Reducing COPD readmission rates through care bundles/order sets
Risk assessment, and adherence to GOLD guidelines
Chronic Obstructive Pulmonary Disease (COPD) was the third leading cause of death in 2016 behind heart disease and cancer with 155,041 deaths. Almost 15.7 million adults have a diagnosis of COPD in the United States, which is understated because of unknown or misdiagnosis of the disease. Studies have shown that medications and pulmonary rehabilitation have decreased the symptoms of dyspnea and increased exercise capacity. The hospital readmission reduction program (HRRP) was established by the Affordable Care Act to reduce hospital readmission rates for chronic diseases. Short-term acute-care hospitals are reimbursed under the inpatient prospective payment system (IPPS) within the Medicare program. The HRRP requires the Center for Medicare and Medicaid services (CMS) to reduce payments to IPPS hospitals for excessive readmissions. Patient non-adherence has been researched to determine the factors for 30-day readmission for COPD exacerbations. While guidelines such as the Global Initiative for Obstructive Lung Disease (GOLD) guidelines have been developed clinician adherence to these guidelines is inconsistent. when treating patients with COPD exacerbations. GOLD is a standard criterion for rating COPD severity and provides guidelines for management and prevention of COPD exacerbations. The inclusion of COPD to readmission penalties should encourage health care systems to implement bundled care plans, COPD order sets, and adherence to GOLD treatment guidelines for people admitted to the hospital with acute exacerbation of COPD to reduce 30-day readmission rates.
Keywords: Chronic obstructive pulmonary disease, COPD exacerbation, 30-day hospital readmission
TABLE OF CONTENTS
PICOT Question/Statement of Problem ………………………………………………..…..….….6
COPD Treatment Guidelines…………………………………………………………..…..….…..7
Decrease symptoms of Dyspnea/Increase Exercise Capacity
Decrease symptoms of Dyspnea/Increase Exercise Capacity
Literature Search Strategies……………………………………………………………..……….12
COPD Care Bundles……………………………………………………………………14
COPD Order sets…………………………………………..…………………………….18
COPD Risk Assessment………………………………………………..…………………24
Gap in the Literature……………………………………………………………………..………25
Implications for Practice and Research………………………………………………..…………26
Introduction and Problem Statement
Chronic obstructive pulmonary disease (COPD) is defined as a progressive pulmonary disease restricting airflow and is used in broad terms to describe restrictive airflow in patients with chronic bronchitis, emphysema, and chronic obstructive asthma (CDC, 2017). COPD was the third leading cause of death in 2016 in the United States with almost 15.7 million adults with a diagnosis of COPD ((Ruppel, Carlin, Hart, & Doherty, 2018). COPD exacerbation is a worsening of respiratory symptoms when a person does not adhere to their medication regime, continues smoking, are exposed to irritants, bacteria and/or viruses which can lasts a few days or even months depending upon other comorbidities (Bracken, 2016). COPD exacerbations lead to more than 700,000 hospitalizations in the US per year with an in-hospital mortality of approximately 2.5 percent (Bracken, 2016).Furthermore, it has a clinical and economic burden that effects the patient, healthcare system, and the economy. In 2010 the cost of COPD was to reach $50 billion total with indirect costs at $20 billion and $30 billion in direct health care expenses (Guarascio, Ray, Finch, Self, 2013). The indirect costs refer to the morbidity and mortality caused by COPD. The disabling effects prevents approximately 51% of individuals with COPD from being able to work, forcing them to collect disability benefits. The direct health care costs are related to diagnosis, treatment, prevention, and rehabilitation. These costs include physician visits, hospitalization, home care, and medications (Guarascio, et al., 2013).
The major cause and progression of COPD is tobacco smoke and according to the CDC (2018), 39% of individuals with a diagnosis of COPD still smoke. Other factors include exposure to household and workplace air pollutants, genetic factors, and respiratory infections (CDC, 2017). The groups more likely to report having COPD are aged 64 and older, women, American Indian/Alaska Natives, multiracial non-Hispanics, individuals who were unemployed, retired, or unable to work, individuals with less than a high school education, divorced, widowed, separated, current smokers, former smokers, and people with a history of asthma (CDC, 2017). Individuals with COPD experience shortness of breath or dyspnea with activity and have difficulty walking, climbing stairs, performing activities of daily living, and have a decline in participation in social activities (CDC, 2017). They may also have cognitive impairment because of decreased oxygen intake, may need a portable oxygen tank, and have an increase in emergency department visits and hospitalization (CDC, 2017).
Does standardization, use of order sets, risk assessments, and adherence to Global Initiative for Obstructive Lung Disease (GOLD) guidelines for treating acute exacerbation of COPD decrease 30-day readmission rates?
