Seppo T. Rinne

Impact of Multisystem Health Care on Readmission and Follow-up Among Veterans Hospitalized for Chronic Obstructive Pulmonary Disease.

Background: Chronic obstructive pulmonary disease (COPD) is one of the most common causes of readmission at Veterans Affairs (VA) hospitals. Previous studies demonstrate worse outcomes for veterans with multisystem health care, though the impact of non-VA care on COPD readmissions is unknown. Objective: To examine the association of use of non-VA outpatient care with 30-day readmission and 30-day follow-up among veterans admitted to the VA for COPD. Design: This is a retrospective cohort study using VA administrative data and Medicare claims. Subjects: In total, 20,472 Medicare-eligible veterans who were admitted to VA hospitals for COPD during October 1, 2008 and September 30, 2011. Measures: We identified the source of outpatient care during the year before the index hospitalization as VA-only, dual-care (VA and Medicare), and Medicare-only. Outcomes of interest included any-cause 30-day readmission, COPD-specific 30-day readmission and follow-up visit within 30 days of discharge. We used mixed-effects logistic regression, controlling for baseline severity of illness, to examine the association between non-VA care and postdischarge outcomes. Results: There was no association between non-VA care and any-cause readmission. We did identify an increased COPD-specific readmission risk with both dual-care [odds ratio (OR)=1.20; 95% confidence interval (CI), 1.02–1.40] and Medicare-only (OR=1.41; 95% CI, 1.15–1.75). Medicare-only outpatient care was also associated with significantly lower rates of follow-up (OR=0.81; 95% CI, 0.72–0.91). Conclusions: Differences in disease-specific readmission risk may reflect differences in disease management between VA and non-VA providers. Further research is needed to understand how multisystem care affects coordination and other measures of quality for veterans with COPD.

Organizational Practices Affecting Chronic Obstructive Pulmonary Disease Readmissions

Chronic obstructive pulmonary disease (COPD) contributes to more than 700,000 hospitalizations annually in the United States, and approximately 20% of patients are readmitted within 30 days (1, 2). To control costs and improve quality, the Center for Medicare and Medicaid Services implemented the Hospital Readmission Reduction Program (HRRP), which financially penalizes hospitals with high readmission rates for select conditions, including COPD (3). Despite pressure to improve COPD care, few organizational practices have been shown to reduce COPD readmissions (4). Moreover, no studies have examined the effectiveness of organizational practices to reduce COPD readmission across multiple hospitals. Results of this study were previously presented as an abstract (5).

Phosphodiesterase-5 Inhibitor Therapy for Pulmonary Hypertension in the United States. Actual versus Recommended Use.

Rationale: Care of patients with pulmonary hypertension is complex. Although pulmonary vasodilators are effective for Group 1 pulmonary hypertension, clinical guidelines and the Choosing Wisely Campaign recommend against routine use for Groups 2 and 3 pulmonary hypertension (the most common types of pulmonary hypertension) because of a lack of benefit, potential for harm, and high cost (

Implementation of guideline-based therapy for chronic obstructive pulmonary disease: Differences between men and women veterans

10,000‐

Impact of Guideline Changes on Indications for Inhaled Corticosteroids Among Veterans with COPD

13,000 per patient per year treated). Little is known about how these medications are used in practice. Objectives: To determine national patterns of phosphodiesterase‐5 inhibitor prescribing for pulmonary hypertension in the Veterans Health Administration. Methods: Retrospective analysis of Veterans prescribed phosphodiesterase‐5 inhibitor for pulmonary hypertension between 2005 and 2012 at any Veterans Health Administration site. Patients were identified by presence of an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for pulmonary hypertension and one or more outpatient prescriptions for daily phosphodiesterase‐5 inhibitor therapy. We developed and validated, using gold‐standard chart abstraction, an International Classification of Diseases, Ninth Revision, Clinical Modification‐based algorithm to assign pulmonary hypertension group. Our primary outcome was the proportion of patients who received potentially inappropriate phosphodiesterase‐5 inhibitor, as determined by guideline recommendations (Group 1 pulmonary hypertension: appropriate; Groups 2/3: potentially inappropriate; Groups 4/5: uncertain value), among all patients prescribed phosphodiesterase‐5 inhibitor for pulmonary hypertension. Secondary outcomes included proportion of treated patients who received guideline‐recommended right heart catheterization. Results: Among 108,777 Veterans with pulmonary hypertension, 2,790 (2.6% [95% confidence interval, 2.5‐2.7%]) received daily phosphodiesterase‐5 inhibitor therapy. Among treated patients, 541 (19.4% [95% confidence interval, 18.0‐20.9%]) received appropriate treatment, 1,711 (61.3% [95% confidence interval, 59.5‐63.1%]) potentially inappropriate treatment, and 358 (12.8% [95% confidence interval, 11.6‐14.1%]) treatment of uncertain value. The number of potentially inappropriately treated patients per year increased substantially over the study period (53 in 2005, 748 in 2012). On the basis of chart abstraction in a randomly selected subset of patients treated with phosphodiesterase‐5 inhibitor, half (110 of 230, 47.8% [95% confidence interval, 41.3‐54.5%]) had documented right heart catheterization to confirm presence or type of pulmonary hypertension. After factoring presence of and data from right heart catheterization into our treatment appropriateness algorithm, only 11.7% (95% confidence interval, 8.0‐16.8%) received clearly appropriate treatment. Conclusions: Most Veterans with pulmonary hypertension do not receive phosphodiesterase‐5 inhibitor therapy. However, among treated Veterans, almost two‐thirds of phosphodiesterase‐5 inhibitor prescriptions are inconsistent with pulmonary hypertension guidelines, exposing patients to potential harm and creating a financial burden on the healthcare system. Further study is warranted to clarify the effects of these prescription patterns on pulmonary hypertension outcomes.

