http://informahealthcare.com/pgm ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2015; 127(4): 343–348 DOI: 10.1080/00325481.2015.1015394

CLINICAL FOCUS: PULMONARY & RESPIRATORY CONDITIONS AND MANAGEMENT ORIGINAL RESEARCH

Chronic obstructive pulmonary disease exacerbation: A single-center perspective on hospital readmissions Postgraduate Medicine Downloaded from informahealthcare.com by Nanyang Technological University on 08/25/15 For personal use only.

Shadi B. Hijjawi1, Marwan Abu Minshar1 and Gulshan Sharma1,2 1

Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, and 2Division of Pulmonary and Critical Care Medicine, University of Texas Medical Branch, Galveston, TX, USA Abstract

Keywords:

Background. Chronic obstructive pulmonary disease (COPD) is the third most common cause in the United States of hospital readmission within 30 days of discharge. Readmissions, which are attributed to poor quality of care, are costly. We examined the factors associated with 30-day readmission in patients hospitalized with acute exacerbation of COPD. Our hypothesis was that early readmissions among patients with COPD are related to patient factors rather than system or provider factors. Methods. We performed a retrospective chart review of all patients discharged from our facility from June 2010 to May 2011 with a primary discharge diagnosis of COPD. Detailed patient characteristics were obtained from the electronic medical record. Patients were followed for 30 days post–discharge date. We examined the differences in baseline characteristics of patients readmitted within 30 days and those not readmitted. Results. A total of 160 patients were admitted for 192 hospitalizations during the study period; 31 patients (19.4%) were readmitted within 30 days. Patients who were readmitted did not differ from those who were not readmitted of the following factors: baseline medication use, length of stay, and outpatient follow-up postdischarge. Readmitted patients were more likely to be black, to have coronary artery disease, to have a history of alcohol abuse, and to be on supplemental oxygen. Multivariate analysis showed a 2.17 odds of 30-day readmission (95% CI, 1.16–4.09) in patients with alcohol abuse, and 2.52 (95% CI, 1.18–5.38) in those on supplemental oxygen. Conclusion. In our study population, 19.4% of acute exacerbation COPD patients were readmitted within 30 days. Patient factors (such as alcohol abuse and advanced disease) were associated with 30-day readmission.

Chronic obstructive pulmonary disease, exacerbation, provider, follow-up, readmission

Introduction Chronic obstructive pulmonary disease (COPD) is a major global public health problem and is the third-leading cause of death in the United States [1]. It also causes substantial suffering and economic hardship. In the United States, more than 820 000 patients were hospitalized for COPD in 2008 [2], and this condition represented $32 billion in direct and indirect health care costs in 2002 [3]. Although COPD is a chronic, slowly progressive disease, many patients also have exacerbations—acute worsening of symptoms. Exacerbations are usually triggered by infection [4], and are typically defined as a change in symptoms that requires a change in treatment. Exacerbations are also associated with increased mortality rates [5-9], and with declines in health status [10,11] and lung function [12]. Severe exacerbations require a hospital admission [13], and are responsible for up to 70% of the direct health care costs associated with COPD. An important component of these expenditures is hospital readmissions [14-16].

History Received 13 June 2014 Accepted 28 July 2014

Chronic obstructive pulmonary disease is the third most common cause of hospital readmission within 30 days of discharge. National efforts are geared toward reducing 30-day readmissions [17] and reducing exacerbations by providing guidelines-concordant treatment and individualized action plans to reduce emergency department (ER) visits and hospitalizations [18]. Identifying risk factors for hospitalization and readmission have important health policy implications, but little is known of the factors that cause readmission – and, more importantly, the ways to prevent them – are not clear [19]. Oddone et al. [20] studied general medical readmissions and categorized the preventable reasons as constituting system, provider, and patient factors [20]. We examined 30-day readmission and the factors associated with early readmission in patients hospitalized with acute exacerbation of COPD (AECOPD). Our hypothesis was that most early readmissions among patients with COPD are related to patient factors rather than system or provider factors.

