Intense Support for Hospitalized Patients With COPD Results in Fewer Readmissions

Retraction and republication: The JAMA article referenced in this story was retracted and republished on October 8, 2019. Please refer to the updated findings here.

A study of hospitalized patients with chronic obstructive pulmonary disease (COPD) found that a 3-month program combining transition and long-term self-management support resulted in significantly fewer COPD-related hospitalizations and emergency department visits, as well as improved health-related quality of life (HRQoL), 6 months postdischarge.

The study was unique in that it was codeveloped with patients, caregivers, and stakeholders, the authors said, and provided support to both patients and caregivers, including support during transitions as well as with long-term COPD self-management.¹ In addition, unlike similar studies, patients with COPD and comorbidities were not excluded and the intervention used an action plan that did not include the administration of steroid or antibiotic prescriptions.

This single-site randomized clinical trial was conducted in Baltimore, Maryland, with 240 patients who were hospitalized due to COPD. They were randomized to intervention or usual care, and followed up for 6 months after hospital discharge.

Specialized COPD nurses delivered the comprehensive intervention to 120 patients for 3 months. The usual care group (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care.

The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The coprimary outcome was change in participants’ HRQoL measured by the St George’s Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful).

A majority of the patients were female, with an average age of nearly 65. The mean (SD) baseline SGRQ score was 63.1 (19.9) in the intervention group and 62.6 (19.3) in the usual care group.

The intervention group had fewer COPD-related acute care events, as defined by hospitalizations or acute care visits: in the intervention group, the mean number of acute care events per participant at 6 months was 0.72 (95% CI, 0.45-0.97) vs 1.40 (95% CI, 1.01-1.79) in the usual care group (difference, 0.68 [95% CI, 0.22 to 1.15]; P = .004).

The mean change in participants’ SGRQ total score at 6 months went in opposite directions, with the score in the intervention group improving by 1.53 points and the usual care group worsening by 5.44 points (adjusted difference, −6.69 [95% CI, −12.97 to −0.40]; 0 = .04).

During the study period, there were 15 deaths (intervention: 7; usual care: 8) and 337 hospitalizations (intervention: 135; usual care: 202).

The researchers wrote that the study had several features that may have increased program effectiveness:

• Starting COPD self-management conversations while hospitalized may have increased patient engagement.
• Connecting patients with the COPD nurse while still at the hospital and continuing follow-up for 3 months may have helped with continuity of care and relationship building.
• Providing support at home or via telephone increased outreach to patients who may have found it difficult to leave home due to illness may have helped.
• Individualized support according to patient needs and priorities and giving the nurse flexibility to work with the patient on using standardized program tools, rather than following a more rigid approach, may have been a factor.
• Encouraging early communications with clinicians whenever signs of exacerbation were detected, which may have helped reduce hospitalizations.

The study had several limitations: it was a single-site study; the site included a high proportion of low-income and less-educated participants, who may have a greater need for intense intervention; spirometry evidence of airflow obstruction was not required for study enrollment, so it is possible that some patients may have been incorrectly diagnosed as having COPD.

An accompanying JAMA editorial called the study “an important contribution,” although there are outstanding questions that need to be addressed by a larger study.² It isn’t known how these outcomes might be replicated in other hospitals. COPD is the third-leading cause of death in the United States, and patients often suffer from cycles of hospitalizations. CMS includes COPD in its Hospital Readmission Reduction Program, but many clinicians and health systems lack guidance on how to manage the disease.

The editorial said the shift to value-based care may encourage health systems to adopt interventions that prevent hospitalizations, although each will have to consider a cost-benefit analysis.

References

1. Aboumatar H, Naqibuddin M, Chung S, et al. Effect of a program combining transitional care and long-term self-management support on outcomes of hospitalized patients with chronic obstructive pulmonary disease: a randomized clinical trial. [published online November 12, 2018]. JAMA. doi:10.1001/jama.2018.17933.

2. Rinne ST, Lindenauer PK, Au DH. Intensive intervention to improve outcomes for patients with COPD. [published online November 12, 2018]. JAMA.