EDITORIALS Reducing the Risk of Rehospitalization in Patients with Chronic Obstructive Pulmonary Disease Exacerbations Fewer Known Unknowns Jerry A. Krishnan1,2 and Valentin Prieto-Centurion2 1 University of Illinois Hospital and Health Sciences System, Chicago, Illinois; and 2Breathe Chicago Center, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Illinois
Chronic obstructive pulmonary disease (COPD) affects 12 to 24 million individuals and is the third leading cause of death in the United States. Each year, exacerbations of COPD lead to about 800,000 hospitalizations, with about 20% of patients needing to be rehospitalized within 30 days of discharge (1, 2). Studies have documented substantial practice variation and gaps in the quality of hospital-based care in patients with COPD exacerbations (3, 4). Although the link between quality of care and risk of rehospitalizations within 30 days is incompletely understood (5), rehospitalizations in patients with COPD exacerbations account for about $325 million per year in healthcare expenditures for the U.S. Centers for Medicare and Medicaid Services (CMS) (6). It is therefore not surprising that CMS, beginning in October 2014, will impose financial penalties to hospitals with higher than expected all-cause 30-day hospital rehospitalization rates after an index hospitalization for COPD exacerbation (7). This expansion of the CMS Hospital Readmission Reduction program builds on financial penalties in place for “excess” rehospitalizations for patients hospitalized for heart failure, pneumonia, or myocardial infarction. Unfortunately, as documented in a recent Systematic Review of published literature, there is inadequate evidence to recommend specific pre-discharge interventions (e.g., inhaler education, action plan in case of clinical deterioration), post-discharge interventions (e.g., home
visits to provide education and to assess clinical status), or bridging interventions (e.g., hospital-to-home transition navigator) to lower the 30-day risk of rehospitalizations in patients hospitalized for COPD exacerbations (8). Five published randomized clinical trials were identified in the Systematic Review, with more than 15 unique pre-, post-, and bridging interventions in the various trials (range, 9–11 interventions per trial) (8). None of the five trials were designed to evaluate interventions to reduce the 30-day risk of rehospitalization; instead, these trials focused on outcomes at 6 months or 12 months. Moreover, results were inconsistent across the five trials (from benefit to lack of effect to harm). The reason for the disparate findings across the five trials is unclear. Potential explanations include variable levels of efficacy across the different sets of interventions employed in each trial and/or heterogeneity of effects when a specific intervention is applied in different patient populations. It is in this context that two studies published in this issue of AnnalsATS offer new information. Nguyen and colleagues (pp. 695–705) conducted a large retrospective cohort study in approximately 4,600 adults (mean age, 72 yr) enrolled in an integrated health system and hospitalized for a COPD exacerbation (9). At all ambulatory visits, patients in this health system are routinely queried about their “exercise vital sign,” a self-report of their level of physical activity. Nguyen and colleagues found that
patients who reported (at least 1 min/wk) moderate to vigorous physical activity at an ambulatory visit that preceded the index hospitalization for a COPD exacerbation (median of 71 d before the index hospitalization) were about one-third less likely to be rehospitalized compared with less active patients, even after adjusting for a variety of potential confounders. Other factors independently associated with an increased risk of rehospitalizations include the number of comorbid conditions, need for supplemental oxygen after hospital discharge, and previous hospitalizations (COPD-specific and all-cause). Since associations in an observational study do not necessarily imply causality, this “exercise vital sign” may (as acknowledged by the authors) simply be an easy-tomeasure marker of disease severity or other factor directly linked with the risk of rehospitalization. Validation studies in other populations, including an assessment of sensitivity and specificity, are needed before a declaration about the utility of the exercise vital sign as a risk-stratification (screening) tool can be made. Alternatively, the exercise vital sign may be a modifiable risk factor for rehospitalization. Deconditioning is common in patients with COPD, and leads to excessive exertional fatigue and respiratory symptoms and reductions in physical activity, which together result in further deconditioning. This “vicious cycle of inactivity” is especially common following COPD exacerbations and identifies patients at high
(Received in original form April 21, 2014; accepted in final form April 21, 2014 ) Supported by a National Institutes of Health T32 (2T32HL082547) institutional training grant (V.P.-C.), and by Patient Centered Outcomes Research Institute contracts CE-1304-6490 and IH-12-11-4365. Correspondence and requests for reprints should be addressed to Jerry A. Krishnan, M.D., Ph.D., Medical Center Administration Building, 914 South Wood Street, MC 973, Chicago, IL 60612. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 5, pp 797–798, Jun 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201404-169ED Internet address: www.atsjournals.org