Correspondence: Shadi B. Hijjawi, MD, Department of Internal Medicine, University of Texas Medical Branch, 301 University Boulevard, 4.112 John Sealy Annex, Galveston, TX 77555-0561, USA. Tel: +1 832 549 1473. Fax: +1 409 772 9532. E-mail: [email protected]  2015 Informa UK, Ltd.

Postgraduate Medicine Downloaded from informahealthcare.com by Nanyang Technological University on 08/25/15 For personal use only.

344

S. B. Hijjawi et al.

Postgrad Med, 2015; 127(4):343–348

Methods

Results

This study was approved by the institutional review board at the University of Texas Medical Branch. It was conducted at a single university teaching hospital between June 2010 and May 2011. We performed a retrospective chart review of all patients with a primary discharge diagnosis of COPD based on International Classification of Diseases (ICD-9) codes 491. XX, 492.XX, and 496.0. Detailed information on patients’ characteristics and demographic factors was obtained from the electronic medical record. Patient comorbidities, including substance and alcohol abuse, were reviewed, and the diagnosis of AECOPD was confirmed using standard American Thoracic Society criteria [21]. We enrolled a patient more than once as a primary encounter if the patient was readmitted within the study period but > 1 month after the previous primary admission. All enrolled patients were followed for 30 days after discharge, making note of a readmission, an ER visit, or a primary care physician (PCP) follow-up at our institution. If the patient was readmitted within 30 days of discharge more than once, only the first readmission was included for analysis. In our data collection we included most of the factors shown to affect future readmission, categorizing them, based on a prior study, as patient, provider, or system factors [20]. Patient factors included age, sex, race, insurance, body mass index, employment, marital status, and comorbidities. System and provider factors included workup during hospitalization, treatment on discharge, and discharge plan, including planned follow-up as an outpatient. When available, data on transthoracic echo before or during admission was reviewed to document left ventricle ejection fraction and right ventricle systolic pressure; we also recorded the last documented pulmonary function test. The partial pressure of carbon dioxide in arterial gas (PaCO2) on admission was determined by examining the arterial blood gas and the serum bicarbonate level in the chemistry when PaCO2 was not available as a surrogate for hypercapnia. The discharge summary was reviewed for discharge medications, discharge plan including arranged follow-up as an outpatient, and the record of patient clinic visits. The first 30-day readmission after the index COPD admission was investigated to determine the primary reason for readmission.

A total of 160 patients had a total of 192 hospitalizations during the study period. Table 1 shows the baseline characteristics of the studied cohort. The average age was 65.8 years. More than half were women (53%) and 20.6% were black. The majority of the enrolled patients (68%) were Medicare beneficiaries. Comorbidities were common: 68% had hypertension, 25% had coronary artery disease, and 21% had congestive heart failure. Less than half of the patients (44%) were actively smoking at the time of the index admission; and 23 (14.4%) were actively drinking. The mean body mass index of the cohort was 28.4 kg/m2; 51 (32%) were obese. The readmission rate was not significantly different between obese and nonobese patients. A total of 138 patients had only 1 admission; 15 were admitted twice and 7 were admitted ‡ 3 times. Table 2 shows the characteristics of the process of care during the index admission. The mean length of stay was 3.32 (± 3.23) days and the median was 2 days. Almost all patients received a short-acting b-agonist (91%) and oral

Outcomes The primary outcomes were 30-day readmission postdischarge for AECOPD and the reasons for early rehospitalization. Secondary outcomes were ER visits and outpatient follow-ups with a PCP within 30 days of discharge. Statistical analysis Frequencies were obtained as per admission depending on the variable under investigation. A t test and X2 test were used to compare continuous and categorical variables, respectively. A multivariate generalized estimating equation model to adjust for clustering at the patient level was used to examine the factors associated with 30-day readmission. All p values < 0.05 were considered statistically significant.