Statement of Purpose
The purpose of this review is to determine if adherence to GOLD guidelines, the use of order sets, and risk assessment for exacerbation for patients admitted with acute exacerbation of COPD will improve standardization of patient care and improve patient outcomes by decreasing 30-day readmission rates. This paper will examine the role that providers play in the integrated care of COPD patients with factors other than medication, pulmonary rehabilitation, and patient adherence which have shown decreases in 30-day readmission rates.
A diagnosis of COPD is determined by a healthcare professional based on signs and symptoms, health history, and lung function testing (Ruppel, et al., 2018). Spirometry is an important test to establish a diagnosis of COPD (Ruppel, et al., 2018). According to the National Lung Health Education Program (NLHEP), the use of spirometry is the consensus for detection and management of COPD (Ruppel, et al., 2018). The use of pre- and post-bronchodilator spirometry should be used by primary healthcare professionals to identify individuals with COPD to guide therapy according to guidelines. Spirometry is measured using forced expired volume in one second (FEV1). This is a measure of how quickly the lungs can be emptied in one second (Venes, 2005). The stages of COPD use the FEV1 percentage to express the degree of disease severity. Stage I (mild) post-bronchodilator FEV1 < 80%, Stage II (moderate) post-bronchodilator FEV1 between 50% and 80%, Stage III (severe) post-bronchodilator FEV1 between 30% and 50%, and Stage IV (very severe) post-bronchodilator FEV1 < 30% (Bhatt & Wood, 2008). As this disease progresses, the decrease in FEV1 percentage are used to measure the respiratory impairment in each stage but is not always an indicator of symptom severity (Bhatt & Wood, 2008). There is a need to standardize spirometry interpretation in the primary care settings to improve the accuracy of COPD diagnosis and stage (Ruppel, et al., 2018).
COPD Treatment Guidelines
The Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) provides a pocket guide for health care providers to diagnosis, manage and prevent COPD. GOLD was established in 1997 in collaboration with the UK National Heart, Lung, and Blood Institute, US National Institutes of Health and the World Health Organization (GOLD, 2018). A group of international COPD experts wrote the initial version of the GOLD guidelines in 2001 and the guidelines are periodically updated by the science committee. The GOLD science committee evaluates new scientific evidence and prepares updates and the dissemination committee ensures that recommendations and information is disseminated to the healthcare community and the public. The GOLD National Leaders are individuals from around the world with an interest in promoting the goals of GOLD within their own countries (GOLD,2018). The group meets periodically to share information about programs of health education, COPD management, and prevention.
Overall, smoking cessation is key to reducing symptoms, frequency and severity of exacerbations and improves health status and exercise tolerance (GOLD, 2018). Among the adults with a diagnosis of COPD, 39% or over six million people still smoke (CDC,2018). Recommended pharmacological treatments need to be individualized and guided by the severity of symptoms, risk for exacerbation, and comorbidities. In additional, drug availability, side effects, cost, patient’s response, ability to use various drug delivery devices, and inhaler technique should be assessed regularly (GOLD, 2018). Influenza and pneumococcal vaccination should be given to reduce lower respiratory infections. Pulmonary rehabilitation should be a part of the treatment plan to improve symptoms, quality of life, and physical and emotional participation in activities of daily living (GOLD, 2018). Supplemental oxygen may be indicated for more severe COPD cases as well as surgical interventional treatments (GOLD, 2018).
The pharmacological therapies for COPD include bronchodilators which increase FEV1 and reduces symptoms. Short acting beta agonists (SABA) and long acting beta2-agonists (LABA) relax airway smooth muscles to decrease bronchoconstriction (GOLD, 2018). have Both short acting antimuscarinic drugs (SAMA) and long acting antimuscarinic drugs (LAMA) block the bronchoconstrictor impact of acetylcholine on M3 muscarinic receptors expressed in the airway smooth muscles (GOLD, 2018). According to GOLD (2018), combination bronchodilator therapy may increase the degree of bronchodilation and have a lower risk of side-effects when compared to increasing the dose of a single bronchodilator. The use of anti-inflammatory agents such as inhaled corticosteroids in combination with LABA should be used for patients with moderate to severe COPD and in acute COPD exacerbations (GOLD, 2018).
GOLD (2018) recommends pulmonary rehabilitation, education, self-management, and integrated care programs for patients with COPD. Pulmonary rehabilitation is currently the most effective therapeutic strategy to improve shortness of breath, health status and exercise tolerance. Self-management with health care provider support can improve health status and decrease hospitalization and ED visits (GOLD, 2018). Education alone has not shown to be effective in improving health status as well as integrated care and telehealth (GOLD, 2018).
Supplemental oxygen has been shown to increase survival in patients with severe resting hypoxemia and may relieve breathlessness (GOLD, 2018). Supplemental oxygen does not lengthen life or sustained health status, lung function, or improve 6-minute walk distance in patients with stable COPD, moderate resting or exercise induced arterial desaturation (GOLD, 2018). Lung volume reduction surgery improves survival in severe emphysema patients, bullectomy is associated with decreased dyspnea, improved lung function and exercise tolerance in select patients, and lung transplantation with very severe COPD has shown improved quality of life and functional capacity (GOLD, 2018).