Editorials
797
EDITORIALS risk for adverse health outcomes, including rehospitalization (10, 11). Pulmonary rehabilitation, which includes physical activity training and self-management education, seeks to break this vicious cycle of inactivity. A meta-analysis of clinical trials found that pulmonary rehabilitation following a COPD exacerbation can significantly lower the risk of rehospitalization and mortality after hospital discharge (12). Nguyen and colleagues speculate that the benefits of pulmonary rehabilitation after a COPD exacerbation suggest that the exercise vital sign could be a modifiable risk factor. In other words, the exercise vital sign could be used to identify patients who would benefit from programs intended to increase physical activity and thereby lower the risk of hospitalizations (and rehospitalizations). Much of the epidemiology regarding COPD rehospitalizations is based on studies in older patients (65 yr or older) with COPD. The study by Sharif and colleagues in this issue of AnnalsATS (pp. 685–694) sought to determine the risk and predictors of 30-day rehospitalization among younger patients hospitalized for COPD exacerbations (13). The study population
consisted of approximately 8,300 commercially ensured patients age 40 to 64 years (mean age, 56 yr) enrolled in a large private health insurance plan. In this retrospective cohort study, Sharif and colleagues used insurance and pharmacy claims data and report a 9% 30-day risk of rehospitalization (about half of the rehospitalization rate when older patients hospitalized for COPD exacerbations are included). Multivariable analyses identified some patient-level factors associated with greater risk of rehospitalization (e.g., male sex, number of comorbid conditions). Prescriptions for bronchodilators, oral corticosteroids, antibiotics, and completion of a follow-up visit within 30 days of hospital discharge were also associated with a lower risk of rehospitalization. These findings, including modifiable risk factors (e.g., prescriptions for guidelinerecommended medications) are largely consistent with observational studies that include older patient populations (14, 15). However, as with other studies, the overall model fit was only “moderate” (c-statistic about 0.7), likely because data about socioeconomic resources (some of which may also be modifiable) were not available for analyses. There is increasing
References 1 Wier LM, Elixhauser A, Pfuntner A, Au DH. Overview of hospitalizations among patients with COPD, 2008: Statistical Brief #106. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville, MD: Agency for Health Care Policy and Research (US); 2006–2011 Feb [accessed 2014 May 13]. Available from: http://www. hcup-us.ahrq.gov/reports/statbriefs/sb106.pdf 2 Elixhauser A, Au DH, Podulka J. Readmissions for chronic obstructive pulmonary disease, 2008: Statistical Brief #121. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville, MD: Agency for Health Care Policy and Research (US); 2006–2011 Sep [accessed 2014 May 13]. Available from: http://www.hcup-us.ahrq. gov/reports/statbriefs/sb121.pdf 3 Mularski RA, Asch SM, Shrank WH, Kerr EA, Setodji CM, Adams JL, Keesey J, McGlynn EA. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest 2006;130:1844–1850. 4 Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B, Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2006;144:894–903. 5 Stefan MS, Pekow PS, Nsa W, Priya A, Miller LE, Bratzler DW, Rothberg MB, Goldberg RJ, Baus K, Lindenauer PK. Hospital performance measures and 30-day readmission rates. J Gen Intern Med 2013;28: 377–385. 6 Medicare Payment Advisory Commission (MEDPAC). Report to the Congress: promoting greater efficiency in Medicare, 2007 [accessed 2014 Apr 14]. Available from: http://www.medpac.gov/documents/ jun07_entirereport.pdf 7 Feemster LC, Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med 2014; 189:634–639.
798
recognition that differences in socioeconomic resources (e.g., stable housing, social support, transportation) in different patient subgroups explain a substantial proportion of the variance in the risk of rehospitalization (16). The studies by Nguyen and coworkers and by Sharif and colleagues address some known unknowns when it comes to reducing the risk of rehospitalizations. Together, these studies build on a growing body of evidence that suggests that strategies to reduce hospital readmissions following COPD exacerbations are likely to be more effective if they address more than the quality of COPD-specific care in the hospital (i.e., patient selfmanagement skills, comorbid conditions, barriers to care linked to socioeconomic resources, and quality and access to care after discharge). While there are now fewer known unknowns, we still do not have an evidence-based approach to reducing hospital readmissions following COPD exacerbations in the United States. It is now time to address this known unknown. n Author disclosures are available with the text of this article at www.atsjournals.org.