Table 1. Baseline demographic characteristics of patients hospitalized with AECOPDa. Age range (mean ± SD), years Gender Male Female Race Caucasian Black Hispanic Employment Employed Not Employed Marital status Married Others Insurance Medicare Others Comorbiditiesb Asthma ESRD/CKD PH Heart failure HTN CAD Cancer Psychiatric disease Alcoholism Active smoker Other indices BMI range (mean ± SD) (n = 156) LVEF range (mean ± SD), % (n = 127) RVSP range (mean ± SD), mm Hg (n = 66) FEV1%Prd range (mean ± SD) (n = 54)

26–95 (65.77 ± 12.47) 76 (47.5%) 84 (52.5%) 122 (76.3%) 33 (20.6%) 5 (3.1%) 40 (25%) 120 (75%) 46 (28.7%) 114 (71.3%) 108 (67.5%) 52 (32.5%) 16 (10%) 15 (9.4%) 15 (9.4%) 33 (20.6%) 109 (68.1%) 40 (25%) 37 (23.1%) 46 (28.7%) 23 (14.4%) 70 (43.8%) 16–59 (28.4 ± 9) 10–65 (53.15 ± 9.61) 26–85 (47 ± 12.45) 21–86 (49.9 ±17.1)

n = 160. Sum of total comorbidities > 100% because patients can have > 1 comorbidity. Abbreviations: AECOPD = Acute exacerbation of chronic obstructive pulmonary disease; BMI = Body mass index; CAD = Coronary artery disease; CKD = Chronic kidney disease; ESRD = End stage renal disease; FEV1%Prd = Forced expiratory volume in 1st second % predicted; HTN = Hypertension; LVEF = Left ventricle ejection fraction; PH = Pulmonary hypertension; RVSP = Right ventricle systolic pressure; SD = Standard deviation. a

b

COPD readmissions

DOI: 10.1080/00325481.2015.1015394

Postgraduate Medicine Downloaded from informahealthcare.com by Nanyang Technological University on 08/25/15 For personal use only.

Table 2. Characteristics of the process of care during index admissiona. Length of stay during index admission: range (mean ± SD), days ABG PCO2 range (mean ± SD), mmHg (n = 58) Chemistry CO2 range (mean ± SD) Treatment on discharge Short-acting b-Agonist Long-acting b-Agonist Short-acting Muscrinic Antagonist Long-acting Muscrinic Antagonist Inhaled Corticosteroids Oral steroids Antibiotics Oxygen supplement Others Discharge plan Planned outpatient follow-up appointment Disposition to Home Others Had an outpatient follow-up visit within 30 days Had the outpatient follow-up with PCP

1–24 (3.32 ± 3.23) 31–121 (54.9 ± 17.26) 9–48 (29.8 ± 5.63) 175 (91.1%) 3 (1.6%) 136 (70.8%) 35 (18.2%) 34 (17.7%) 166 (86.5%) 128 (66.7%) 99 (51.6%) 27 (14.1%) 188 (97.9%) 158 (82.3%) 34 (17.7%) 119 (62%) 85/119 (71.4%)

a n = 192. Abbreviations: ABG = Arterial blood gas; PCP = Primary care physician; SD = Standard deviation.

steroids (86.5%). Most of the patients received a short-acting muscarinic antagonist (71%) and antibiotics (67%). Half of the patients were discharged on new oxygen (O2) therapy or continued their own home treatment. A few of the patients (18%) received inhaled corticosteroids and a long-acting muscarinic antagonist (18%). On discharge, almost all patients (97.9%) were scheduled with an outpatient appointment. Overall, two thirds (62%) were actually followed as an outpatient; 71% of them had their follow-up with their PCP. Of the patients readmitted, 58% were followed as an outpatient, compared with 66% of those not readmitted; the difference was not statistically significant (p = 0.35). Outcome characteristics are listed in Table 3. Of the 160 patients, 31 (19.4%) were readmitted a total of 37 times within 30 days of discharge, three fourths from the ER and 19% from the clinic. Half of the readmissions (n = 19) were due to AECOPD, followed by pneumonia and congestive Table 3. Outcome characteristics. 30-day readmissions 30-day ER visit only COPD is the reason for ER visit 30-day mortality Source of readmission ER Clinic Others Primary reason for readmissionb COPD Pneumonia Congestive Heart Failure Others

