Among patients who are hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), use of an evidence-based COPD transition bundle with a care-coordinator is associated with mixed results — decreasing 7-day and 30-day hospital readmissions, but increasing length of stay (LOS) in the hospital and emergency department (ED) revisits. These were among the results of a multicenter cohort study published in the journal Chest.
The researchers’ primary objective was to explore the effectiveness of a COPD transition bundle with or without a care-coordinator, on rates of rehospitalizations and ED revisits. This bundle included: demonstration of proper inhaler technique; discharge plan and discharge summary sent to family physician; optimization of respiratory prescriptions; referral to pulmonary rehabilitation; screening for comorbid conditions; and smoking cessation referral as appropriate. A secondary study objective was to examine the impact of the transition bundle on care continuity following hospital discharge. The investigators therefore conducted a clinical trial (ClinicalTrials.gov identifier: NCT03358771) with a nested randomized controlled trial (RCT) from February 2017 to June 2019 at 5 participating hospitals in Alberta, Canada.
The study enrolled 2 patient cohorts: (1) those offered the transition bundle group (ie, EXPLAIN); and (2) those who received usual care (ie, with no bundle offered). Patients in the transition bundle group were randomized to a care-coordinator. An AECOPD transition bundle was implemented in each of the participating hospitals, with all patients who were randomized to the care-coordinator contacted within at least 72 hours postdischarge.
Overall, 4140 patients who were admitted with clinical characteristics of an AECOPD were discharged from 1 of 5 of the implementation hospitals between February 2017 and June 2019. A total of 604 participants from 5 Alberta, Canada, hospitals in 3 cities who met eligibility criteria were enrolled in the current study — 320 with a care-coordinator arm and 284 not randomized to a care-coordinator and receiving routine care — whereas 3106 patients who were discharged from the same hospitals received usual care. The primary study outcomes were 7-day, 30-day, and 90-day hospital readmissions; median LOS; and 30-day ED revisits.
Individuals in the transition bundle cohort were 83% (relative risk [RR], 0.17; 95% CI, 0.07-0.35) less likely to be readmitted to the hospital within 7 days of discharge and were 26% (RR, 0.74; 95% CI, 0.60 to 0.91) less likely to be readmitted to the hospital within 30 days of discharge. Readmissions at 90 days, however, remained unchanged (RR, 1.05; 95% CI, 0.93-1.18).
Use of the transition bundle was associated with a 7.3% (RR, 1.07; 95% CI, 1.00 -1.15) relative increase in LOS and a 76% (RR, 1.76; 95% CI, 1.53-2.02) increased risk for experiencing a 30-day ED revisit. Use of a care-coordinator did not affect rates of readmissions or ED revisits.
Limitations of the current study include the fact that as a clinical trial conducted within a real-world setting, a true RCT was impossible to perform. A cohort with a nested RCT design was utilized, which led to unbalanced comparisons and an RCT that was underpowered.
The investigators concluded that future research should include an assessment of the intensity of care-coordinator/patient interaction needed for change, the reticence of health care providers to use the bundle, and the dependability of implementation of the elements of the bundle.
Atwood CE, Bhutani M, Ospina MB, et al. Optimizing COPD acute care patient outcomes using a standardized transition bundle and care-coordinator: a randomized clinical trial. Chest. Published online April 8, 2022. doi:10.1016/j.chest.2022.03.047