8 Prieto-Centurion V, Markos MA, Ramey NI, Gussin HA, Nyenhuis SM, Joo MJ, Prasad B, Bracken N, Didomenico R, Godwin PO, et al. Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations: a systematic review. Ann Am Thorac Soc 2014;11:417–424. 9 Nguyen HQ, Chu L, Liu IL, Lee JS, Suh D, Korotzer B, Yuen G, Desai S, Coleman KJ, Xiang AH, et al. Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease. Ann Am Thorac Soc 2014;11:695–705. 10 Moy ML, Teylan M, Weston NA, Gagnon DR, Garshick E. Daily step count predicts acute exacerbations in a US cohort with COPD. PLoS ONE 2013;8:e60400. 11 Garcia-Aymerich J, Farrero E, Felez ´ MA, Izquierdo J, Marrades RM, Anto´ JM; Estudi del Factors de Risc d’Aguditzacio´ de la MPOC investigators. Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax 2003;58:100–105. 12 Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2011;10:CD005305. 13 Sharif R, Parekh TM, Pierson KS, Kuo Y-F, Sharma G. Predictors of early readmission among patients aged 40 to 64 years hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc 2014;11:685–694. 14 McGhan R, Radcliff T, Fish R, Sutherland ER, Welsh C, Make B. Predictors of rehospitalization and death after a severe exacerbation of COPD. Chest 2007;132:1748–1755. 15 Stefan MS, Rothberg MB, Shieh MS, Pekow PS, Lindenauer PK. Association between antibiotic treatment and outcomes in patients hospitalized with acute exacerbation of COPD treated with systemic steroids. Chest 2013;143:82–90. 16 Prieto-Centurion V, Gussin HA, Rolle AJ, Krishnan JA. Chronic obstructive pulmonary disease readmissions at minority-serving institutions. Ann Am Thorac Soc 2013;10:680–684.
AnnalsATS Volume 11 Number 5 | June 2014
Chronic obstructive pulmonary disease (COPD) affects 12 to 24 million individuals and is the third leading cause of death in the United States. Each year, exacerbations of COPD lead to about 800,000 hospitalizations, with about 20% of patients needing to be rehospitalized within 30 days of discharge (1, 2). Studies have documented substantial practice variation and gaps in the quality of hospital-based care in patients with COPD exacerbations (3, 4). Although the link between quality of care and risk of rehospitalizations within 30 days is incompletely understood (5), rehospitalizations in patients with COPD exacerbations account for about $325 million per year in healthcare expenditures for the U.S. Centers for Medicare and Medicaid Services (CMS) (6). It is therefore not surprising that CMS, beginning in October 2014, will impose financial penalties to hospitals with higher than expected all-cause 30-day hospital rehospitalization rates after an index hospitalization for COPD exacerbation (7). This expansion of the CMS Hospital Readmission Reduction program builds on financial penalties in place for “excess” rehospitalizations for patients hospitalized for heart failure, pneumonia, or myocardial infarction. Unfortunately, as documented in a recent Systematic Review of published literature, there is inadequate evidence to recommend specific pre-discharge interventions (e.g., inhaler education, action plan in case of clinical deterioration), post-discharge interventions (e.g., home
visits to provide education and to assess clinical status), or bridging interventions (e.g., hospital-to-home transition navigator) to lower the 30-day risk of rehospitalizations in patients hospitalized for COPD exacerbations (8). Five published randomized clinical trials were identified in the Systematic Review, with more than 15 unique pre-, post-, and bridging interventions in the various trials (range, 9–11 interventions per trial) (8). None of the five trials were designed to evaluate interventions to reduce the 30-day risk of rehospitalization; instead, these trials focused on outcomes at 6 months or 12 months. Moreover, results were inconsistent across the five trials (from benefit to lack of effect to harm). The reason for the disparate findings across the five trials is unclear. Potential explanations include variable levels of efficacy across the different sets of interventions employed in each trial and/or heterogeneity of effects when a specific intervention is applied in different patient populations. It is in this context that two studies published in this issue of AnnalsATS offer new information. Nguyen and colleagues (pp. 695–705) conducted a large retrospective cohort study in approximately 4,600 adults (mean age, 72 yr) enrolled in an integrated health system and hospitalized for a COPD exacerbation (9). At all ambulatory visits, patients in this health system are routinely queried about their “exercise vital sign,” a self-report of their level of physical activity. Nguyen and colleagues found that