37/192 (19.3%)a 22/192 (11.5%) 12/22 (54.5%) 5/160 (3.1%) 28 (75.7%) 7 (18.9%) 2 (5.4%) 19 (51.4%) 6 (16.2%) 1 (2.7%) 19 (51.4%)

n = 31 patients: 4 patients gave a total of 10 readmissions and 27 patients gave a total of 27 readmissions. b Sum of total reasons of readmission > 100% because patient can have > 1 reason for readmission. Abbreviation: COPD = Chronic obstructive pulmonary disease. a

345

heart failure (a patient could have > 1 reason for readmission, for example, a patient with AECOPD could also be receiving treatment for congestive heart failure). Four patients had a total of 10 recurrent readmissions, whereas the other 27 patients were each readmitted only once within 30 days of discharge. Other than those readmitted to the hospital, 11.5% visited the ER within 30 days of discharge; more than half of them were evaluated for a COPD exacerbation and discharged from the ER. The overall 30-day mortality was around 3% due to non-COPD reasons. A univariate analysis showed no difference between those who were and were not readmitted on the factors of baseline medication use, length of stay, serum bicarbonate level, and outpatient follow-up. Patients who were readmitted were more likely to be black, to have coronary artery disease, to have a history of alcohol abuse, or to be on supplemental oxygen (Table 4). Including these and others factors in a multivariate generalized estimating equation model analysis, we found the odds of 30-day readmission was 2.17 (95% CI, 1.16 4.09) in patients with alcohol abuse and 2.52 (95% CI, 1.18 5.38) in patients on supplemental oxygen, after adjusting for other factors.

Discussion For patients with COPD, no validated risk prediction models exist to predict 30-day readmissions or to assess interventions to reduce these readmissions. The risk factors for subsequent hospitalization and death in this population are not well understood. The ability to accurately predict subsequent events would help in providing prognostic information to patients, and in planning interventions and clinical trials aimed at reducing these events [22]. The frequency of readmission varies from 11.6% (48 hours after discharge from the ER) [23] to 63% (1 year after admission to a general hospital) [24-27]. The rate of readmission for COPD within 30 days of discharge for Medicare beneficiaries in 2003–2004 was 22.6% [17]. In a study of US hospitalized COPD patients aged > 65 years in 1984 to 1991, only 14% did not require rehospitalization, whereas 48% were readmitted on ‡ 5 occasions [28]. Previous studies have evaluated risk factors for hospital readmission in COPD patients. Retrospective investigations have shown that social and psychological variables, low forced expiratory volume in 1 second (FEV1), poor performance status, and previous admission for COPD are associated with a greater risk of readmission [29,30]. Prospective studies have found that factors related to a higher risk of readmission include a lower quality of life as measured by the St. George’s Respiratory Questionnaire [30-32], and a lower than usual physical activity or FEV1 stratified according to the European Respiratory Society and Global Obstructive Lung Disease scales [33]. Previous hospitalization within 1 year is a well-known risk factor for future rehospitalization with acute exacerbation of COPD [12,32,34]. An inverse relationship has been found between alcohol use and FEV1 [35], although several studies indicate that modest alcohol intake may actually decrease the rate of FEV1 decline [36,37]. Alcohol has been identified as an

346

S. B. Hijjawi et al.

Postgrad Med, 2015; 127(4):343–348

Table 4. Univariate analysis between patients not readmitted and those readmitted within 30 days of AECOPD (n = 160). Patients not readmitted (n = 129, 80.7%), n (%)

