Inpatient Practice

Reducing COPD Readmissions

On average, about 1 out of 5 patients admitted to the hospital with COPD in the U.S. get readmitted within 30 days. There is a wealth of medical literature analyzing COPD readmissions. For example, we know that patients at risk for readmission include:

  1. Patients without physician follow-up within 30 days of discharge
  2. African Americans
  3. Older patients
  4. Divorced/widowed patients
  5. Those with longer initial hospital stays
  6. Patients in nursing homes
  7. Patients with anemia (hemoglobin < 8)
  8. Patients with renal failure
  9. Patients receiving cancer chemotherapy
  10. Patients with low health literacy
  11. Patients on Medicaid
  12. Patients taking > 5 different medications

There are a lot of reasons why they get readmitted. Some of the reasons include:

  1. Insufficient outpatient follow up
  2. Medication errors
  3. Poor transfer of information to primary care providers
  4. Inability to pay for medications
  5. Inadequate transportation
  6. Incorrect inhaler technique
  7. Lack of a “rapid action plan”

Interestingly, only 28% of patients with an initial hospitalization for COPD are readmitted with COPD. More than half of those readmitted are for non-respiratory conditions such as heart failure, arrhythmias, intestinal infection, sepsis, and electrolyte disturbances. Also, readmissions occur pretty quickly with 50% of readmissions occurring in the first 2 weeks after discharge. So what can we do to reduce COPD readmissions? Successful strategies employ interventions both during the hospitalization and after hospitalization.

During hospitalization:

  • Screen patients for readmission risk factors
  • Communicate with primary care providers
  • “Teach back” to educate patient (respiratory therapists can be valuable)
  • Use interdisciplinary clinical teams
  • Start on maintenance long-acting inhalers
  • Start on roflumilast (if indicated)
  • Discuss end-of-life wishes
  • Comprehensive discharge planning
  • Ensure patients can get and manage their medications
  • Schedule an outpatient follow up visit
  • Make sure patients have a nebulizer

After discharge:

  • Promote self-management (emergency action plans)
  • Follow-up phone calls
  • Develop and use transition clinics
  • Home visits for patients with transportation barriers
  • Electronic medical record management of information
  • Establish community networks
  • Use telemedicine when appropriate
  • Arrange spirometry testing
  • Enroll in pulmonary rehab
  • Smoking cessation

We started a nurse practitioner-run pulmonary transition clinic at our hospital and were able to reduce COPD readmissions to 12.5%. However, we did see a sizable no-show rate and those patients who failed to show had a very high (27%) readmission rate. The specific actions that occur in our transition clinic include:

  • Clinic appointment within 5 days of discharge
  • Assess response to treatment
  • Follow up lab and radiology tests
  • Arrange pulmonary function tests
  • Medication reconciliation
  • Refer to indigent patient medication assistance programs
  • Arrange pulmonary rehabilitation
  • Smoking cessation
  • Insure correct use of inhalers

Readmissions cost all of us in the long run since they increase insurance/Medicare/Medicaid costs. Care coordination and education are key elements of any readmission reduction strategy. Respiratory therapists are often in the best position to champion patient education in the hospital. Ultimately, it requires a culture change in our approach to COPD – culture always trumps hospital policy.

October 14, 2016

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital

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