patients who reported (at least 1 min/wk) moderate to vigorous physical activity at an ambulatory visit that preceded the index hospitalization for a COPD exacerbation (median of 71 d before the index hospitalization) were about one-third less likely to be rehospitalized compared with less active patients, even after adjusting for a variety of potential confounders. Other factors independently associated with an increased risk of rehospitalizations include the number of comorbid conditions, need for supplemental oxygen after hospital discharge, and previous hospitalizations (COPD-specific and all-cause). Since associations in an observational study do not necessarily imply causality, this “exercise vital sign” may (as acknowledged by the authors) simply be an easy-tomeasure marker of disease severity or other factor directly linked with the risk of rehospitalization. Validation studies in other populations, including an assessment of sensitivity and specificity, are needed before a declaration about the utility of the exercise vital sign as a risk-stratification (screening) tool can be made. Alternatively, the exercise vital sign may be a modifiable risk factor for rehospitalization. Deconditioning is common in patients with COPD, and leads to excessive exertional fatigue and respiratory symptoms and reductions in physical activity, which together result in further deconditioning. This “vicious cycle of inactivity” is especially common following COPD exacerbations and identifies patients at high
(Received in original form April 21, 2014; accepted in final form April 21, 2014 ) Supported by a National Institutes of Health T32 (2T32HL082547) institutional training grant (V.P.-C.), and by Patient Centered Outcomes Research Institute contracts CE-1304-6490 and IH-12-11-4365. Correspondence and requests for reprints should be addressed to Jerry A. Krishnan, M.D., Ph.D., Medical Center Administration Building, 914 South Wood Street, MC 973, Chicago, IL 60612. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 5, pp 797–798, Jun 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201404-169ED Internet address: www.atsjournals.org
Editorials
797
EDITORIALS risk for adverse health outcomes, including rehospitalization (10, 11). Pulmonary rehabilitation, which includes physical activity training and self-management education, seeks to break this vicious cycle of inactivity. A meta-analysis of clinical trials found that pulmonary rehabilitation following a COPD exacerbation can significantly lower the risk of rehospitalization and mortality after hospital discharge (12). Nguyen and colleagues speculate that the benefits of pulmonary rehabilitation after a COPD exacerbation suggest that the exercise vital sign could be a modifiable risk factor. In other words, the exercise vital sign could be used to identify patients who would benefit from programs intended to increase physical activity and thereby lower the risk of hospitalizations (and rehospitalizations). Much of the epidemiology regarding COPD rehospitalizations is based on studies in older patients (65 yr or older) with COPD. The study by Sharif and colleagues in this issue of AnnalsATS (pp. 685–694) sought to determine the risk and predictors of 30-day rehospitalization among younger patients hospitalized for COPD exacerbations (13). The study population
consisted of approximately 8,300 commercially ensured patients age 40 to 64 years (mean age, 56 yr) enrolled in a large private health insurance plan. In this retrospective cohort study, Sharif and colleagues used insurance and pharmacy claims data and report a 9% 30-day risk of rehospitalization (about half of the rehospitalization rate when older patients hospitalized for COPD exacerbations are included). Multivariable analyses identified some patient-level factors associated with greater risk of rehospitalization (e.g., male sex, number of comorbid conditions). Prescriptions for bronchodilators, oral corticosteroids, antibiotics, and completion of a follow-up visit within 30 days of hospital discharge were also associated with a lower risk of rehospitalization. These findings, including modifiable risk factors (e.g., prescriptions for guidelinerecommended medications) are largely consistent with observational studies that include older patient populations (14, 15). However, as with other studies, the overall model fit was only “moderate” (c-statistic about 0.7), likely because data about socioeconomic resources (some of which may also be modifiable) were not available for analyses. There is increasing