Patients readmitted (n = 31, 19.3%), n (%)

66.07 (12.23) 28.89 (8.92) n = 126 3.10 (3.04) 53.26 (16.45) n = 46

66.55 (13.54) 26.05 (9.51) n = 30 3.77 (4.36) 50.75 (7.98) n = 12

0.8483 0.1236

29.22 (5.34)

29.97 (4.18)

0.4662

Male Female White Black Hispanic Medicare Medicaid Others No Yes Retired No Yes

60 (46.6) 69 (53.4) 104 (80.7) 21 (16.2) 4 (3.1) 85 (65.8) 10 (7.8) 34 (26.4) 37 (28.7) 38 (29.5) 54 (41.9) 89 (69) 40 (31)

15 (48.4) 16 (51.6) 18 (58.1) 12 (38.7) 1 (3.2) 23 (74.2) 2 (6.4) 6 (19.4) 2 (6.4) 13 (42) 16 (51.6) 25 (80.6) 6 (19.4)

0.7036

No Yes No Yes No Yes No Yes No Yes No Yes No Yes

116 (90) 13 (10) 106 (82.1) 23 (17.9) 42 (32.6) 87 (67.4) 101 (78.2) 28 (21.8) 100 (77.5) 29 (22.5) 119 (92.2) 10 (7.8) 67 (52.3) 61 (47.7)

27 (87.1) 4 (12.9) 22 (71) 9 (29) 10 (32.3) 21 (67.7) 19 (61.3) 12 (38.7) 24 (77.4) 7 (22.6) 20 (64.5) 11 (35.5) 20 (64.5) 11 (35.5)

No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes

127 (99.2) 1 (0.8) 12 (9.4) 116 (90.6) 39 (30.5) 89 (69.5) 109 (85.2) 19 (14.8) 108 (84.4) 20 (15.6) 18 (14.1) 110 (85.9) 36 (28.1) 92 (71.9) 81 (63.3) 47 (36.7) 43 (33.6) 85 (66.4)

30 (96.8) 1 (3.2) 2 (6.5) 29 (93.5) 10 (32.3) 21 (67.7) 23 (74.2) 8 (25.8) 25 (80.6) 6 (19.4) 3 (9.7) 28 (90.3) 10 (32.3) 21 (67.7) 23 (74.2) 8 (25.8) 13 (41.9) 18 (58.1)

Variable Mean age (SD), years Mean BMI (SD), kg/m2 n = 156 Mean LOS (SD), days Mean ABG PCO2 (SD), mm Hg n = 58 Mean chemistry CO2 (SD) Demographic features Gender

Postgraduate Medicine Downloaded from informahealthcare.com by Nanyang Technological University on 08/25/15 For personal use only.

Race Insurance Employed Married Comorbidities Asthma Congestive heart failure Hypertension Coronary artery disease Cancer Alcohol abuse Active smokerc Medications on discharge Long-acting b-agonistc Short-acting b-agonistc Short-acting muscarinic antagonist

c

Long-acting muscarinic antagonistc Inhaled corticosteroidsc Oral steroidsc Antibiotics

c

Oxygenc Outpatient follow-upc

p value

0.4207 0.4575

0.0166a 0.5035 0.0185a 0.2062 0.7444 0.1551 0.9958 0.0468b 0.9739 < 0.0001b 0.2219 0.3529 1.0000 0.8465 0.1447 0.6144 0.7679 0.6489 0.0002b 0.3529

a

p value from Fisher exact test. p value from X2 test. c n = 159. This variable is missing on one patient among those not readmitted. Abbreviations: ABG = Arterial blood gas; AECOPD = Acute exacerbation of chronic obstructive pulmonary disease; BMI = Body mass index; LOS = Length of stay; SD = Standard deviation. b

independent predictor of peripheral edema in patients with COPD [38], but was not found to be an independent marker of COPD-related hospitalization [39]. Furthermore, alcohol use has been identified as a significant predictor of COPD mortality [40]. However, a prospective study in a veterans’

outpatient population based on subjective assessment of drinking habit found no increased risk of COPD exacerbation independent of tobacco use [41]. This study included a typical veterans population consisting mainly of men, and therefore generalization to the whole community is problematic.

