Outpatient Follow-up Visit and 30-Day Emergency Department Visit and Readmission in Patients Hospitalized for Chronic Obstructive Pulmonary Disease

Department of Internal Medicine, Sealy Center of Aging, University of Texas Medical Branch, Galveston, USA.
Archives of internal medicine (Impact Factor: 17.33). 10/2010; 170(18):1664-70. DOI: 10.1001/archinternmed.2010.345
Source: PubMed


Readmissions in patients with chronic obstructive pulmonary disease (COPD) are common and costly. We examined the effect of early follow-up visit with patient's primary care physician (PCP) or pulmonologist following acute hospitalization on the 30-day risk of an emergency department (ER) visit and readmission.
We conducted a retrospective cohort study of fee-for-service Medicare beneficiaries with an identifiable PCP who were hospitalized for COPD between 1996 and 2006. Three or more visits to a PCP in the year prior to the hospitalization established a PCP for a patient. We performed a Cox proportional hazard regression with time-dependent covariates to determine the risk of 30-day ER visit and readmission in patients with or without a follow-up visit to their PCP or pulmonologist.
Of the 62 746 patients admitted for COPD, 66.9% had a follow-up visit with their PCP or pulmonologist within 30 days of discharge. Factors associated with lower likelihood of outpatient follow-up visit were longer length of hospital stay, prior hospitalization for COPD, older age, black race, lower socioeconomic status, and emergency admission. Those receiving care at nonteaching, for-profit, and smaller-sized hospitals were more likely to have a follow-up visit. In a multivariate, time-dependent analysis, patients who had a follow-up visit had a significantly reduced risk of an ER visit (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.83-0.90) and readmission (HR, 0.91; 95% CI, 0.87-0.96).
Continuity with patient's PCP or pulmonologist after an acute hospitalization may lower rates of ER visits and readmission in patients with COPD.

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Available from: James S Goodwin, Oct 13, 2015
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    • "Recently, we reported on gaps in COPD management in Swiss primary care with overuse of inhaled corticosteroids in moderate COPD and too little emphasis on smoking cessation counseling and patient education [7] (Figure 1). Such deficiencies in health care delivery lead to increased morbidity and excessive use of health care resources [8] and disclose the need for quality improvement. "
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    ABSTRACT: The Swiss health ministry launched a national quality program 'QualiCCare' in 2011 to improve health care for patients with COPD.The aim of this study is to determine whether participation in the COPD quality initiative ('QualiCCare') improves adherence to recommended clinical processes and shows impact on patients' COPD care and on the impact of COPD on a person's life. CAROL is a cluster-randomized controlled trial with randomization on the general practioner (GP) level. Thirty GPs will be randomly assigned to equally sized intervention group or control group.Each GP will approach consecutively and regardless of the reason for the current consultation, patients aged 45 years or older, with a smoking history of >= ten pack-years (PY). Patients with confirmed (by spirometric evaluation) COPD will be included in the study. GPs in the intervention group will receive 'QualiCCare' education, which addresses knowledge, decision-making and behavioural aspects as well as delivery of care according to COPD quality indicators and evidence-based key elements. In the control group, no educational intervention will be applied and COPD patients will be treated as usual. The study period is one year.The primary outcome measure is an aggregated score of relevant clinical processes defining elements in the care of patients with COPD: smoking cessation counseling, influenza vaccination, motivation for physical activity, appropriate pharmacotherapy, patient education and collaborative care. Given a power of 90% and a significance level alpha of 5%, 15 GPs recruiting eight patients each will be necessary in both study arms. With an assumed dropout rate of 20%, 288 patients will need to be included. It is important to develop and implement interventions that add value to COPD care considering quality and efficiency. Care pathways modifying the knowledge and behavior of physicians have the potential for improving care by transferring knowledge to clinical practice.Trial registration:
    Trials 03/2014; 15(1):96. DOI:10.1186/1745-6215-15-96 · 1.73 Impact Factor
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    • "Most importantly, too few studies to date have assessed the impact of multi-disciplinary integrated interventions extending from the hospital to the family physician practice and patient home. Most current literature focuses either on in-hospital [11] or ambulatory care [12,13] interventions. Yet, the breadth of risk factors identified in the literature, spanning health care setting characteristics [14], availability of health care resources [15], area level patterns of health care practice [16], and care trajectories [17,18] point to the need for developing and testing interventions in real world settings in various population groups. "
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    ABSTRACT: Readmission reduction is at the focus of health care systems worldwide in efforts to improve efficiency across care settings. Yet, setting targets for readmission reduction is complicated due to inconsistencies in evidence pointing to effective organization-wide interventions and because of inverse incentives (such as maintaining high occupancy rates). Nonetheless, readmission reduction is one of the few quality measures that, if implemented properly, can serve as a catalyst for system integration. Appropriate mechanisms should be applied to hospitals as well as ambulatory settings to ensure that accountability is assigned to all stakeholders.
    Israel Journal of Health Policy Research 01/2013; 2(1):2. DOI:10.1186/2045-4015-2-2
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    • "We have used 5 % national Medicare data to describe the growth of hospitalists from 1996 through 2006,17,18 to evaluate the association of care by hospitalists with length of stay,17–20 to assess how the impact of hospitalists varies by patient and hospital characteristics,18 to examine how hospitalist care affects continuity of care,21–23 to describe the growing role of hospitalists in caring for surgical patients,24 and to describe the outcomes of hospitalist care.19,20,23,25 We found that hospitalist care was associated with shorter length of stay and lower hospital costs, but with higher medical costs post-discharge.19,20 "
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    ABSTRACT: BACKGROUND: There have been no prior population-based studies of variation in performance of hospitalists. OBJECTIVE: To measure the variation in performance of hospitalists. DESIGN: Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models. SUBJECTS: 131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006-2009. MAIN MEASURES: We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits. KEY RESULTS: In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008-2009 vs. 2006-2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively. CONCLUSIONS: There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.
    Journal of General Internal Medicine 11/2012; 28(3). DOI:10.1007/s11606-012-2255-6 · 3.42 Impact Factor
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