, mortality at 1 year was 26.2%, including 45.7%, 41.8%, and 24.4% among those same respective groups. Daily risk of readmission declined by 50% within 28, 39, and 43 days and plateaued at 46, 54, and 61 days among those receiving invasive, noninvasive, and no ventilation, respectively. Risk of death declined by 50% by 3, 4, and 17 days and plateaued by 21, 18, and 24 days in the same respective groups. Risks of hospitalization and death were significantly higher after discharge for COPD than among the general Medicare population. Discharge from the hospital is associated with prolonged risks of readmission and death that vary with need for ventilator support. Interventions limited to the first month after discharge may be insufficient to improve longitudinal outcomes.

A strategy to implement a chronic obstructive pulmonary disease discharge care bundle on a large scale

Care bundles may be an effective tool to standardise care for patients admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). However, it is unclear how care bundles can be implemented without the need for additional resources. We redeployed a respiratory early discharge service (REDS) to deliver a COPD discharge bundle. We audited the effect of this service redesign on length of stay (LOS) and uptake of referrals to smoking cessation and pulmonary rehabilitation services. Of 1,742 patients with COPD, 1,170 received the discharge care bundle. Mean LOS for patients who received the discharge care bundle was 6.17days versus 7.08days for patients who did not. Smoking cessation and pulmonary rehabilitation referrals increased during the project year. A COPD discharge care bundle can be implemented on a large scale by redeploying a REDS without an increase on hospital LOS.

Does Telehealth Monitoring Identify Exacerbations of Chronic Obstructive Pulmonary Disease and Reduce Hospitalisations? An Analysis of System Data.

BackgroundThe increasing prevalence and associated cost of treating chronic obstructive pulmonary disease (COPD) is unsustainable. Health care organizations are focusing on ways to support self-management and prevent hospital admissions, including telehealth-monitoring services capturing physiological and health status data. This paper reports on data captured during a pilot randomized controlled trial of telehealth-supported care within a community-based service for patients discharged from hospital following an exacerbation of their COPD.ObjectiveThe aim was to undertake the first analysis of system data to determine whether telehealth monitoring can identify an exacerbation of COPD, providing clinicians with an opportunity to intervene with timely treatment and prevent hospital readmission.MethodsA total of 23 participants received a telehealth-supported intervention. This paper reports on the analysis of data from a telehealth monitoring system that captured data from two sources: (1) data uploaded both manually and using Bluetooth peripheral devices by the 23 participants and (2) clinical records entered as nursing notes by the clinicians. Rules embedded in the telehealth monitoring system triggered system alerts to be reviewed by remote clinicians who determined whether clinical intervention was required. We also analyzed data on the frequency and length (bed days) of hospital admissions, frequency of hospital Accident and Emergency visits that did not lead to hospital admission, and frequency and type of community health care service contacts—other than the COPD discharge service—for all participants for the duration of the intervention and 6 months postintervention.ResultsPatients generated 512 alerts, 451 of which occurred during the first 42 days that all participants used the equipment. Patients generated fewer alerts over time with typically seven alerts per day within the first 10 days and four alerts per day thereafter. They also had three times more days without alerts than with alerts. Alerts were most commonly triggered by reports of being more tired, having difficulty with self-care, and blood pressure being out of range. During the 8-week intervention, and for 6-month follow-up, eight of the 23 patients were hospitalized. Hospital readmission rates (2/23, 9%) in the first 28 days of service were lower than the 20% UK norm.ConclusionsIt seems that the clinical team can identify exacerbations based on both an increase in alerts and the types of system-generated alerts as evidenced by their efforts to provided treatment interventions. There was some indication that telehealth monitoring potentially delayed hospitalizations until after patients had been discharged from the service. We suggest that telehealth-supported care can fulfill an important role in enabling patients with COPD to better manage their condition and remain out of hospital, but adequate resourcing and timely response to alerts is a critical factor in supporting patients to remain at home.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 68856013; http://www.isrctn.com/ISRCTN68856013 (Archived by WebCite at http://www.webcitation.org/6ofApNB2e)

Adherence to Long-Acting Bronchodilators After Discharge for COPD: How Much of the Geographic Variation is Attributable to the Hospital of Discharge and How Much to the Primary Care Providers?

