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A study to investigate high readmission rates for COPD

Denise Gibbons, MA Adv Nurs Prac, Dip Care Respiratory Patients.

Respiratory Nurse Specialist

Chronic obstructive pulmonary disease (COPD) is a major cause of ill health and death in adults. COPD is an umbrella term for a group of diseases that include chronic asthma, chronic bronchitis and emphysema (Bourke and Brewis, 1999). At least 600 000 people in the UK have COPD, a prevalence of about 1% (Calverly and Bellamy, 2000). As the disease progresses, problems are compounded by episodes of acute exacerbations.

Chronic obstructive pulmonary disease (COPD) is a major cause of ill health and death in adults. COPD is an umbrella term for a group of diseases that include chronic asthma, chronic bronchitis and emphysema (Bourke and Brewis, 1999). At least 600 000 people in the UK have COPD, a prevalence of about 1% (Calverly and Bellamy, 2000). As the disease progresses, problems are compounded by episodes of acute exacerbations.An acute exacerbation is defined by the British Thoracic Society (BTS, 1997) as a worsening of a previous stable condition. Increase in symptoms such as cough, breathlessness and sputum production affect the patient’s ability to cope with simple activities of daily living.Acute exacerbations of COPD are one of the most common causes of acute hospital admission for a respiratory problem within the UK (Roberts et al, 2001). The cost to the NHS of caring for respiratory disease patients was estimated at 2.5 billion in the year 2000, with around two-fifths of these costs being for inpatient care (Respiratory Alliance, 2003). Although only an estimated 2% of the COPD population require admission to hospital, exacerbations account for up to 21% of all respiratory admissions, with a mean hospital stay of 10.3 days (Johnson and Stevenson, 2002). In addition, at least 34% of patients are readmitted within three months (Roberts et al, 2001).A readmission is an emergency admission to hospital within 28 days of discharge (DoH, 2002). Data is derived from completed patient discharge summary forms (PDS), which are input into trust patient administration systems. This, in turn, informs the national Hospital Episode Statistics (HES) database, which advises NHS trust level performance indicators.South Tyneside Health Care Trust rated significantly more poorly than the national average between 2001 and 2002, with a standardised readmission rate of 6.69% (DoH, 2002). Further analysis of the 2001 NHS trust data by an independent company demonstrated that readmission rates for patients with COPD were the highest among our peers.This study aims to explore why there is a high readmission rate for acute exacerbations of COPD within South Tyneside. It includes studying two identifiable outcomes - discharge planning and referral and hospital presentation data. The impact of the local acute respiratory assessment service (ARAS) on the management of COPD is also examined.

Methodology
We performed a retrospective study of readmissions with an acute exacerbation of COPD to South Tyneside District Hospital between 1 January 2001 and 31 December 2001.Problems around data accuracy were encountered. The hospital episode statistics data identified 65 readmission episodes. The ARAS staff also kept a database but the two datasets did not correspond, so the health records from both were examined.A data collection tool was designed to reflect the local discharge standard (Box 1). This was used to examine adherence to the standard for the initial discharge. The tool also collected data examining presenting clinical indicators to determine appropriateness of diagnosis on readmission (Box 2).A pilot study was undertaken to assess the reliability and validity of the data collection tool.

Results
Sample - There were significant problems with data accuracy regarding admission episodes. The final sample was found to be 61 COPD readmission episodes out of 406 discharges. This results in a readmission rate of 15%. This was generated by 24 patients:- 18 had single readmission episodes- Six had multiple readmissions, accounting for 43 out of 61 episodes.- Therefore 25% of the patients accounted for 70% of the readmission episodes (Figure 1).Patient demographics are shown in Table 1.Thirty episodes were readmitted via accident and emergency. Twenty-five episodes were self-referred via the ARAS. The remaining six were readmitted by their GP (Figure 2).Spirometry was performed to measure the forced expiratory volume in the first second (FEV1). This is used to classify the severity of COPD (BTS, 1997). Spirometry was unknown for three patient episodes (n=58); 95% were classified as severe COPD (FEV1 <40%) and 5% moderate COPD (FEV1 40-59%). The range of FEV1 on admission is shown in Table 2.Ten out of 24 patients had domiciliary long-term oxygen therapy (LTOT). The same 10 patients were also on home nebuliser therapy. A further two had intermittent oxygen therapy.Eleven patients lived alone but with informal or formal support. Eleven lived with their spouse or other relatives. One lived alone with no support and one lived in sheltered accommodation.The patients’ post codes were used to determine which council ward they lived in. Thirteen out of 20 council wards covered by the trust were inhabited by the sample of 24 patients. All but one were areas of high deprivation.Discharge standard - One readmission episode had to be excluded from the evaluation of this standard, as the relevant section in the health record could not be found. Of the remaining 60 episodes, five did not have ARAS support as they were not referred during the admission.There were 12 specific discharge criteria to meet (Box 1) for 60 episodes. These were examined for differences between episodes with and without the service’s intervention (Figures 3a-c)Results indicate that patients discharged with ARAS intervention achieved 94% of the discharge standard. For patients who did not have intervention, only 67% of the standard was achieved. This was largely attributable to quality of documentation.The most common criterion not achieved was that the patient’s chest X-ray was not normal. However, it was beyond the limitations of this study to investigate the significance of this finding. It may have been appropriate to discharge the patient with an abnormal chest X-ray if further investigations were to be performed.Six per cent of data items relating to discharge criteria could not be identified from the patients’ records. This was because the information had not been recorded and charts and reports were missing.Analysis of the results demonstrate that the most commonly unknown criteria were:- Respiration rate (21%)- Blood pressure (19%)- Pulse rate (16%)- Oxygen saturation (12%).Readmission data - Analysis of the criteria used to diagnose an acute exacerbation of COPD found that 58 episodes achieved one or more of the four diagnostic criteria (Box 2).Three episodes, despite being coded on the patient discharge summary forms as an acute exacerbation of COPD, did not achieve any of the criteria. In conclusion, the results suggested that 95% of the readmissions were in fact re-presenting with symptoms of an acute exacerbation.There was no correlation between episodes which had or had not achieved all of the discharge standard and time between readmission. Those patients who achieved the discharge standard had a mean of 14 days between admissions (range 2-26 days). Those who did not achieve the standard had a mean of 16 days (range 1-28 days). The mean for all episodes was 15 days.Sixty-one readmission episodes generated by 24 patients accounted for 240 bed days. The mean length of stay for the readmission was four days with a range between 0 and 14 days.

