Background: Chronic Obstructive Pulmonary Disease (COPD) is among the top three leading causes of hospital readmissions in the United States. Acute Exacerbation of Chronic Obstructive Pulmonary Disease(AECOPD) is associated with increased morbidity, mortality, and cost with AECOPD accounting for more than half of the 15.5 billion USD spent on COPD[1,2]. In this project, we aim to reduce the AECOPD readmission rate at Geisinger Community Medical Center (GCMC).
Methods: Starting from October 2018, a multidisciplinary team which includes: general medicine, pulmonary medicine, care management, social worker, billing, and administrative departments at GCMC implemented several interventions. A proven care order set was implemented for all AECOPD admissions, which includes; enrollment of patients in ProvenCare COPD pact team, standardized medical management per Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, pulmonary consultation for each admission, follow up appointment with COPD clinic, 24 hour post discharge calls, and providing patients with help cards for symptom management. Readmission cases were reviewed retrospectively in our monthly multidisciplinary meeting to ensure accurate diagnosis, and appropriate coding. Multiple educational seminars were held to raise the awareness of accurate diagnosis with among the hospitalists, and residents. We obtained the baseline 30-day readmission data from October 2017 to June 2018, and compared it with the intervention period from October 2018 to June 2019. We used chi-squared test for statistical comparison between the two periods. We conducted a chart review in July 2019 to assess the number of no-shows post discharge in the COPD clinic, and the major comorbidities in patients with COPD enrolled in Geisinger Health Plan.
Results: A total of 175 patients were admitted from October 2017 to June 2018 with a 30-day readmission rate of 18.85%. 194 patients were admitted during the intervention period with a 30-day readmission rate of 15.97% (p-value = 0.4662)[Figure1]. The absolute risk reduction was 2.88%. The readmission rate for patients under medicare coverage was 23.38 % prior to intervention compared to 21.90% in the intervention period with an absolute risk reduction of 1.48%. 92 out of 194 (47.42%) patients admitted at GCMC with AECOPD were no shows in the COPD clinic post discharge. Hypertension (69.54%), positive depression screen (47.0%), coronary artery disease (37.21%), diabetes mellitus (32.50%) were the four major comorbidities in 19,146 COPD patients.
Conclusions: The proven care order set has shown to reduce the AECOPD readmission rate. Socioeconomic determinants of health must be addressed, as higher readmission rates were observed among patients under medicare coverage. We hypothesized that multiple concurrent diseases, transportation issues, and depression may be a major determinant. In August 2019, we implemented a low cost transportation program. We also started to conduct educational seminars for primary care physicians, hospitalists, and residents to address the importance of appropriate management of other comorbidities including depression. We plan to identify the main reasons for no-shows in our next survey with an action plan based on the results.