Treatments for COPD depend upon the severity of the symptoms and stage of the disease. Treatment plans are determined by a primary care physician and implemented by a multidisciplinary team. Treatments are selected to lessen symptoms, severity and frequency of exacerbations and increase physical activity tolerance. Medications are prescribed for dyspnea, coughing, and wheezing. Pulmonary rehabilitation teaches breathing techniques, energy conservation and training, as well as provides nutritional counseling (CDC, 2017). According to the GOLD guidelines, medications, pulmonary rehabilitation, and other therapies are effective in managing COPD.
The following studies illustrate the successful use of medication and pulmonary rehabilitation to decrease dyspnea and increase exercise capacity in individuals with COPD.
Two studies examined the use of medications and pulmonary rehabilitation to decrease the symptoms of dyspnea. Yohannes, Willgoss, and Vestbo (2011), conducted a meta-analysis of 16 random controlled trials with a large sample size of adults over 40 years of age with COPD. Statistically significant improvements in dyspnea were found with the use of Tiotropium versus placebo in individuals with stable COPD. Tiotropium reduced the frequency of COPD exacerbations and related hospitalization (Yohannes, et al., 2011). Beeh and associates (2014) conducted a study of individuals with moderate to severe COPD to examine the effect of QVA149 on lung volume and exercise tolerance. Once daily dual bronchodilator QVA149, with a fixed dose combination of long acting beta2-agonist and long acting muscarinic antagonist glycoprronium, was used on patients with moderate to severe COPD in accordance to the GOLD guidelines (Beeh, Korn, Beier, Jadayel, Henley, D’Andrea, & Banerji, 2014). Statically significant improvements were seen in exercise endurance time at the end of 21 days in the QVA149 group in comparison to the placebo group (Beeh, et al., 2014).
GOLD recommends pulmonary rehabilitation for patients with COPD (GOLD, 2018). Two studies evaluated the use of medications and pulmonary rehabilitation to decrease dyspnea and improve exercise capacity. Wen-hua, Jin-wu, Xin, Lin, Hai-yan, Yu-qi, and Rui (2015) conducted a systematic review and meta-analysis to examine dyspnea, skeletal muscle strength, and lung function improvements following resistance training for patients with stable moderate to very severe COPD. Resistance training lead to statistically significant improvements in dyspnea compared with the non-exercise control group (Wen-hua, et al., 2015). Pradella, Belmonte, Maia, Delgado, Luise, Nascimento, and Jardim (2015) conducted a randomized study to examine the impact of a low cost and home based pulmonary rehabilitation program. Pulmonary rehabilitation increases exercise capacity with an increase in the 6-minute walk test and decreased by more than 4 units in all St. George’s Respiratory Questionnaire (SGRQ) domains during the 24-session study (Pardella, et al., 2015).
GOLD (2018) guidelines promote the use of long-acting bronchodilators for patients with moderate to very severe COPD and recommends pulmonary rehabilitation, education, self-management, and integrated care programs for patients with COPD. These studies demonstrate that medications and pulmonary rehabilitation have statistically improved dyspnea and exercise capacity for COPD patients. This paper will examine the role that providers play in the integrated care of COPD patients with factors other than medication, pulmonary rehabilitation, and patient adherence.
Medications and pulmonary rehabilitation have shown improvement in decreasing dyspnea and increasing exercise capacity in individuals with COPD. Patient and/or clinician non-adherence to recommendations could explain exacerbations and 30-day readmission rates. Focusing on individual behaviors have been explored but an examination of clinician behaviors in the adherence to GOLD guidelines is equally important. Clinician training and education regarding the GOLD guidelines, use of order sets and use of COPD care bundles for patients hospitalized with COPD exacerbations is examined through the diffusion of innovation theory.
The Diffusion of Innovation Theory focuses on the adoption of new ideas, behaviors, and/or products through communication to explain how, over time, an idea, behavior, or product gains momentum and diffuses through a specific population (LaMorte, 2016). This theory has five established adopters categories 1) innovators; 2) early adapters, 3) early majority, 4) late majority, and 5) laggards (LaMorte, 2016). Innovators are the 2.5% of those individuals who will be the first to try the innovation and are risk takers. Early adopters are 13.5% of those who will be the opinion leaders and embrace change. The early majority are the 34% who will adopt a new idea before the average person and needs evidence that the idea works. The late majority are the 34% who are skeptical of change and adopts a new idea after the majority has tried it. Fifteen percent are labeled laggards they do not like change and are bound by tradition and need statistics and pressure from the other adopter groups to accept a new idea (LaMorte, 2016). These categories of adopters can guide the implementation of interventions in an organization. The innovation would include the implementation of new COPD order sets, COPD care bundles, GOLD guidelines, and new protocols for treating patients with acute exacerbation of COPD.