COPD readmissions

Postgraduate Medicine Downloaded from informahealthcare.com by Nanyang Technological University on 08/25/15 For personal use only.

DOI: 10.1080/00325481.2015.1015394

We found the odds of 30-day readmission was 2.17 (95% CI, 1.16–4.09) in patients with alcohol abuse even after adjusting for active tobacco use. Our study results are representative of both sexes, as women constituted > 50% of the population, unlike the studies that used veterans and thus had lower female populations. However, sex had no statistically significant effect on AECOPD readmissions. Blacks constituted 20% of our study population but were more likely to be readmitted than other patients. However, multivariate analysis found this factor to be insignificant. In one study, PaCo2 ‡ 45 mm Hg (hypercapnia) at the time of hospital discharge was found to be a predictor of subsequent readmissions [32]. Although the presence of hypercapnia during exacerbation has been considered an indicator of a poor prognosis [7], some patients develop hypercapnia only during an acute exacerbation and revert to normocapnia during recovery; prognosis in these patients with reversible hypercapnia was similar to that in normocapnic patients [42,43]. Measuring CO2 in serum chemistry reflects the degree of bicarbonate (HCO3). This value is usually elevated with hypercapnia but its interpretation is complex if the patient is on diuretics due to metabolic alkalosis. In our study data, hypercapnia was not a significant prediction for subsequent readmissions. Oxygen therapy is a mainstay in AECOPD treatment and long-term oxygen therapy (LTOT) is the cornerstone of treatment in patients with severe COPD, a measure shown to improve survival in hypoxemic patients. Adherence to LTOT ranges from 45% to 70%, and utilization for > 15 hours per day is widely accepted as efficacious. Although several studies have addressed the level of patient adherence to LTOT, few have suggested or evaluated interventions that enhance compliance [44]. In our study, we found that readmission is more likely for those on O2 supplement (odds ratio, 2.52). This difference could be due to the fact that such patients have more severe disease or due to poor compliance with the O2 therapy, a factor not addressed here. An earlier study found that patients who had an outpatient follow-up visit post–COPD admission had a significantly reduced risk for subsequent ER visits and readmission [45]. In our study, we found that almost all of the patients discharged from the hospital had a scheduled outpatient follow-up appointment, which reflects provider awareness of the importance of continued care for AECOPD after discharge to prevent readmission. Failure to schedule follow-up in an outpatient setting postdischarge is a potentially modifiable risk factor. Other interventions, such as home visits, telephone follow-up, and use of mobile technologies to connect with patients postdischarge, should be considered for patients who are unable to keep their clinic appointments for whatever reason. Limitations We examined only readmission to our hospital and may have underestimated the true 30-day readmission rate of our study population. However, 19.4% is within the national benchmark of reported rates for COPD and other common causes of

347

rehospitalization [17]. Information on transthoracic echo, pulmonary function test, and lab results was not available for all patients. This study did not include information on quality of life, compliance with medications or supplemental oxygen, psychosocial issues, or social determinants of health. In addition, we did not evaluate the reasons for failure to keep a clinic follow-up appointment or to respond to other types of followup such as home health visits and phone calls. Finally, this is a retrospective cohort study from a single institution with a small sample size over a 1-year period; results from such studies should be applied with caution. Recommendations and clinical implications Patient factors are important as US health systems continue to work on improving system and provider factors to reduce 30-day readmissions. Using an electronic health record to identify patients at high risk of readmission will help tailor the resources to those most in need.

Conclusion In our study population, 19.4% of AECOPD patients were readmitted within 30 days. Patient factors (such as alcohol abuse and advanced disease) were associated with 30-day readmission.

