Kris Vanhaecht

In-hospital care pathways for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease: From statistical significance to clinically relevance

For the treatment of chronic obstructive pulmonary disease (COPD), an international widely accepted guideline, Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) is available. However, patients in different patient groups still receive suboptimal care, and studies showed that teams can enhance their interprofessional collaboration and coordination. To improve the care for patients with a COPD exacerbation, the European Pathway Association (www.E-P-A.org) launched the European Quality of Care Pathways (EQCP) study. This study started in 2007 and included hospitals from Belgium, Italy and Portugal. The aim of this study was to evaluate the impact of care pathways (CPs) on variation in care, adherence to guidelines, patient outcomes and teamwork for patients admitted with a COPD exacerbation. CPs are defined as ‘complex interventions for the mutual decision making and organization of predictable care for a well-defined group of patients during a well-defined period’. In general, this EQCP study learned us two things regarding the reduction in length of stay and readmission rates for patients with a COPD exacerbation. First, the implementation of this in-hospital CP led to significantly reduced 30-day readmission rates (in the CP group, 9.7% of the patients were readmitted within 30 days, while in the control group, 15.3% were readmitted). The CP had no significant impact on length of stay (12.0 days in the CP group compared to 12.4 days in the control group) or on six-month readmission rate (27.3% in the CP group compared to 33.0% in the control group). This significant reduction in 30-day readmission rates is important for hospitals, as based on the worldwide data of the World Health Organization, this effect is expected to lead to a reduction of approximately four million readmissions. Second, although a golden standard is available, a significant number of patients still receive underuse. This was visualized by an importance-performance analysis. In importance-performance analysis, the importance rate, based on guidelines or international Delphi results, is plot against the performance rate, measured as process indicators on adherence to guidelines. Care activities with high importance but low performance are high priorities for hospitals. Based on the EQCP data before the implementation of our CP, hospitals should have five high priorities, these priorities are performed in less than 20% of the patients, and are (i) smoking cessation intervention in active smokers at admission, (ii) adequate discharge management, (iii) performance of revalidation tests during the past year, (iv) education regarding inhaler therapy in patients for whom inhaler therapy is prescribed and (v) education regarding home oxygen therapy in patients for whom home oxygen is prescribed. The impact of these care activities on COPD is not only a direct effect but mainly an indirect effect. To improve the care patients receive, behavioural change by both the patient and the interprofessional team is needed. Receiving adequate information and advice is a first step in behavioural change and