The Diffusion of Innovation Theory focuses on the adoption of new ideas, behaviors, and/or products through communication to explain how, over time, an idea, behavior, or product gains momentum and diffuses through a specific population (LaMorte, 2016). Knowledge is the first step in the adoption of an innovation such as the use of order sets, care bundles, and the GOLD guidelines. Knowledge is developed when a provider is exposed to an innovation and gains some understanding about its functions and mechanisms, such as how to use care bundles and order sets (Mohammadi, Poursaberi, & Salahshoor, 2018). The next set is persuasion which is the perceived attributes of the innovation as having: 1) relative advantage, 2) compatibility, 3) simplicity, and 4) trialability (Mohammadi, Poursaberi, & Salahshoor, 2018). Providers will need to perceive that COPD guidelines, order sets, and care bundles will improve patient outcomes without adding additional workload to the providers schedule. The final step is the decision to adopt the innovation or reject the innovation (Mohammadi, Poursaberi, & Salahshoor, 2018). The providers will need to be trained on how to use the COPD order sets and care bundles for this innovation to be adopted. GOLD guidelines must be implemented to all COPD patients admitted, possibility through the assistance of the multi-disciplinary team or through the new COPD order sets.
Evidence based practice has been shown to improve the quality of care, improve patient outcomes, and lower healthcare cost but some clinicians appear to be resistant to change preferring to maintain traditions by doing things the way they have always been done (Hanrahan, et al., 2015). One researcher referred to this concept as sacred cow gone to pasture (Hanrahan, et al., 2015). The term “sacred cows” refers to old habits in practice, considered routine, and above dispute, regardless of evidence to the contrary (Hanrahan, et al., 2015). Understanding categories of adoption helps in the diffusion of innovation theory to plan change. Multiple strategies should be used across the implementation phases to achieve full integration of evidence-based practices, sustain gains and successfully diffuse the innovation of using order sets and care bundles and adhering to GOLD guidelines. Healthcare systems are very complex social systems, containing individuals with varying backgrounds, experiences, and values (Morton & Wiedenbeck, 2010). To successfully enable adoption of a new system, social and behavioral factors must be addressed particularly during the planning phase (Morton & Wiedenbeck, 2010).
Literature Search Strategies
The search engines used for this literature review were PubMed and CINAHL. The PubMed search used the article type of clinical trial, comparison study, controlled trial, observational study, systematic review, and where narrowed to articles within the past five years. The initial search using the term “COPD” yielded 22,977 articles and was further narrowed with the addition of the MeSH terms in the order; exacerbation (n=2592), readmission (n=169), 30-day (n=142), and hospital (n=27). The exclusion criteria eliminated five non-US articles focusing on changes in blood sugar, pneumonia, asthma, CHF, non-invasive ventilation and the evaluation of a risk assessment scale.
The initial CINAHL search was limited to the past 5 years and yielded 11,589 articles for the term “COPD” and was narrowed down by including exacerbation, 30-day readmission, hospital, and filter for only academic articles (5,857, 1,337, 32, 30, 21, respectively). The exclusion criteria eliminated four non- US studies, one on depression, one on asthma, six articles that were not about 30-day readmissions, and five duplicate articles.
The literature chosen for review included six studies focusing on the use of COPD care bundles (n=2), order sets (n=1), COPD guidelines (n=3), and COPD risk assessment (n=1). The literature review included only studies done in the United States and written within the past five years. The focus was to determine what clinicians can improve on during acute exacerbation COPD (AECOPD) hospital admissions rather than focusing on patient barriers or deficiency.
Four major categories were found to influence 30-day readmissions of acute exacerbations of COPD: 1) COPD care bundles, 2) COPD order sets, 3) use of GOLD guidelines and 4) risk assessments. A care bundle is a set of three to five evidence-based practices structured to improve the process of care and patient outcomes (Camporota & Brett, 2011). Care bundles simplify decisions, reduce omissions, reduce medical errors, and promotes goal-oriented care (Camporota & Brett, 2011). An order set is a prepackaged group of electronic orders which a physician can place for a specified diagnosis or a specific length of time. When order sets are used there is a significant reduction in in-hospital mortality and an increase in core measures compliance (Ballard, et al., 2008). GOLD guidelines address the management and prevention of COPD and provides evidence-based recommendation for clinicians and patients (GOLD, 2018). The risk assessment after COPD exacerbation (RACE) is a risk stratification tool used as a predictive scale to identify individuals at higher risk of AECOPD 30-day readmission (Lau, Siracuse, & Chamberlain, 2017).
