August 21, 2018
Too many COPD patients end up back in the hospital too soon after being discharged. That’s why researchers recently assessed 30-day readmission rates among more than 1 million patients who were hospitalized for treatment of acute exacerbations. The highest readmission rates occurred within the first 72 hours of discharge and 58% of the readmissions occurred in the first 15 days, according to the study.
The key to reducing readmission rates among these complex patients is to improve transitions of care, according to David Jacobs, PharmD, PhD, an assistant professor at the University of Buffalo School of Pharmacy and Pharmaceutical Sciences. He said health-system pharmacists need to play active roles in medication reconciliations for COPD patients, educating them about the proper ways to take inhaled therapies, and ensuring they have access to the drugs they’re prescribed.
Why has there been more focus on reducing risks of COPD readmissions?
The emphasis increased after passage of the Affordable Care Act’s Readmissions Reduction Program. With healthcare resources stretched thin, hospitals don’t want to incur Medicare reimbursement reductions due to avoidable readmissions. COPD readmissions were added to the program a couple years ago, so we wanted to better understand the causes of acute exacerbations and how those factors related to patients ending up back in the hospital.
Our study utilized a nationwide readmission database taken to better understand the predictive factors of COPD readmissions. We came up with more generalizable findings than those from other studies that focused on readmissions at individual facilities. We weren’t surprised that the overall 30-day readmission rate was about 20%, which was in line with previous literature. The interesting aspect of our study was that we looked at how soon after discharge patients were being readmitted. The findings showed we need to determine why they’re being readmitted within a few days of leaving the hospital.
What can be done to reduce incidences of short-term readmissions?
Improvements need to be made to transitions of care. How can we transition these patients from inpatient settings to outpatient settings with more of a focus on COPD? Many transitions of care programs focus on general diseases, but COPD is a unique multifactorial disease. It requires a great deal of follow-up from a medication standpoint because it’s one of the only diseases where adherence to inhalers and using inhalers properly are of utmost importance.
A risk stratification algorithm is also needed. We need to identify high-risk patients, so limited healthcare resources can be used to keep them from being readmitted. A COPD-specific risk stratification algorithm within index hospitalizations hasn't been developed, but that’s something we think is very important to consider. After high-risk patients are identified within electronic health records or health information exchanges, providers across many levels of care can work in concert to transition the patients from hospital to home in the best possible way.
What would the optimal transition of care model include?
We don’t yet know what factors decrease readmission rates. General care transition programs involve better communication among providers and follow-up phone calls and face-to-face interactions with patients. A lot of COPD patients don’t go to pharmacies after discharge to pick up their prescriptions. That means two, three or four days might pass before they take needed medications, and that delay increases their risk of readmission. We’re looking at transitions of care from a pharmacy standpoint to improve medication management, address medication-related issues and discrepancies, and address social aspects to make sure COPD patients obtain needed medications and utilize them correctly. It’s going to take a multifaceted program and a total team effort.
What factors add to the complexity of caring for COPD patients?
Patients with respiratory diseases typically have the lowest rates of medication adherence because they need inhaler-based therapies, which are inherently costlier and difficult to use, so the most important issue is getting medications into patients’ hands. We have to look at not only care provided at the hospital level, but also factors at the systems level so providers are on the same page when it comes to ensuring patients adhere to needed medications after they leave the hospital.
Ongoing research at individual clinics and large health systems address some of these issues and how to better identify high-risk patients so we can work collectively both locally and nationally to implement change. I think we're moving toward identifying high-risk patients, having a better understanding of the issues involved in caring for them properly, and implementing improvement programs to address them.
What can health-system pharmacists do to improve the care of COPD patients?
Pharmacists can play a major role in the care transition process. We’re trying to get pharmacists more involved in medication management in primary care settings and following up with patients after discharge to assess social determinants of health and to ensure patients are on the right medications and taking them properly. Healthcare resources are stretched thin, so most hospitals are already looking at how to involve pharmacists in care transitions and patient care teams to address medication-related problems.
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