ABSTRACTIn moderate–severe chronic obstructive pulmonary disease (COPD), long-acting bronchodilators (LBs) are recommended to improve the quality of life. The aims of this study were to measure adherence to LBs after discharge for COPD, identify determinants of adherence, and compare amounts of variation attributable to hospitals of discharge and primary care providers, i.e. local health districts (LHDs) and general practitioners (GPs). This cohort study was based on the Lazio region population, Italy. Patients discharged in 2007–2011 for COPD were followed up for 2 years. Adherence was defined as a medication possession ratio >80%. Cross-classified models were performed to analyse variation. Variances were expressed as median odds ratios (MORs). An MOR of 1.00 stands for no variation, a large MOR indicates considerable variation. We enrolled 13,178 patients. About 29% of patients were adherent to LBs. Adherence was higher for patients discharged from pneumology wards and for patients with GPs working in group practice. A relevant variation between LHDs (MOR = 1.21, p = 0.001) and GPs (MOR = 1.28, p = 0.035) was detected. When introducing the hospital of discharge in the model, the MOR related to LHDs decreased to 1.05 (p = 0.345), MOR related to GPs dropped to 1.22 (p = 0.086), whereas MOR associated with hospitals of discharge was 1.38 (p < 0.001). Treatments with proven benefit for COPD were underused. Moreover, a relevant geographic variation was observed. This heterogeneity raises equity concerns in access to optimal care. The reduction of variability among LHDs and GPs after entering the hospital level proved that differences we observe in primary care partially ‘reflect’ the clinical approach of hospitals of discharge.

Predictors of Pharmacotherapy for Tobacco Use Among Veterans Admitted for COPD: The Role of Disparities and Tobacco Control Processes.

Many smokers admitted for chronic obstructive pulmonary disease (COPD) are not given smoking cessation medications at discharge. The reasons behind this are unclear, and may reflect an interplay of patient characteristics, health disparities, and the receipt of inpatient tobacco control processes. We aimed to assess potential disparities in treatment for tobacco use following discharge for COPD, examined in the context of inpatient tobacco control processes. Smokers aged ≥ 40years, admitted for treatment of a COPD exacerbation within the VA Veterans Integrated Service Network 20, identified using ICD-9 discharge codes and admission diagnoses from 2005-2012. The outcome was any tobacco cessation medication dispensed within 48hours of discharge. We assessed potential predictors administratively up to 1year prior to admission. We created the final logistic regression model using manual model building, clustered by site. Variables with p < 0.2 in biviariate models were considered for inclusion in the final model. We identified 1511 subjects. 16.9% were dispensed a medication at discharge. In the adjusted model, several predictors were associated with decreased odds of receiving medications: older age (OR per year older 0.96, 95 % CI 0.95-0.98), black race (OR 0.34, 95 % CI 0.12-0.97), higher comorbidity score (OR 0.89, 95 % CI 0.82-0.96), history of psychosis (OR 0.40, 95 % CI 0.31-0.52), hypertension (OR 0.75, 95 % CI 0.62-0.90), and treatment with steroids in the past year (OR 0.80, 95 % CI 0.70-0.90). Inpatient tobacco control processes were associated with increased odds of receiving medications: documented brief counseling at discharge (OR 3.08, 95 % CI 2.02-4.68) and receipt of smoking cessation medications while inpatient (OR 5.95, 95 % CI 3.19-11.10). Few patients were treated with tobacco cessation medications at discharge. We found evidence for disparities in treatment, but also potentially beneficial effects of inpatient tobacco control measures. Further focus should be on using novel processes of care to improve provision of medications and decrease the observed disparities.

GP supply, deprivation and emergency admission to hospital for COPD and diabetes complications in counties across Ireland: an exploratory analysis.