COPD Care Bundles
Two studies were reviewed focusing on the use of COPD care bundles for patients admitted to the hospital with AECOPD. Both studies had small sample sizes and providers were not required to use the care bundles. The two studies identified risk factors for AECOPD, the need for patient education, and the necessity for follow up appointments. Important goals in reducing readmission rates is for providers to identify the risk factors for COPD exacerbations and to intervene prior to discharge. A single-center, randomized trial of admitted patients with AECOPD was conducted to determine if providers using a pre-discharge care bundle for patients with AECOPD would reduce readmissions and emergency department (ED) visits (Jennings, et al., 2015). The study took place at the Henry Ford Hospital between February 2010 and April 2013 and examined the difference in composite risk of hospitalization or ED visits for AECOPD 30 days after discharge and at 90 days (Jennings, et al., 2015). A sample of 1225 patients were assessed for eligibility and excluded based on a history of asthma, interstitial lung disease, bronchiectasis, presence of tracheal stents or tracheotomy, lung cancer, and any cancer with a life expectancy of less than one year, active chemotherapy, or radiation treatment, active substance abuse, or neuromuscular disorders affecting the respiratory system, language barriers, live in a nursing home, intensive care unit (ICU) stay during the current admission, and significant delirium or dementia (Jennings, et al., 2015). The final study sample consisted of 172 patients divided into two groups with 79 patients in the control group called the standard care group and 93 patients in the bundle group (Jennings, et al., 2015). The bundle group received smoking cessation counseling, screen for gastroesophageal reflux disease (GERD), depression or anxiety, standardized inhaler education, and a 48-hour post-discharge follow up call (Jennings, et al., 2015). Both groups underwent spirometry one to two days prior to discharge and received systemic steroids, antibiotics, and inhaler therapy at the primary team’s discretion and received education regarding inhaler use (Jennings, et al., 2015).
The AECOPD bundle included an assessment of tobacco exposure, smoking cessation counselling and program referrals, and provision of nicotine patches. They also identified and counseled about the risks of second hand smoke exposure. The next component was an assessment of gastroesophageal reflux disease (GERD) with a questionnaire and patients were given information about lifestyle changes and dietary modifications. In addition, patients were screened for anxiety and/or depression using established instruments. The COPD education included an assessment of current behaviors used to manage their COPD, inhaler/nebulizer education, exacerbation action plan information, and breathing technique information (Jennings, et al., 2015).
The 30-day readmission rate for the control group was 22.78% versus the bundle group at 19.35% (risk difference, -3.43%; 95% CI, -15.68% to 8.82%; P = .58). The time to readmission in 30 and 90 days was similar between the groups (log-rank test P = .71 and .88, respectively). Although the percentage dropped slightly, the study authors determined there was not a significant reduction in the bundle group’s 30-day readmissions or ED visits. They recommended that more resources are needed to produce a measurable effect. The authors noted that the greatest predictor of readmission was the number of previous exacerbations. They believed that the bundle group’s readmission rate may have increased due this group being more aware of exacerbation symptoms and initiated treatment earlier compared to the control group (Jennings, et al., 2015).
The limitations of this study included the identified risk factors, which were reported to the primary team, but the interventions used were left up the judgement of the primary team. They did not examine patient adherence for the risk factors identified, which could have provided further information related to specific interventions. In addition, patients were excluded that were unlikely to benefit from the educational interventions. The study was small, with only 172 patients and was conducted in only one setting.
The second study examined whether COPD exacerbation care bundles used by providers, improved the standard of care, length of stay, and readmission rates. A prospective, observational study design of 44 patients was performed in a single tertiary care facility from January 2015 through June 2016. The authors developed the care bundle to assess the length of stay, readmission rate, hospital cost, patient education, pulmonologist follow-up, and timeliness of medication administration (Parikh, Shah, & Tandon, 2016). The two cohorts were described as those with an electronic COPD care bundle and the control group of those treated without the care bundle. There were 22 patients in each cohort.
The COPD care bundle was incorporated into the hospital’s electronic medical record system (Parikh, Shah, & Tandon, 2016). The care bundle included standard nursing protocols, appropriate inhaler technique education, and medication options for inhalers, nebulizers, steroids, and antibiotics (Parikh, Shah, & Tandon, 2016). The menu care bundle in the electronic health record system provided physicians with check boxes in the COPD order set for anti-cholinergic nebulizers, beta-adrenergic inhalers or nebulizer, systemic glucocorticoids in oral or IV form, antibiotics for purulent sputum or require invasive or non-invasive ventilatory support, bipap, and a consult section for bronchial hygiene to evaluate and treat and/or consult to pulmonary (Parikh, Shah, & Tandon, 2016).
The study found that the mean length of stay for the bundle group was 51.2 hours versus 101.1 hours for the control group (Parikh, Shah, & Tandon, 2016). The 30-day readmission rate for the bundle group was 9.1% versus 54.4% in the control group (P-value = 0.001) and the 90-day hospital costs for the bundle group was $7,652 versus $19,954 in the control group (Parikh, Shah, & Tandon, 2016). They also reported that 100% of the bundle group received inhaler teaching, 59.1% rate of pulmonologist follow-up after discharge, and a mean reduction in time to steroid administration of two hours (P-value = 0.015) versus 27.3%, 18.2%, and 4.3 hours respectively in the control group (Parikh, Shah, & Tandon, 2016). The study results show the use of a standardized COPD care bundle will significantly decrease 30-day readmission rates as well as length of stay and hospital costs. This study illustrates the benefits of a COPD care bundle and the importance of enforcing clinical guidelines (Parikh, Shah, & Tandon, 2016).
