A recently study found that 74% of patients with chronic obstructive pulmonary disease (COPD) admitted to the hospital 2 or more times per year have unmet social determinants of health (SDOH) needs. Longitudinal intervention with such patients by a health care worker led to fewer readmissions but no improvements in mortality or health-related quality of life. These findings were recently published in BMC Pulmonary Medicine.
A mixed methods quality improvement initiative was undertaken by researchers from Boston Medical Center (BMC), a safety-net hospital for patients of low socioeconomic status, after a BMC program designed to reduce COPD readmissions was found to be ineffective. Researchers identified patients with unmet SDOH needs who were then followed by a nurse practitioner/community health worker team through one month post-discharge.
The researchers identified 1811 adults age 18 years or older admitted to BMC hospital or the clinical observation unit for COPD between January 1 and December 31, 2018. The investigators then screened these patients’ medical records for SDOH needs using a standardized instrument, the THRIVE screening tool. After a pilot program was instituted for those patients with unmet SDOH needs, the investigators gathered further data from nurse practitioner and community health worker logs and qualitative interviews.
Of the 1811 patients admitted with COPD in 2018, 776 (42.8%) had 2 or more admissions (median 2), with a median of 12 total days in hospital (interquartile range 6 to 22 days). Patients insured by Medicaid had 70% higher odds of 2 or more admissions (adjusted odds ratio [AOR], 1.7; 95% CI, 1.1-2.7). Patients with the following comorbidities also had higher odds of 2 or more admissions: mental health disorders (AOR, 1.5; 95% CI, 1.1- 1.9), cardiac disease (AOR, 2.0; 95% CI, 1.5-2.8) and substance use disorders (AOR, 1.8; 95% CI, 1.4-2.4).
A total of 70 patients were identified from a list of patients scheduled in clinic after hospital discharge. Of these, 19 (27%) could not be reached. Another 9 patients did not meet the criteria of 2 or more admissions per year. In all, 74% (31/42) screened positive for unmet SDOH needs. In general, 87.0% (27/31) expressed interest in getting help with resources, and 75% (24/32) communicated interest in meeting a community health care worker to address their needs.
Factors impacting COPD self-management included social isolation, anxiety, depression, smoking, substance abuse, comorbidities, housing and food insecurity, lack of transportation to medical appointments, education needs, unemployment, difficulty paying for medications or utilities, caregiver issues, and a limited understanding of COPD.
Strengths of this study include its mixed-methods approach, which informed the development and evaluation of the quality improvement initiative, and a focus on the understudied population of COPD patients frequently admitted to a safety-net hospital. Limitations were the small sample size and the single site used, which restricts generalizability, as well as volunteer participants who may not have reflected the views of all COPD patients.
“In this study we show it is essential for COPD discharge bundles in hospitals serving marginalized populations to address how SDOH and comorbidities influence COPD self-management,” the authors wrote. “Our longitudinal [nurse practitioner/community health worker] intervention appears to be a feasible and acceptable strategy to intervene on these factors,” they add.
Kearney L, Wiener RS, Dahodwala M, et al. A mixed methods study to inform and evaluate a longitudinal nurse practitioner/community health worker intervention to address social determinants of health and chronic obstructive pulmonary disease self-management. BMC Pulm Med. 2022;22(1):74. doi:10.1186/s12890-022-01863-w