Geographical variation in rates of emergency inpatient admission for chronic disease may be due to variation in health need. However, it may also reflect differences in the provision of services which reduce the risk of inpatient admission for chronic disease, such as primary care. The aim of this paper was to examine the effect of primary care provision [general practitioner (GP) supply] and deprivation on county-specific rates of emergency admission to hospital for diabetes complications and chronic obstructive pulmonary disease (COPD) in Ireland. Data on emergency inpatient discharges were obtained from the hospital inpatient enquiry (HIPE) system. Secondary data on GP supply were obtained from a recently published study, while secondary data on deprivation were obtained from the Small Area Health Research Unit. The effect of county-level GP supply and deprivation on age-standardised rates of discharge for diabetes complications and COPD were examined, adjusting for population density and the proportion of the population who were eligible for free primary care. Greater deprivation and lower GP supply are associated with increased rates of discharge from hospital for COPD and diabetes complications. However, these associations are stronger in counties where a lower proportion of the population are eligible for free primary care. Geographical variation in rates of admission to hospital for chronic disease is associated with both population need and health system factors. These findings suggest that primary care resourcing must be a key consideration in any efforts to tackle acute hospital capacity problems.

Clinical factors, including All Patient Refined Diagnosis Related Group severity, as predictors of early rehospitalization after COPD exacerbation.

Background:Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations carry a high risk for early rehospitalization. We wished to identify the basic clinical factors associated with a high risk of rehospitalization, and to see how well the standardized All Patient Refined Diagnosis Related Group (APR-DRG) severity of illness (SOI) subclassification predicted rehospitalization if combined with other simple clinical measures.Methods:We identified adult patients aged ≥40 years discharged from a major hospital in the Southwestern USA with a COPD discharge diagnosis during the study index period (1 October 2009 to 30 September 2010). Patients readmitted within 30 days (“early rehospitalization”) and 90 days (“any rehospitalization”) were each compared with those not rehospitalized. Clinical parameters (including demographics, comorbidities) and recent healthcare utilization were examined for their association with rehospitalization. Factors independently associated with rehospitalization were then combined with the index admission APR-DRG SOI assessment using conditional linear regression to find the best models in terms of the highest C-statistic.Results:Among 306 patients hospitalized for COPD, 62 (20.3%) had a rehospitalization within 90 days and 28 (9.2%), an early readmission. An APR-DRG SOI subclassification ≥3 was a modest independent predictor of early or any readmission, with adjusted odds ratios ranging from 2.09 to 3.33. Models that combined the APR-DRG SOI subclassification with clinical factors present before the index hospitalization had strong C-statistics of ≥0.80. Good models without the APR-DRG SOI subclassification but including a history of recent hospitalizations before the index hospitalization were also identified.Conclusions:An APR-DRG SOI subclassification of ≥3 for the index COPD admission is associated with an increased risk of early rehospitalizations, and can be combined with a few historical clinical factors to create strong predictive models for rehospitalization. This study demonstrates that hospitals can use commonly collected clinical information to help identify COPD patients at a high risk of failure after discharge.

Capsule commentary on Ingebrigsten et al., Low use and adherence to maintenance medication in chronic obstructive pulmonary disease in the general population.