The limitation of this study was the small study size of only 44 patients and a single tertiary care university hospital. Selection bias may have influenced potentially stable patients receiving the COPD care bundle more often than acutely ill patients (Parikh, Shah, & Tandon, 2016). The use of the care bundle was not a mandatory requirement during admission, its use was left up to the treating physician.
COPD order sets
One study examined the use of an acute exacerbation of COPD management electronic order sets in the electronic medical health system. A pre- and post-intervention study of 420 patients with acute exacerbation of COPD from January 2009 through September 2012 at a tertiary care academic institution at the University of Texas Medical Branch in Galveston, Texas (Sonstein, Clark, Seidensticker, Zeng, & Sharma, 2014). The study was divided into two periods, one from January 2009 through February 2011 and the second period from March 2011 through September 2012. The standardized order set for acute exacerbation of COPD was developed internally into their electronic medical health system and used the 2007 GOLD guidelines (Sonstein, et al., 2014). The order set included management options during the inpatient encounter and orders to schedule a 14-day hospital follow up with the primary care physician. The pre-intervention group did not have any order sets or clinical protocols available for the management of acute exacerbation of COPD (Sonstein, et al., 2014). The two groups did not differ significantly in the use of inhaled corticosteroids or inhaled long-acting beta agonists. The pneumococcal vaccination rates were higher in the post intervention period versus the pre-intervention period, 57%, 45% respectively (p-value = 0.02). There was an increase in patients who received long acting muscarinic antagonist usage 3%, 25% respectively (p = 0.002) and who were discharge with supplemental oxygen 57%, 42.9% respectively (p-value = 0.005) in post-intervention patients (Sonstein, et al., 2014). All cause 30-day readmission rates were 22% during the baseline period and 20% during the intervention period (p = 0.73) and 9% and 10% (p = 0.91) for the baseline and intervention groups, respectively (Sonstein, et al., 2014). The study did not show a decrease in hospital length of stay. The primary outcome measure was corticosteroid dose administration in the first 48 hours and secondary measures were corticosteroid dosage during the entire hospitalization, length of stay, hospital follow-up, and 30-day readmission rates (Sonstein, et al., 2014). Although the implementation of clinical guidelines can be a useful tool to ensure standardized care to improve overall quality of care, this study found no difference in the hospital follow-up rates, length of stay, and 30-day readmission rates between the two periods (Sonstein, et al., 2014).
The study limitations include a small sample size of 420 patients at a tertiary care academic institution and may not include sample patients applicable to a national standard. The spirometry data was available in less than 50% of the subjects. The order set was only used 40% of the time during the first six months post-implementation. The use of corticosteroids was reported as being higher than the recommended dose even though the dose was reduced by 51% from baseline. Educating providers on the use of order sets through the diffusion of innovation theory could improve the 40% adherence rate achieved during this study.
As of 2018, the GOLD guidelines have been updated and disseminated. Three studies were reviewed related to the adherence to these guidelines. All three studies showed a variation in provider adherence to GOLD guidelines. None of the studies addressed provider education related to GOLD guidelines. Limitations included one study with a small sample size and two studies used patient information from electronic databases.
The first study assessed whether physicians consistently adhere to GOLD guidelines for COPD acute exacerbation patients in the inpatient setting. A retrospective cohort analysis of 94 patients admitted between December 2010 through August 2012 in a 506-bed urban academic hospital in Detroit, Michigan which used a computer prescriber order entry and bar code technology to document medication administration (Lipari, Smith, Kale-Pradhan, & Wilhelm, 2017). There were 611 patients identified with a diagnosis of COPD but 517 were excluded from the study due to outpatient encounters, no shortness of breath (SOB) at admission, SOB due to heart failure exacerbation, pneumonia, or other diagnosis, those under the age of 18, and those missing data relevant to the study (Lipari, et al., 2017).
The appropriate therapy in accordance with GOLD guidelines was defined as the administration of short-acting beta agonist (SABA) with or without short-acting muscarinic antagonist (SAMA) as a nebulizer or metered dose inhaler, IV or oral systemic corticosteroid, and an antibiotic for bronchitis and pneumonia based on guidelines for empiric antibiotic therapy (Lipari, et al., 2017). The prescribing pattern showed that all patients in the study received an inhaled short-acting beta agonist and there were 52 patients who also received short-acting anticholinergic. There were 78 received systemic corticosteroids and of those three received 30 and 40 mg of prednisone and 71 received 40 mg or more of prednisone. There were 64 received antibiotics for pulmonary indications, 46 received appropriate antibiotics based on the indication, and five patients received antibiotics for non-pulmonary indications. Only two patients, of the 94 study patients, were managed in complete adherence with GOLD recommendations (Lipari, et al., 2017).