Acknowledgment The authors would like to thank Yue Wang, MS, for her assistance in the statistical analysis.

Declaration of interest The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

References [1] Hoyert DL, Xu JQ. Deaths: preliminary data for 2011. Natl Vital Stat Rep 2012;61:1–52. [2] Wier LM, Elixhauser A, Pfuntner A, Au DH. Overview of Hospitalizations among Patients with COPD, 2008: Statistical Brief No. 106. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. 2011. Available from http://www.ncbi.nlm.nih.gov/books/ NBK53969/. [3] National Heart, Lung, and Blood Institute. Morbidity and mortality: 2002 chartbook on cardiovascular, lung, and blood diseases. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 2002. [4] Sethi S. Bacteria in exacerbations of chronic obstructive pulmonary disease: phenomeno or epiphenomenon? Proc Am Thorac Soc 2004;1:109–14. [5] Patil SP, Krishnan JA, Lechtzin N, Diette GB. In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Intern Med 2003;163:1180–6. [6] Groenewegen KH, Schols AMWJ, Wouters EFM. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD. Chest 2003;124:459–67.

Postgraduate Medicine Downloaded from informahealthcare.com by Nanyang Technological University on 08/25/15 For personal use only.

348

S. B. Hijjawi et al.

[7] Connors AF Jr, Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med 1996;154:959–67. [8] Ai-Ping C, Lee K-H, Lim T-K. In-hospital and 5-year mortality of patients treated in the ICU for acute exacerbation of COPD: a retrospective study. Chest 2005;128:518–24. [9] Almagro P, Calbo E, Ochoa de Echaguen A, et al. Mortality after hospitalization for COPD. Chest 2002;121:1441–8. [10] Spencer S, Calverley PMA, Burge PS, Jones PW. Impact of preventing exacerbations on deterioration of health status in COPD. Eur Respir J 2004;23:698–702. [11] Seemungal TA, Donaldson GC, Paul EA, et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157:1418–22. [12] Donaldson GC, Seemungal TAR, Bhowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002;57:847–52. [13] Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest 2000;117:398S–401S. [14] Halpern MT, Stanford RH, Borker R. The burden of COPD in the U.S.A.: results from the Confronting COPD survey. Respir Med 2003;97:S81–9. [15] Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest 2000;117:5S–9S. [16] Strassels SA, Smith DH, Sullivan SD, Mahajan PS. The costs of treating COPD in the United States. Chest 2001;119:344–52. [17] Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418–28. [18] Sharif R, Cuevas CR, Wang Y, et al. Guideline adherence in management of stable chronic obstructive pulmonary disease. Respir Med 2013;107:1046–52. [19] Bahadori K, FitzGerald JM. Risk factors of hospitalization and readmission of patients with COPD exacerbation – systematic review. Int J Chron Obstruct Pulmon Dis 2007;2:241–51. [20] Oddone EZ, Weinberger M, Horner M, et al. Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions. J Gen Intern Med 1996;11:597–607. [21] Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. American Thoracic Society. Am J Respir Crit Care Med 1995;152:S77–S121. [22] McGhan R, Radcliff T, Fish R, et al. Predictors of rehospitalization and death after a severe exacerbation of COPD. Chest 2007;132:1748–55. [23] Murata GH, Gorby MS, Kapsner CO, et al. A multivariate model for the prediction of relapse after outpatient treatment of decompensated chronic obstructive pulmonary disease. Arch Intern Med 1992;152:73–7. [24] Roberts CM, Lowe D, Bucknall CE, et al. Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax 2002;57:137–41. [25] Garcia-Aymerich J, Farrero E, Felez MA, et al. Risk factors of readmission to hospital for a COPD exacerbation: a prospective study. Thorax 2003;58:100–5. [26] Lau AC, Yam LY, Poon E. Hospital re-admission in patients with acute exacerbation of chronic obstructive pulmonary disease. Respir Med 2001;95:876–84. [27] Vega Reyes JA, Montero Perez-Barquero M, Sanchez Guijo P. Assessing COPD-associated morbidity: factors of prognosis. Med Clin (Barc) 2004;122:293–7.

