Proactive, virtual intervention improves quality of life after discharge for COPD exacerbation

A pragmatic health system-level intervention improved quality of life for patients discharged after COPD exacerbation but failed to reduce 180-day readmission or mortality, researchers reported.

“Despite national policy efforts to drive improvement, most patients discharged after COPD do not receive care known to improve health outcomes for COPD, and there is scant evidence that overall quality of care has improved,” David H. Au, MD, MS, professor in the department of medicine at the Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, and colleagues wrote in the American Journal of Respiratory and Critical Care Medicine.

The stepped-wedge clinical trial included 365 primary care providers and 352 patients after hospital discharge for COPD exacerbation from two Department of Veteran Affairs medical centers and 10 outpatient clinics. Researchers reviewed health records and designed treatment recommendations given to PCPs. The pragmatic health system-level intervention involved the intervention team meeting to review COPD recommendations and common comorbid conditions each week via virtual consultation. Recommendations were entered as unsigned orders for uptake that could be accepted, modified or canceled. Providers and patients made final treatment decisions.

The primary outcomes were quality of life measured by the Clinical COPD Questionnaire score and readmission and/or mortality at 180 days after discharge. The secondary outcome was the Veterans RAND 12-Item Health Survey physical component score.

Fifty-four percent of patients were in the control group and 45.7% of patients were assigned the pragmatic health system-level intervention.

Researchers reported a significantly better Clinical COPD Questionnaire score among individuals in the intervention group (adjusted OR = –0.47; 95% CI, –0.85 to –0.09).

However, there was no reduction in 180-day readmission and/or mortality (aOR = 0.83; 95% CI, 0.49-1.38).

Of the 161 patients in the intervention group, researchers entered 519 recommendations as unsigned orders, with 77.3% of these recommendations endorsed by PCPs.

Researchers observed no significant differences between the control group and the intervention group regarding generic health status with the Veterans RAND 12-Item Health Survey (control, 29.92 vs. intervention, 33.25).

“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 researchers wrote. “Additional work is needed to challenge current models of providing specialty care, focusing on expanding the reach and impact at population levels.”