Within 30-days of discharge, 24 patients were readmitted with nine having a COPD exacerbation. Of the nine patients who were readmitted, four did not receive antibiotics or steroids and one patient received antibiotics but not steroids. Overall admission rates for COPD were greater in the spring with eleven admissions per month, but the readmission rate was greater in the winter with 2.3 readmissions per month. The study authors stressed the importance of standardize treatment and the use of GOLD recommendations for all patients admitted with an acute exacerbation of COPD (Lipari, et al., 2017).
The limitation of the study was the small sample size of 94 patients. There could have been selection bias because those chosen for the study had an admitting diagnosis of COPD exacerbation and clinically presented with shortness of breath in the initial progress note at admission. There could have been omission because of the nature of electronic charting. The study authors did not evaluate the dosing and during of antibiotic use as well as the duration of corticosteroids.
The second study found an inverse relationship between nonadherence to GOLD guidelines and COPD exacerbations. A retrospective study of 878 patients with spirometrically confirmed COPD who were followed from 2005 to 2010 at one VA medical center to examine the inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD (Foda, Brehm, Goldsteen, & Edelman, 2017). They found that 19% were appropriately treated using the guidelines, 14% were overtreated, 44% were undertreated, and 23% were not treated by any guidelines (Foda et al., 2017). The study group contained 34.9% of patients with mild COPD, 5% with moderated, 25% with severe, and 34.7% with very severe COPD (Foda et al., 2017). The study authors found that the rate of exacerbation in all GOLD classes were significantly less than found in previous studies and that undertreatment predicted fewer exacerbations in the almost 50% in the moderate and severe COPD categories (Foda et al., 2017). Furthermore, therapeutic guidelines at this facility need to be re-evaluated regarding prescribers’ high level of nonadherence to GOLD or any other treatment guidelines for COPD patients.
The study limitations were that all the patients assessed were from the VA medical center. The use of electronic data systems can have omitted data if not correctly or completely entered by clinicians and the other in the healthcare team.
The third study was a noninterventional retrospective descriptive study of 199,679 COPD patients in cohort 1 and 30,493 COPD patients in cohort 2 during the study period of January 2009 through December 2013 (Simeone, et al., 2017). The data was retrieved from the US administrative claims data and included enrollment, pharmacy, and medical claims from the IMS PharMetrics Plus database, composed of adjudicated claims for the 150 million insured enrollees across the US including commercial and Medicare patients (Simeone, et al., 2017). The study analyzed the effect of initiation of triple therapy maintenance treatment among patients with COPD in the US per GOLD recommendations. The first objective was to estimate the proportion of all, and all treated, COPD patients receiving triple therapy. The second objective was to characterize those on triple therapy and assess the congruence of triple therapy use with GOLD guidelines.
Cohort 1 was identified as patient with a COPD diagnosis during the study period who had two or more outpatient medical claims or at least one inpatient medical claim with a primary or secondary diagnosis of COPD (Simeone, et al., 2017). The patients were at least 40 years of age at the date of diagnosis and had to be enrolled in a health plan for 24 consecutive months after the initial diagnosis and received triple therapy during the 24 months. Cohort 2 was a separate set of patients who initiated the triple therapy during the study period, were over 40 years of age at the initial COPD diagnosis and were enrolled in a health plan for 12 consecutive months prior to initiation of the triple therapy.
Of all the 199,678 patients in cohort 1, 7.5% received triple therapy after diagnosis, and 25.5% of all treated patients received triple therapy. In cohort 2, 30,493 patients had a mean age of 64.7 years who initiated triple therapy were identified. Using claims-based algorithm, 34.5% of cohort 2 patients were classified as having mild COPD (GOLD 1), 40.8% had moderate COPD (GOLD 2), 22.5% had severe COPD (GOLD3), and 2.3% had very severe COPD (GOLD 4). When using exacerbation severity and frequency, 60.6% of patients were classified as GOLD 1 and 2 and 39.4% were classified as GOLD 3 and 4 (Simeone, et al., 2017).
Triple therapy is recommended for the most severe COPD patients but 25% of all treated patients received triple therapy. This study found that among all COPD patients who received triple therapy, approximately 75% had either mild or moderate COPD. The study also found that spirometry was infrequently assessed and many of the patients who received triple therapy may have only mild to moderate COPD. The potential overprescribing of triple therapy is not congruent to GOLD guidelines since GOLD recommends triple therapy for only severe and very severe COPD patients who are highly symptomatic and experiencing two or more exacerbations or at least one exacerbation leading to a hospitalization per year (Simeone, et al., 2017).
Study limitations could include issues with retrospective claims database studies. The claims may not accurately reflect the patients’ condition, the medications actually administered, and other treatments not billed separately. The severity of COPD could not be conclusively determined because spirometry was infrequently assessed. The study did not address any of the risk assessments such a smoking history, alcohol use, activity level, socioeconomic status, comorbidities, and other factors that contribute to the severity level of COPD.
