Comorbidities May Wipe Out Value of Follow-up Visits in Preventing Readmissions for COPD

Follow-up exams shortly after discharge for an acute exacerbation of chronic obstructive pulmonary disease (COPD) didn't reduce a patient's risk of hospital readmission, which was more likely to hinge on whether the person had comorbidities, according to a study in Chronic Obstructive Pulmonary Diseases.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the Diagnosis, Management, and Prevention of Obstructive Lung Disease 2017 report suggested that management of COPD must include identification and treatment of comorbidities. Patients with COPD often suffer from multiple comorbidities that are associated with poor prognoses, increased healthcare costs, and worse overall health. While previous studies have shown that benefits of rapid follow-ups had the most significant impact on patients with multiple comorbidities, patients who were most likely to attend a follow-up appointments were receiving care at small, non-teaching, for-profit hospitals, which could have an incentive to bill for the appointment.

Researchers conducted the study to determine whether follow-up appointments soon after discharge from large hospitals could lower the risk of all-cause 30-day readmission among COPD patients, particularly for those with multiple comorbidities.

Researchers retrospectively examined electronic health records of all acute exacerbation of COPD (AECOPD)-related hospitalizations from patients who were at least 40 years old and were treated between June 2011 to June 2016 at a large, urban, academic medical center. Diagnoses of AECOPD were determined by International Classification of Diseases (ICD)-9 or ICD-10-CM coding. Records of hospitalizations were excluded if they resulted in patient death, transfer between hospitals, discharge against medical advice, or discharge to hospice care. The study defined a follow-up as a visit to a primary care provider or any medical subspecialist within 10 days of discharge.

Researchers adjusted for demographics, payer status, use of tobacco and aclohol and the number of chronic conditions defined by the Charlson Comorbidity Index (CCI), or early follow-up appointments had an effect on the risk of readmission. Researchers calculated the cumulative proportion of 30-day readmissions that occurred each day after discharge.

Researchers did not find an association between early follow-up appointments and the risk of 30-day readmission. However, the study found that comorbidities were predictors of readmission risk. Out of 2653 hospital discharges, 468 patients, or 17.7%, were readmitted within 30 days. A total of 644 individuals, or 24.3% attended a follow-up appointment within 10 days of discharge. Patients with a CCI of at least 2 were more likely to be readmitted than with a lower index.

In the study, 32% of readmissions occurred by day 7. “This high proportion of patients admitted within the first week suggests that an intervention targeted at early follow-up may already be too late,” researchers said.

Researchers suggested that utilization of intervention techniques is the most effective way to lower the risk of readmission.

“This study is a reminder of the need for a comprehensive approach to COPD. While short-term follow up may benefit some patients, interventions such as patient/caregiver education, pulmonary rehabilitation, advice on smoking cessation, inhaler use, and an exacerbation action plan, are likely the best approach to reduce readmission risk,” researchers concluded.

Reference

Budde J, Agarwal P, Mazumdar M, Braman SS. Follow-up soon after discharge may not reduce COPD readmissions. Chronic Obstr Pulm Dis. 2019;6(2):129-131. doi: 10.15326/jcopdf.6.2.2018.0149.