Pilot Program
Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions
A chronic obstructive pulmonary disease care service improves timely access to follow-up care and patient education at the time of transition from...
Data Collection
A standardized questionnaire was used prospectively for patients in the transitional care program group to assess patient education, primary residence, presence of a caregiver, fall history, medication adherence, and cognitive status (using Mini-Cog).13 Additional information (patient age, number of outpatient medications prior to and following the admission, presence of Beers criteria outpatient medications prior to and following the admission, new outpatient prescriptions, and changes to existing prescriptions as a result of the hospitalization) was gathered prospectively from patient interviews or from chart review.
For patients included in the comparison group, a retrospective administrative chart review was conducted to collect information such as age, sex, ethnic group, admission within 1 year prior to index admission, frailty, and Charlson Comorbidity Index (CCI) score, a method of categorizing comorbidities of patients based on the diagnosis codes found in administrative data.14 Each comorbidity category has an associated weight (from 1 to 6), based on the adjusted risk of mortality or resource use, and the sum of all the weights results in a single comorbidity score for a patient (0 indicates no comorbidities; higher scores predict greater risk of mortality or increased resource use).
We used the index developed from 17 disease categories. The range for CCI was 0 to 25. Frailty was defined as the presence of any of the following frailty-related diagnoses: anemia; fall, head injury, other injury; coagulopathy; electrolyte disturbance; or gait disorder. These diagnoses are either primary frailty characteristics within the frailty phenotype or have been shown in prior studies to be associated with the frailty phenotype.15-18 While more widely accepted frailty definitions exist,these other definitions require direct examination of the patient and could not be used in this project because we did not directly interact with the comparison group.16,19 The frailty definition used has been previously identified as a predictor of health care utilization and 30-day readmission in a veteran population.20 Whether or not the CPS detected a postdischarge medication error was recorded. All CPS recommendations were documented.
An index admission was defined as a hospital admission that occurred during the project period. Thirty-day readmission was defined as a hospital admission that occurred within 30 days of the discharge date of an index admission. Each index admission was considered individually for readmission (yes vs no) even if it occurred in the same patient over the project period. A 30-day readmission was not considered an index admission. An admission that occurred after a 30-day readmission was considered a subsequent index admission. Patients who died in the hospital were not included in this analysis, as they would not have participated in the entire intervention.
Statistical Analysis
We compared characteristics between patients who received GMED and patients who never received GMED (comparison group). Generalized estimating equations (GEE) were used to determine whether the rate of 30-day readmission (yes vs no) in the transitional care program group differed from that of the comparison group. In our GEE analysis, we assumed a binomial distribution and the logit link to model the log-odds of readmission as a linear function of transitional care program status (yes vs no) and other covariates, including age, frailty, hospital admission within 1 year prior to the index admission, and CCI score as covariates. Thirty-day readmission status associated with each index admission was coded as 1 for a readmission within 30 days of the discharge date of the index admission, or 0 for no readmission within 30 days.