Factors Associated with Differential Readmission Diagnoses Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease
BACKGROUND: Readmissions after exacerbations of chronic obstructive pulmonary disease (COPD) are penalized under the Hospital Readmissions Reduction Program (HRRP). Understanding attributable diagnoses at readmission would improve readmission reduction strategies.
OBJECTIVES: Determine factors that portend 30-day readmissions attributable to COPD versus non-COPD diagnoses among patients discharged following COPD exacerbations.
DESIGN, SETTING, AND PARTICIPANTS: We analyzed COPD discharges in the Nationwide Readmissions Database from 2010 to 2016 using inclusion and readmission definitions in HRRP.
MAIN OUTCOMES AND MEASURES: We evaluated readmission odds for COPD versus non-COPD returns using a multilevel, multinomial logistic regression model. Patient-level covariates included age, sex, community characteristics, payer, discharge disposition, and Elixhauser Comorbidity Index. Hospital-level covariates included hospital ownership, teaching status, volume of annual discharges, and proportion of Medicaid patients.
RESULTS: Of 1,622,983 (a weighted effective sample of 3,743,164) eligible COPD hospitalizations, 17.25% were readmitted within 30 days (7.69% for COPD and 9.56% for other diagnoses). Sepsis, heart failure, and respiratory infections were the most common non-COPD return diagnoses. Patients readmitted for COPD were younger with fewer comorbidities than patients readmitted for non-COPD. COPD returns were more prevalent the first two days after discharge than non-COPD returns. Comorbidity was a stronger driver for non-COPD (odds ratio [OR] 1.19) than COPD (OR 1.04) readmissions.
CONCLUSION: Thirty-day readmissions following COPD exacerbations are common, and 55% of them are attributable to non-COPD diagnoses at the time of return. Higher burden of comorbidity is observed among non-COPD than COPD rehospitalizations. Readmission reduction efforts should focus intensively on factors beyond COPD disease management to reduce readmissions considerably by aggressively attempting to mitigate comorbid conditions.
© 2020 Society of Hospital Medicine
Readmissions following hospitalization for exacerbations of chronic obstructive pulmonary disease (COPD) are common and economically burdensome.1 The Affordable Care Act2 outlined the Hospital Readmissions Reduction Program (HRRP),3 which aims to improve the quality of care and reduce the costs for patients with pneumonia, myocardial infarction, congestive heart failure, and COPD.3 With the implementation of the HRRP, readmission reduction has become a key priority of health systems.
Multiple approaches to reduce readmissions are published, with variable degrees of success across respiratory and all-cause rehospitalizations.4 Patient self-management programs are heterogenous with inconsistent utilization reductions.5-7 While some transitional care programs demonstrate benefits,8-10 one notable study of an intensive transitional care and self-management program showed increaseNod acute care utilization without improving health-related quality of life.11-13 Another study of COPD comprehensive care management was stopped prematurely for increased mortality in the intervention group.14 Telehealth monitoring may predict exacerbations,15,16 but inconsistent effects on quality of life and utilization are observed.17,18 Pulmonary rehabilitation improves quality of life but not healthcare utilization.19 Dispensing respiratory medications at hospital discharge shows improved prescription fills and fewer readmissions,20 further reinforced by inhaler training prior to discharge.21 Postdischarge oxygen therapy does not improve health-related quality of life or acute care utilization.22 The fact that these approaches have not reliably succeeded raises the need for further study on the drivers of readmissions in COPD. Previous studies found differences in factors associated with the timing of COPD readmissions and return diagnoses.23,24 While HRRP is Medicare-specific, health systems likely use programs targeting their entire population when planning readmission reduction strategies. Previous analyses were primarily single-center studies25 and Medicare24 or private insurance claims.26
In this analysis, we explore how comorbidity burden27-29 may differentially influence readmissions for recurrent COPD exacerbations versus other diagnoses. Our approach uses a national all-payer sample that covers a diverse geographic area across the United States, providing robust estimates of factors influencing readmission and valuable insights for planning and implementing effective readmission reduction programs. By including data from a period that encompasses the implementation of HRRP, we also provide new information on the factors in the HRRP postimplementation that are not yet available in published literature.