References 1 Wier LM, Elixhauser A, Pfuntner A, Au DH. Overview of hospitalizations among patients with COPD, 2008: Statistical Brief #106. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville, MD: Agency for Health Care Policy and Research (US); 2006–2011 Feb [accessed 2014 May 13]. Available from: http://www. hcup-us.ahrq.gov/reports/statbriefs/sb106.pdf 2 Elixhauser A, Au DH, Podulka J. Readmissions for chronic obstructive pulmonary disease, 2008: Statistical Brief #121. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville, MD: Agency for Health Care Policy and Research (US); 2006–2011 Sep [accessed 2014 May 13]. Available from: http://www.hcup-us.ahrq. gov/reports/statbriefs/sb121.pdf 3 Mularski RA, Asch SM, Shrank WH, Kerr EA, Setodji CM, Adams JL, Keesey J, McGlynn EA. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest 2006;130:1844–1850. 4 Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B, Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2006;144:894–903. 5 Stefan MS, Pekow PS, Nsa W, Priya A, Miller LE, Bratzler DW, Rothberg MB, Goldberg RJ, Baus K, Lindenauer PK. Hospital performance measures and 30-day readmission rates. J Gen Intern Med 2013;28: 377–385. 6 Medicare Payment Advisory Commission (MEDPAC). Report to the Congress: promoting greater efficiency in Medicare, 2007 [accessed 2014 Apr 14]. Available from: http://www.medpac.gov/documents/ jun07_entirereport.pdf 7 Feemster LC, Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med 2014; 189:634–639.
798
recognition that differences in socioeconomic resources (e.g., stable housing, social support, transportation) in different patient subgroups explain a substantial proportion of the variance in the risk of rehospitalization (16). The studies by Nguyen and coworkers and by Sharif and colleagues address some known unknowns when it comes to reducing the risk of rehospitalizations. Together, these studies build on a growing body of evidence that suggests that strategies to reduce hospital readmissions following COPD exacerbations are likely to be more effective if they address more than the quality of COPD-specific care in the hospital (i.e., patient selfmanagement skills, comorbid conditions, barriers to care linked to socioeconomic resources, and quality and access to care after discharge). While there are now fewer known unknowns, we still do not have an evidence-based approach to reducing hospital readmissions following COPD exacerbations in the United States. It is now time to address this known unknown. n Author disclosures are available with the text of this article at www.atsjournals.org.
8 Prieto-Centurion V, Markos MA, Ramey NI, Gussin HA, Nyenhuis SM, Joo MJ, Prasad B, Bracken N, Didomenico R, Godwin PO, et al. Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations: a systematic review. Ann Am Thorac Soc 2014;11:417–424. 9 Nguyen HQ, Chu L, Liu IL, Lee JS, Suh D, Korotzer B, Yuen G, Desai S, Coleman KJ, Xiang AH, et al. Associations between physical activity and 30-day readmission risk in chronic obstructive pulmonary disease. Ann Am Thorac Soc 2014;11:695–705. 10 Moy ML, Teylan M, Weston NA, Gagnon DR, Garshick E. Daily step count predicts acute exacerbations in a US cohort with COPD. PLoS ONE 2013;8:e60400. 11 Garcia-Aymerich J, Farrero E, Felez ´ MA, Izquierdo J, Marrades RM, Anto´ JM; Estudi del Factors de Risc d’Aguditzacio´ de la MPOC investigators. Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax 2003;58:100–105. 12 Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2011;10:CD005305. 13 Sharif R, Parekh TM, Pierson KS, Kuo Y-F, Sharma G. Predictors of early readmission among patients aged 40 to 64 years hospitalized for chronic obstructive pulmonary disease. Ann Am Thorac Soc 2014;11:685–694. 14 McGhan R, Radcliff T, Fish R, Sutherland ER, Welsh C, Make B. Predictors of rehospitalization and death after a severe exacerbation of COPD. Chest 2007;132:1748–1755. 15 Stefan MS, Rothberg MB, Shieh MS, Pekow PS, Lindenauer PK. Association between antibiotic treatment and outcomes in patients hospitalized with acute exacerbation of COPD treated with systemic steroids. Chest 2013;143:82–90. 16 Prieto-Centurion V, Gussin HA, Rolle AJ, Krishnan JA. Chronic obstructive pulmonary disease readmissions at minority-serving institutions. Ann Am Thorac Soc 2013;10:680–684.
AnnalsATS Volume 11 Number 5 | June 2014
