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COPD Workshop Finds Deficiencies in Efforts to Cut Hospital Readmissions

Allison Inserro

Six areas that need improvement emerged from a workshop examining best practices and models to reduce hospital readmissions in patients with chronic obstructive pulmonary disease (COPD). The proceedings of the workshop are published in the February issue of the Annals of the American Thoracic Society.

This workshop included different perspectives, including patients, providers, and payers, and included a review of existing readmission reduction programs.

CMS instituted a penalty for 30-day readmissions as part of their Hospital Readmission Reduction Program (HRRP) in 2014. However, there was, and has been, a lack of published evidenced on effective hospital-based programs to reduce readmissions. In response, hospitals began to develop and implement their own programs in an effort to avoid financial penalties.

Patients with lower socioeconomic status are more likely to have COPD, be hospitalized for COPD, be readmitted after a COPD-related hospitalization, and have higher death rates from COPD. Thus, financial penalties worry safety net hospitals heavily, since they serve this population.

The areas that emerged are:

Communication problems. Poor communication at the time of diagnosis, care transitions, and clinical deterioration leads to a worsened patient experience as well as outcomes, according to patients and patient advocate stakeholders.

Complicating factors, including social determinants of health. Readmissions may be a proxy for other health factors or outcomes, such as quality of life, social determinants of health (SDOH), adherence deficit, or multimorbidity. Stakeholders said interventions to reduce readmissions may need to expand to include improvements in patient education, behavior modification through health coaching, and facilitation of prompt access to outpatient healthcare expertise.

Implementation issues. COPD guidelines are necessary but not enough to reduce readmissions and/or healthcare costs. Due to the readmission penalty targeting all-cause, not just COPD-related, readmissions, efforts to address multimorbidity and SDOH are also needed.

Lack of rigorous evaluation. The success of readmission reduction programs is difficult to evaluate. There is a lack of rigorous study design and complicated cost frameworks, including variations in diagnostic coding.

Adjusting metrics for quality. Programs should address quality of care, not just quantity of readmissions. The 30-day readmission metric may need to have the time frame adjusted; additional metrics should show whether hospital-based interventions improve COPD care and impact patient-centered outcomes, such as mortality, patient satisfaction, adherence, self-efficacy, symptoms, and exercise tolerance.

Flagging high-risk patients. Improvement is needed to identify risk factors for readmission and/or high-risk patients. The authors said there is no 30-day, COPD-specific risk-prediction tool to identify patients at high risk of 30-day readmission that specifically addresses the CMS HRRP penalty. There is 1 published tool for 90-day readmissions, but again, there is room for improvement. However, there are patient characteristics that have been identified as increasing risk, including comorbid anxiety, multimorbidity, and delays to follow-up with primary care physicians.

Reference
Press VG, Au DH, Bourbeau J, et al. Reducing chronic obstructive pulmonary disease hospital readmissions. an official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2019;16(2):161-170. doi: 10.1513/AnnalsATS.201811-755WS. 
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