Postgrad Med, 2015; 127(4):343–348

[28] Cydulka RK, McFadden ER, Emerman CL, et al. Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1997;156: 1807–12. [29] Stehr DE, Klein BJ, Murata GH. Emergency department return visits in chronic obstructive pulmonary disease: the importance of psychosocial factors. Ann Emerg Med 1991;20:1113–16. [30] Osman IM, Godden DJ, Friend JA, et al. Quality of life and hospital re-admission in patients with chronic obstructive pulmonary disease. Thorax 1997;52:67–71. [31] Miravitlles M, Guerrero T, Mayordomo C, et al. Factors associated with increased risk of exacerbation and hospital admission in a cohort of ambulatory COPD patients: a multiple logistic regression analysis. The EOLO Study Group. Respiration 2000;67: 495–501. [32] Almagro P, Barreiro B, Ochoa de Echaguen A, et al. Risk factors for hospital readmission in patients with chronic obstructive pulmonary disease. Respiration 2006;73:311–17. [33] Tsoumakidou M, Tzanakis N, Voulgaraki O, et al. Is there any correlation between the ATS, BTS, ERS and GOLD COPD’s severity scales and the frequency of hospital admissions? Respir Med 2004;98:178–83. [34] Lusuardi M, Blasi F, Terzano C, et al. Standards of care and clinical predictors in patients hospitalised for a COPD exacerbation – the Italian SOS (Stratification Observational Study). Monaldi Arch Chest Dis 2009;71:153–60. [35] Garshick E, Segal MR, Worobec TG, et al. Alcohol consumption and chronic obstructive pulmonary disease. Am Rev Respir Dis 1989;140:373–8. [36] Cohen BH, Celentano DD, Chase GA, et al. Alcohol consumption and airway obstruction. Am Rev Respir Dis 1980;121:205–15. [37] Tabak C, Smit HA, Heederik D, et al. Diet and chronic obstructive pulmonary disease: independent beneficial effects of fruits, whole grains, and alcohol (the MORGEN study). Clin Exp Allergy 2001;31:747–55. [38] Jalleh R, Fitzpatrick MF, Jan MA, et al. Alcohol and cor pulmonale in chronic bronchitis and emphysema. BMJ 1993;306: 374–4. [39] Garcia-Aymerich J, Monso E, Marrades RM, et al. Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study. Am J Respir Crit Care Med 2001;164: 1002–7. [40] Tabak C, Smit HA, Rasanen L, et al. Alcohol consumption in relation to 20-year COPD mortality and pulmonary function in middleaged men from three European countries. Epidemiology 2001;12: 239–45. [41] Greene CC, Bradley KA, Bryson CL, et al. The association between alcohol consumption and risk of COPD exacerbation in a veteran population. Chest 2008;134:761–7. [42] Costello R, Deegan P, Fitzpatrick M, McNicholas WT. Reversible hypercapnia in chronic obstructive pulmonary disease: a distinct pattern of respiratory failure with a favorable prognosis. Am J Med 1997;102:239–44. [43] Haidl P, Clement C, Wiese C, et al. Long-term oxygen therapy stops the natural decline of endurance in COPD patients with reversible hypercapnia. Respiration 2004;71:342–7. [44] Katsenos S, Constantopoulos SH. Long-term oxygen therapy in COPD: factors affecting and ways of improving patient compliance. Pulm Med 2011;2011:325362. [45] Sharma G, Kuo Y-F, Freeman JL, et al. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med 2010;170:1664–70.

Chronic obstructive pulmonary disease exacerbation: A single-center perspective on hospital readmissions.

Chronic obstructive pulmonary disease (COPD) is the third most common cause in the United States of hospital readmission within 30 days of discharge. ...
209KB Sizes 0 Downloads 6 Views