Ingebrigsten, et al.1 conducted a population-based study of patients with chronic obstructive pulmonary disease (COPD) in Denmark. Participants (n = 5,812) were stratified by COPD severity and maintenance respiratory medication use was examined for 1 year. Less than 10 % of the cohort used any maintenance respiratory medications and even among patients with more severe COPD, use of respiratory medications was less than 40 %. Exacerbating this problem was that even among those prescribed medications, adherence was low. These findings are not unique to suburban Copenhagen. A recent retrospective observational study of health insurance claims in the United States tracked patients after a COPD discharge and noted that only 56 % filled a prescription for a long-acting bronchodilator in the 180 days post-hospitalization, with higher filling rates in the first 90 days as compared to days 91–180.2 This investigation provides a valuable perspective on the prevalence and management of one of the leading causes of death and morbidity in the world. True population-based epidemiological investigations are expensive as they require detailed clinical measurements of a large number of persons, yet they are essential for appropriate public health surveillance. The overall prevalence rate (∼10 %) is consistent with other reports. What is perhaps most startling is the low concordance with international practice guidelines for maintenance respiratory medications. Evidence-based practice guidelines are meant to ensure the appropriate use of resources to achieve maximal health outcomes; adherence to global initiative for chronic obstructive lung disease (GOLD) guidelines for respiratory medications have been associated with lower health costs.3 Improvement will require direct patient engagement. A global patient study4 documented the mismatch between patients’ perceptions of COPD and the impact of the disease on their lives. Their delays to treatment for exacerbations and perhaps overconfidence in their ability to manage their disease likely also underlie poor long-term adherence to maintenance medications. Physicians and other health care professionals also must be mindful of their roles in appropriate diagnosis, management, and monitoring of these patients. Together, we have many opportunities to reduce the burden of COPD, locally, nationally, and internationally, as Ingebrigsten and colleagues have aptly demonstrated.

P154 The Impact Of A Discharge Care Bundle On The 30-day Readmission Rate Following Hospitalisation For Acute Copd Exacerbation

Introduction National audit reports high rates of early readmission following hospitalisation for chronic obstructive pulmonary disease (COPD) exacerbation. Discharge bundles aim to optimise care and reduce readmission. Frimley Park Hospital NHS Foundation Trust interacts with different community respiratory teams across three counties. Aims We hypothesised that a novel COPD discharge bundle would reduce re-admission. We also wished to see if the bundle was effective across multiple community administrations, and in patients with a history of frequent exacerbation. Methods Admissions with a primary COPD diagnostic code and cases referred to the COPD nurse were collated during Q4 2013/14. Patients were classified according to whether they were assessed by the COPD nurse using the discharge bundle. Readmissions within 30-days and 3-months were identified using a hospital clinical database. Readmissions with COPD exacerbation (infective or non-infective) were included, as well as COPD associated lower respiratory tract infection or pneumonia. The database identified frequent severe exacerbators (patients with >1 admission in the previous year), and recorded age and length of stay as surrogates of disease complexity. Results 24 patients were excluded (18 had other diagnoses, 4 died, and 2 lived out of area). Table 1 shows the characteristics of the remaining 156 patients according to whether they completed the bundle. There was no overrepresentation of short (zero or one day) length of stay patients in the group not completing the bundle. 17.5% of patients completing the bundle were re-admitted within 30-days, compared to 34% who did not (p = 0.027). A similar trend was seen at 3-months. No difference was observed in the timing or duration of readmissions. Logistic regression using covariates of age, length of stay, history of frequent severe exacerbation and discharge bundle use, suggested the latter two variables were both independent predictors of re-admission at 30-days: OR 5.70 (95% CI 2.46 to 13.2, p Discussion Two-thirds of patients completed a discharge bundle during the Trust’s busiest quarter for COPD admission. Patients completing the discharge bundle had a significantly lower rate of 30-day readmission.

Application of discharge planning services in patients with chronic obstructive pulmonary disease

Objective To evaluate the effect of discharge planning services in patients with chronic obstructive pulmonary disease （ COPD ） .Methods Eighty six COPD patients were divided into two groups . There were 43 cases in each group .The patients in the experimental group received discharge planning services , while the control group received routine follow-up services.The quality of life was measured by the Seattle Obstructive Lung Disease Questionnaire （SOLDQ） and was compared between groups on the 30th, 60th and 180th days after discharge .Results After 6 month intervention , the incidence of disease , hospital readmission and body max index of the experimental group were （1.08 ±0.53）, （0.68 ±0.30） and （22.64 ±3.60）, respectively.Those in the control group were （2.57 ±1.12）, （1.70 ±0.80） and （17.55 ±2.74）.There were significant differences between the two groups （t=-2.957, -3.549, 3.078, respectively;P〈0.05）. There were no significant different in self care knowledge before admission to the hospital between the two groups （P〉0.05）.Before discharge, the self care knowledge in the experimental group were （15.23 ±3.59）, which were significantly higher than （13.27 ±3.22） in the control group （t =2.806,P〈0.05）.There were no significant different in the SOLDQ score before admission to the hospital between the two groups （P〉0.05）. After 6 month intervention , the score of physical function , emotional function and satisfaction with self care in the experimental group were significantly higher than those in the control group （t=14.300, 10.673, 11.231, respectively;P〈0.05）.Conclusions Discharge planning services can enhance the ability of self-care and reduce the frequency of acute exacerbation . Key words: COPD Discharge planning Quality of life Self-care

