Implementation of Standardized Care Path for COPD Exacerbations

ABSTRACT

Introduction: Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) is a major cause of hospitalization and re-admissions. Lack of standardized management and non-adherence to guideline-directed treatment may lead to poor outcomes and increase cost. Interventions implemented by health systems to reduce readmissions have had varied success. Heterogeneity in the target patient population is a significant challenge. The Cleveland Clinic COPD Care Path consists of an admission order set that incorporates multi-disciplinary management, evidence-based medications, and postdischarge integrated care. In this study, we examined impact of this Care Path on quality metrics and 30-day readmissions of patients with proven COPD on spirometry. Methods: We studied patients with spirometry proven persistent airflow obstruction (postbronchodilator FEV1/FVC<70) admitted to the general nursing floor with AECOPD during the 3 years prior to the COVID pandemic (February 2, 2017 to January 31, 2020), excluding those who left against medical advice, hospice and transplant patients. Patient's Care Path status (On vs Off), age, gender, BMI, baseline lung function and comorbidities were recorded. We measured process metrics such as appropriate use of antibiotics and corticosteroids, and post-discharge integrated disease management (rates of prescribing long-acting bronchodilator, follow-up appointments). 30-day readmission rate, length of stay (LOS) observed to expected (O E) ratio and cost per case were recorded. For continuous variables, we used means and standard deviations and the ANOVA test for statistical analysis. For categorical variables, percentages, and the t- test were used. The level of statistical significance was set at p < 0.05. Results: Of the total of 857 patients with airflow obstruction, the Care Path was utilized in 52.8% and 21.94% were readmitted within 30 days. Lower re-admissions were associated with lower comorbidity index and completed follow-up appointments. Lung function, long acting bronchodilator prescription and cost or length of index hospitalization did not affect readmission. The care path was utilized more among patients with lower FEV1/FVC ratio but less in patients with concomitant heart failure. Use of the care path was associated with more follow-up appointments (scheduled and completed), long-acting bronchodilator prescription on discharge, lower cost but not length of stay. On-Care-Path patients did not have a reduced risk of readmission on univariate analysis. Conclusions: The findings from this retrospective study of patients with spirometry proven COPD suggest that using standardized care path for AECOPD hospitalizations is associated with lower cost and facilitates transitions of care. However, length of stay and 30-day readmission rates are unaffected. (Figure Presented).