To avoid COPD readmission penalties and reduce health care expenditures it is important to identify patients at greatest risk for readmission. A retrospective mega-data study was performed to develop a predictive readmission scale to identify COPD patients at higher risk of 30-day readmission. Data was extracted from the State Inpatient Database, which is part of the HCUP of the Agency for Health Research and Quality (Lau, Siracuse, & Chamberlain, 2017).
The values for components of the RACE scale is age, gender, income, race, primary payer, and comorbidities (Lau, Siracuse, & Chamberlain, 2017). The demographic and clinicopathological distribution for both cohorts were similar. Most patients were Caucasian with 74.5% in the derivation cohort and 81.4% in the validation cohort. Patients over the age of 65 were 70.2% of the derivation cohort and 67.2% of the validation cohort. The male to female ratio was 1.25:1 in the derivation cohort and 1.24:1 in the validation cohort. The most common comorbidities were hypertension (63.2%, 64.4%), diabetes mellitus (28.3%, 28.8%), and CHF (26.7%, 22.9%) in the derivation and validation cohort respectively (Lau, Siracuse, & Chamberlain, 2017). They observed that 30-day readmission rates were highest among African Americans, patients over the age of 65, male, from lower income households, and those with multiple comorbidities (Lau, Siracuse, & Chamberlain, 2017).
Patient specific readmission reduction strategies can be implemented to improve patient care was well as reduce readmissions and health care expenditures by identifying these patients as high risk for COPD 30-day readmissions with the use of the RACE scale. The readmission rate was 7.54% in the derivation cohort and 6.70% in the validation cohort. When both cohort groups had the RACE scale applied, it explained 92.3% of readmission variability (Lau, Siracuse, & Chamberlain, 2017).
The limitation of this study is that it used information from only 4 states and cannot conclude that the finding can be used nationwide. Many patients in the study were Caucasian even though the patients listed as highest risk were African American. A similar study should include areas with a higher population of African American patients with COPD to validate their findings. They study authors cited that further limitations could include coding and sampling errors, misclassification, and inaccurate reporting of variables (Lau, Siracuse, & Chamberlain, 2017). The study did not address provider utilization of the RACE scale during AECOPD admissions.
This literature review examined how COPD care bundles and order sets, adherence to GOLD guidelines, and the implementation of risk assessments improve patient care and reduce 30-day readmission rates for acute exacerbation of COPD. The literature illustrated that improvement is needed in provider adherence to GOLD guidelines, use of order sets, use of COPD care bundles, and risk assessments in the treatment of AECOPD patients. The use of evidence-based practice has shown improvements in the quality of care, patient outcomes, and lower healthcare cost but some clinicians are resistant to change preferring to maintain traditions by doing things the way they have always been done (Hanrahan, et al., 2015). Providers are failing to use EBP standards in health care services to about 30% to 40% of patients in the United States (Mohammadi, Poursaberi, & Salahshoor, 2018). This failure could be attributed to the “sacred cow” theory which makes the diffusion of innovation difficult to implement.
Gaps in the Literature
The gaps in the literature includes not having a cohesive plan to decrease 30-day readmission of COPD exacerbation rates. There were no long-term studies done on the implementation of care bundles and order sets for AECOPD patients. The literature included studies related to GOLD guidelines, order sets, and care bundles but did not address how to disseminate this education to providers to improve use and adherence. In one study only two patients, of the 94 study patients, were managed in complete adherence with GOLD recommendations (Lipari, et al., 2017). Another study found that only 19% of patients were treated using GOLD guidelines while 14% were overtreated, 44% were under-treated, and 23% did not follow any guideline. A third study found that approximately 75% of patients with mild to moderate COPD were treated with triple therapy which is contrary to GOLD guidelines. In these articles there was not a discussion about how to increase, improve, or educated providers about the importance and necessity to adherence to the GOLD guidelines.
Implications for Practice and Research
The implications for practice would need to begin with the implementation of risk assessments for COPD patients. Risk assessments begin the process of understanding the causes of COPD, comorbidities, and patient barriers to treatment. With over 10% of patients being readmitted with AECOPD it is crucial to identify these individuals to allow for early intervention and appropriate care (Lau, et al., 2017). Another equally important practice improvement to reduce 30-day readmission would be provider adherence to GOLD guidelines. This would entail the use of care bundles and order sets by hospital clinicians. COPD patient must be assessed for the severity of their disease to implement to proper medications and therapies to decrease the number of exacerbations which in turn should decrease the number of 30-day readmission. Patient teaching and patient adherence to medication regime has been a focus of nursing and I initially believed that this was the key to decreasing 30-day readmission rates. The literature review has shown that non-adherence to GOLD guidelines and lack of participation by clinicians to use care bundles and order sets is a greater problem.
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