Community Paramedics vs. Chronic Disease
Journal Source: Drennan IR, Dainty KN, Hoogeveen P, et al. Expanding paramedicine in the community (EPIC): study protocol for a randomized controlled trial. Trials, 2014; 15: 473, www.trialsjournal.com/content/15/1/473/abstract.
Background—The incidence of chronic diseases, including diabetes mellitus (DM), heart failure (HF) and chronic obstructive pulmonary disease (COPD), is on the rise. The existing healthcare system must evolve to meet the growing needs of patients with these chronic diseases and reduce the strain on both acute care and hospital-based healthcare resources. Paramedics are an allied healthcare resource consisting of highly trained practitioners who are comfortable working independently and in collaboration with other resources in the out-of-hospital setting. Expanding the paramedic’s scope of practice to include community-based care may decrease the utilization of acute care and hospital-based healthcare resources by patients with chronic disease.
Methods/Design—This will be a pragmatic, randomized controlled trial comparing a community paramedic intervention to standard of care for patients with one of three chronic diseases. The objective of the trial is to determine whether community paramedics conducting regular home visits, including health assessments and evidence-based treatments, in partnership with primary care physicians and other community-based resources, will decrease the rate of hospitalization and emergency department use for patients with DM, HF and COPD. The primary outcome measure will be the rate of hospitalization at one year. Secondary outcomes will include measures of health system utilization, overall health status and cost-effectiveness of the intervention over the same time period.
Discussion—The results of this study will be used to inform decisions around the implementation of community paramedic programs. If successful in preventing hospitalizations, it has the ability to be scaled up to other regions, both nationally and internationally.
While Journal Watch typically reviews completed study trials, the excitement around the approval of this randomized controlled trial on the effects of a community paramedicine intervention on patient suffering from some of the most difficult-to-control chronic conditions warrants highlighting in this column.
The researchers selected patient conditions that frequently result in preventable emergency department visits and admissions. In fact, here in the United States, HF and COPD are currently included as two of the five diagnosis codes CMS uses for assessing readmission bonuses or penalties to hospitals. One of the challenges in the U.S. movement toward using community paramedicine as part of an overall mobile integrated healthcare strategy has been the dearth of a randomized control trial such as our friends in Toronto are planning.
Also exciting is that several of the primary and secondary outcome measures employed in the trial are similar to the outcome measures drafted here in the U.S. and being circulated for comment from currently operating MIH programs using the community paramedicine intervention—specifically hospitalizations at one year, health system utilization, patient health status and cost-effectiveness.
Watch the Drennan/Dainty trial closely, as it could serve as an excellent platform for doing companion analyses with community paramedicine interventions in the U.S., perhaps even simultaneously.
Reasons for COPD Readmissions
Journal Source: Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why COPD patients get readmitted: A large national study to delineate the Medicare population for the readmissions penalty expansion. Chest, 2014 Dec 24, http://journal.publications.chestnet.org/article.aspx?articleid=2087937.
Background—The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for 30-day readmissions and was extended to chronic obstructive lung disease (COPD) in October 2014. There is limited evidence available on readmission risk factors and reasons for readmission to guide hospitals to initiate programs to reduce COPD readmissions.
Methods—Medicare claims data from seven states were analyzed from 2006 to 2010, with an index admission for COPD defined by discharge ICD-9 codes as stipulated in the HRRP guidelines. Rates of index COPD admission, readmission, patient demographics, readmission diagnoses and utilization of post-acute care (PAC) were investigated.
Results—Over the study period, there were 26,798,404 inpatient admissions, of which 3.5% were index COPD admissions. At 30 days, 20.2% were readmitted to the hospital. Respiratory-related diseases accounted for only half of the reasons for readmission, and COPD was the most common diagnosis, explaining 27.6% of all readmissions. Patients discharged home without home healthcare were more likely to be readmitted for COPD than patients discharged to PAC (31.1% v. 18.8%). Readmitted beneficiaries were more likely to be dually enrolled in Medicare and Medicaid (30.6% v. 25.4%), have a longer median length of stay (5 v. 4 days), and have more comorbidities.
Conclusion—Medicare patients with COPD exacerbations are usually not readmitted for COPD, and these reasons differ depending on PAC utilization. Readmitted patients are more likely duals, suggesting the addition of COPD to the readmissions penalty may further exacerbate the disproportionately high penalties seen in safety-net hospitals.
Around 12.7 million U.S. adults are estimated to have COPD.1 However, close to 24 million U.S. adults have evidence of impaired lung function, indicating an underdiagnosis of COPD.2 The average cost for a COPD readmission from COPD as a principal diagnosis is $8,400, with a readmission rate of 7.1%. The average cost of a COPD readmission from a diagnosis including COPD is $10,900, with a 17.3% readmission rate. The average COPD readmission costs 118% of an initial COPD admission, which averages $7,100.3 These statistics illustrate why CMS included COPD in the readmission penalty bundle.
The authors note only half of the 30-day readmissions from a primary ICD-9 diagnosis of COPD were due to a primary respiratory ailment. They also point out patients with home health had lower readmission rates than patients discharged without post-acute care.
Although the primary basis for this study was to describe the potential negative impacts on hospitals subject to the HRRP as a result of dually eligible patients, their results also make a compelling argument about ensuring a holistic, integrated and collaborative approach to managing COPD patients in the post-acute care setting. This could involve a combination of clinical, educational and even social service care to minimize the risk of the comorbidities leading to readmission.
—Analysis by Matt Zavadsky
1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey Raw Data, 2011. Analysis performed by the American Lung Association Research and Health Education Division using SPSS and SUDAAN software.
2. Centers for Disease Control and Prevention. Chronic Obstructive Pulmonary Disease Surveillance United States, 1971–2000. MMWR, 2002 Aug 2; 51(SS06): 1–16.
3. Rizzo E. 6 Stats on the Cost of Readmission for CMS-Tracked Conditions. Becker’s Infection Control & Clinical Quality, www.beckershospitalreview.com/quality/6-stats-on-the-cost-of-readmission-for-cms-tracked-