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People with chronic obstructive pulmonary disease (COPD) experience long-term progressive damage to their lungs which worsens airflow and typically leaves a person short of breath. Patients with COPD frequently experience acute worsening in their breathing, called an acute exacerbation of COPD (AECOPD). AECOPDs are a known predictor of COPD disease progression, overall mortality and have a significant impact on the health care system. Patients hospitalized for AECOPD are at increased risk of hospitalization readmission in the next 30 to 90 days. Preventing readmissions after hospitalized AECOPDs can improve quality of life for patients and reduce healthcare utilization.

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The VCAG project includes Brad Drummond, MD, MHS, (top), Michael Rydberg, MD (bottom), Hitesh Patel, MD, and Beth Dowdy, RT.

The Reasons for Hospital Readmissions After COPD Flare Are Complex

AECOPD readmissions, like many other chronic illnesses with acute worsening, are complex in origin. The broad drivers of readmissions include factors related to patients, inpatient discharging providers, outpatient receiving providers, and overall systems. One of the biggest challenges to reducing readmissions after AECOPD is identifying patients admitted for AECOPD in real time to provide timely interventions. These challenges exist because the diagnostic and billing codes typically used to identify patients are not available until the patient is already discharged, and admission complaints are often too non-specific.

Brad Drummond, MD, MHS, associate professor in the division of pulmonary diseases and critical care medicine, is leading a Value-Care Action Group Project to reduce 30- and 90-day readmissions among patients with inpatient admissions for diagnosis of COPD exacerbation. Healthcare systems are particularly interested in AECOPD readmissions because the average cost per AECOPD readmission is between $9,000 and $12,000. By averaging the CMS and internal UNC AECOPD cost estimates, Drummond calculates that every 1% reduction in AECOPD rate can save UNC Medical Center approximately $11,600. As a result, interventions that target AECOPD reduction have the potential to directly impact cost of care as well as patient well-being.

Identifying Modifiable Drivers to Reduce AECOPD Readmissions

“The primary intervention uses a novel EPIC-based algorithm to identify AECOPD patients in real time combined with expansion of an existing COPD Educator Program currently supported by the Respiratory Therapy Department,” Drummond says. “The initial goal is to optimize an EPIC algorithm that uses a combination of admission medication orders specific for AECOPD combined with key text phrase searches to identify AECOPD patients at time of admission. This allows for timely consultation by the COPD educator to fully assess the patient’s risk factors for readmission. To further support the COPD educator, we are also able to send a message to the primary team outlining key recommendations shown to reduce COPD readmissions.”

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High-value is defined by the quality of patient-centered care achieved per unit of cost, derived from measuring health outcomes against the cost of delivering the outcomes.

Drummond, with Hitesh Patel, MD, third-year fellow in pulmonary medicine, and Michael Rydberg, MD, internal medicine resident, are collaborating with Beth Dowdy, RT, in Respiratory Therapy, who has spearheaded a COPD Educator Program since August 2020 to assess COPD patients and provide individualized COPD self-management education to patients and caregivers. These take place over two to three sessions during hospitalization. Sessions focus on assessment (history, symptom burden, goals), COPD education, inhaler technique and exacerbation education.

Failure to recognize a hospitalized AECOPD as a significant health event has been associated with poor future outcomes. This lack of recognition often leads to discharging teams failing to up-titrate inhaled therapies at the time of hospital discharge for AECOPD. Data shows that failure to up-titrate inhaled therapies at the time of discharge as well as securing timely follow-up may be important and modifiable drivers that can reduce AECOPD readmissions.

Value Care Action Group

This project is one of many Value Care Action Group improvement efforts taken up by the department of medicine. Champions in each medicine division are currently encouraging the review of current practices, looking for improvements for high-value outcomes in healthcare. High-value is defined by the quality of patient-centered care achieved per unit of cost derived from measuring health outcomes against the cost of delivering the outcomes. Ron Falk, MD, chair of the department created the group in 2016. Scott Keller is the director of business development keeping the team focused on value-oriented care models. Darren DeWalt, MD, functions as medical director for the team and helps define the projects. John Vargas is the project manager.