Hospital Administrators’ Perspectives on Physician Engagement: A Qualitative Study

Chronic obstructive pulmonary disease (COPD) is common among both men and women, and guidelines recommend the same therapy for both sexes. While previous studies have identified gender differences in other chronic disease management, few studies have examined how implementation of COPD guidelines differs between men and women. We performed a cross-sectional study of veterans admitted to Veterans Affairs (VA) hospitals for COPD during October 1, 2008, to September 30, 2011. We collected information on baseline COPD medications during the 6 months prior to hospitalization and categorized therapies as “appropriate” or “inappropriate” based on current guidelines. We used multivariable logistic regression to examine the differences in COPD medications between men and women, after controlling for baseline patient characteristics. We also examined the differences in hospital outcomes, including length of stay and hospital readmission. We identified 33,558 veterans, including 1149 women and 32,409 men who were admitted to 130 VA hospitals. Women were significantly less likely to have received inhaler therapies prior to admission, with lower rates of short-acting beta agonists, short-acting muscarinic antagonists, long-acting beta agonists, and long-acting muscarinic antagonists compared to men. Women also received fewer appropriate inhaler combinations (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.74–0.93) and more inappropriate combinations (OR = 1.33, 95% CI 1.17–1.51). Women and men were prescribed similar rates of inhaled steroid and oral steroids. Hospital outcomes were also similar between the two groups. These findings highlight a potential gender disparity in appropriate outpatient COPD therapy. Improving the quality of care for patients with COPD should include equitable implementation of guideline-based COPD management.

Chronic Obstructive Pulmonary Disease Readmissions and Other Measures of Hospital Quality

This letter was reposted with corrections on September 13, 2018.

Organizational structure for chronic heart failure and chronic obstructive pulmonary disease.

BACKGROUND OBJECTIVE DESIGN, SETTING, PATIENTS INTERVENTION MEASUREMENTS CONCLUSIONS

Management of Comorbid Chronic Obstructive Pulmonary Disease and Cardiovascular Disease. Moving Past the Agony of the β-Receptor Debate

Rationale: The Centers for Medicare and Medicaid Services recently implemented financial penalties to reduce hospital readmissions for select conditions, including chronic obstructive pulmonary disease (COPD). Despite growing pressure to reduce COPD readmissions, it is unclear how COPD readmission rates are related to other measures of quality, which could inform efforts on common organizational factors that affect high‐quality care. Objectives: To examine the association between COPD readmissions and other quality measures. Methods: We analyzed data from the 2015 Centers for Medicare and Medicaid Services annual files, downloaded from the Hospital Compare website. We included 3,705 hospitals nationwide that had publically reported data on COPD readmissions. We compared COPD readmission rates to other risk‐adjusted measures of quality, including readmission and mortality rates for other conditions, and patient reports about care experiences. Measurements and Main Results: There were modest correlations between COPD readmission rates and readmission rates for other medical conditions, including heart failure (r = 0.39; P < 0.01), acute myocardial infarction (r = 0.30; P < 0.01), pneumonia (r = 0.38; P < 0.01), and stroke (r = 0.29; P < 0.01). In contrast, we found low correlations between COPD readmission rates and readmission rates for surgical conditions, as well as mortality rates for all measured conditions. There were significant correlations between COPD readmission rates and all patient experience measures. Conclusions: These findings suggest there may be common organizational factors that influence multiple disease‐specific outcomes. As pay‐for‐performance programs focus attention on individual disease outcomes, hospitals may benefit from in‐depth assessments of organizational factors that affect multiple aspects of hospital quality.