Management of chronic obstructive pulmonary disease: criteria for an appropriate hospital discharge

Low adherence with prescribed treatments is very common in chronic diseases and represents a significant barrier to optimal management, with both clinical and economic consequences. In chronic obstructive pulmonary disease (COPD), poor adherence, also in terms of premature discontinuation of therapy or improper use of inhaler devices, leads to increased risk of clinical deterioration. By contrast, adherence to appropriate long-term maintenance therapy is associated with improved quality of life and significantly lower risks of hospitalization and re-hospitalization, resulting in important health benefits for the individual patient and a reduction in costs for the national health services. In considering strategies to improve adherence, three main aspects should be addressed: i) patient education; ii) pharmacological alternatives and correct use of inhalers; and iii) adherence to COPD guidelines for appropriate therapy. In this field, healthcare providers play a critical role in helping patients understand the nature of their disease and its management, explaining the potential benefits and adverse effects of treatment, and teaching or checking the correct inhalation technique. These are important issues for patient management, particularly in the immediate aftermath of hospital discharge, because the high risk of re-admission is mainly due to inadequate treatment. Thus, discharge procedure should be considered a key element in the healthcare continuum from the hospital to primary care. This implies an integrated model of care delivery by all relevant health providers. In this context, we developed a structured COPD discharge form that we hope will improve the management of COPD patients, particularly in the aftermath of hospital discharge.

COPD Surveillance—United States, 1999-2011

This report updates surveillance results for COPD in the United States. For 1999 to 2011, data from national data systems for adults aged ≥ 25 years were analyzed. In 2011, 6.5% of adults (approximately 13.7 million) reported having been diagnosed with COPD. From 1999 to 2011, the overall age-adjusted prevalence of having been diagnosed with COPD declined (P = .019). In 2010, there were 10.3 million (494.8 per 10,000) physician office visits, 1.5 million (72.0 per 10,000) ED visits, and 699,000 (32.2 per 10,000) hospital discharges for COPD. From 1999 to 2010, no significant overall trends were noted for physician office visits and ED visits; however, the age-adjusted hospital discharge rate for COPD declined significantly (P = .001). In 2010 there were 312,654 (11.2 per 1,000) Medicare hospital discharge claims submitted for COPD. Medicare claims (1999-2010) declined overall (P = .045), among men (P = .022) and among enrollees aged 65 to 74 years (P = .033). There were 133,575 deaths (63.1 per 100,000) from COPD in 2010. The overall age-adjusted death rate for COPD did not change during 1999 to 2010 (P = .163). Death rates (1999-2010) increased among adults aged 45 to 54 years (P < .001) and among American Indian/Alaska Natives (P = .008) but declined among those aged 55 to 64 years (P = .002) and 65 to 74 years (P < .001), Hispanics (P = .038), Asian/Pacific Islanders (P < .001), and men (P = .001). Geographic clustering of prevalence, Medicare hospitalizations, and deaths were observed. Declines in the age-adjusted prevalence, death rate in men, and hospitalizations for COPD since 1999 suggest progress in the prevention of COPD in the United States.

Lung function impairment, COPD hospitalisations and subsequent mortality

BackgroundHospitalisations and their sequelae comprise key morbidities in the natural history of chronic obstructive pulmonary disease (COPD). A study was undertaken to examine the associations between lung function impairment and...