Extra postdischarge COPD care review improved quality of life, not other outcomes

Providing postdischarge treatment recommendations to primary care clinicians for patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with better quality of life but no improvement in survival or readmission rates, a recent study found.

Researchers performed a stepped-wedge clinical trial at two Veterans Affairs medical centers and 10 outpatient clinics to test whether an interdisciplinary virtual review of patients discharged after hospitalization for COPD exacerbation would improve quality of life and reduce all-cause readmission or mortality at 180 days. Primary care clinicians and their patients were enrolled after hospital discharge. Patients' health records were reviewed by a multidisciplinary team, who developed treatment recommendations and delivered them electronically to primary care clinicians. All recommendations were entered as unsigned orders that could be accepted, modified, or canceled, and final treatment decisions were made by primary care clinicians and patients. The study results were published by the American Journal of Respiratory and Critical Care Medicine on March 24.

Patients were scheduled to see a primary care clinician within two weeks of hospital discharge. Three hundred sixty-five clinicians were enrolled in the study, and over 30 months, 352 patients met the eligibility criteria, 191 (54.3%) in the control group and 161 (45.7%) in the intervention group. Five hundred nineteen recommendations were entered as unsigned orders in the intervention group, and 401 (77.3%) were endorsed. Patients in the intervention group had scores that were clinically significantly better for quality of life as measured by the Clinical COPD Questionnaire six weeks after discharge (adjusted difference, −0.47 [95% CI, −0.85 to −0.09], with 52.6% of outcomes missing) but did not have lower rates of readmission or mortality at 180 days (adjusted odds ratio, 0.83; 95% CI, 0.49 to 1.38), partly because confidence intervals were wide.

Among other limitations, the researchers noted that their trial was underpowered for the outcomes of readmission and mortality and that this may have contributed to the null effect for both. They concluded that a pragmatic health system-level intervention that delivered proactive, specialty-supported care after hospitalization for COPD exacerbation improved quality of life but did not reduce 180-day readmissions or death. “In contrast to studies that have suggested harm associated with interventions to reduce 30-day readmission, we suggest that less intense interventions that tailor therapy to patient's clinical context performed in the setting of ongoing care relationships may produce meaningful clinical benefit from the patient perspective,” the authors wrote. “Additional work is needed to challenge current models of providing specialty care, focusing on expanding the reach and impact at population levels.”