Discussion
This audit demonstrates that 240 bed days were attributed to a disproportionately small number of patients readmitted with an acute exacerbation of COPD. In fact, six patients accounted for 70% of the total readmissions.Standards based on national and local guide-lines were developed to communicate best practice and to try to ensure that all patients received optimal care. However the availability of these does not appear to have guaranteed improvement in patient management, unless managed by the ARAS team.There are a number of potential barriers to the use of clinical guidelines. First, the volume of guidelines available has become overwhelming. Second, if physicians have not participated in their development, they may feel no sense of ownership and may also perceive them as a threat to their competence or autonomy (Buist, 2002).Overall 91% of the discharge standard was achieved (Figure 3c). Results indicate that patients who have intervention from the service achieve a higher percentage of the discharge standard. Also, there was no significant difference in time between readmission for those patients who did not fulfil the discharge standard. These findings are supported by the National Institute for Clinical Excellence (2002), which did not find any evidence to demonstrate that setting a level of compliance to a specific standard necessarily leads to improvement in care. Therefore failure to reach a set standard must be evaluated carefully.One patient was discharged with oedema on three separate occasions and a different patient was discharged with tachycardia. It is well known that peripheral oedema is a common side-effect of oral corticosteroids, which are widely used to treat acute exacerbations of COPD. Also, it would not be uncommon for COPD patients to be tachycardic secondary to their beta2 agonist medication. It would therefore be difficult to know whether failing to achieve the standard impacted on the readmission rate in these cases.There are however, several well-documented risk factors for readmission for COPD patients (Garcia-Aymerich et al, 2001). They are:- Age- Severity of disease- Previous length of hospital stay- Mobility- The need for social support.It is difficult to identify one universal factor that may be used as a predictor of hospital admission. Also, it is unclear whether readmissions are due to incomplete resolution of the initial problem, the presence of co-morbidity or in some instances a general decline in health (Cydulka et al, 1997).Kessler et al (1999) identified a greater risk of hospitalisation for those patients requiring long-term oxygen therapy. A study by Sin and Tu (2000) indicated that elderly patients discharged within two days of admission had a 69% risk of being readmitted within two weeks of discharge. The risk of readmission declined progressively until a length of stay of five days or more.These findings are supported by outcomes from this local study. The average age of the patients was 74, 95% of the sample were categorised as having severe COPD, and 42% of the patients in this study were on long-term oxygen therapy. These risk factors for readmission may have impacted on the overall length of stay.The mean length of stay for COPD readmissions was four days. This is significantly lower than the national average of 10.3 days (Johnson and Stevenson, 2002). This could be attributed to the fact that 87% of the patients on readmission were managed by the assessment service. Nineteen per cent of these were discharged within 24 hours of readmission with home support.Nationally the rise in admission rates for patients with COPD prompted growing interest in the provision of home-care schemes for these patients. Evidence indicates that such schemes reduce overall length of hospital stay (Gibbons et al, 2001; Callaghan, 1998; Conway, 1998). Home support by nurses for patients discharged from hospital with acute exacerbations of COPD demonstrate improvement in patients’ knowledge of the disease and some aspects of functional status (Hermiz et al, 2002). Despite this, patients continue to be referred to hospital for readmission.Both patient and health-care provider factors may affect the pattern of hospital readmission. GPs may find it easier to admit the patient to hospital than to deal with an exacerbation in the community (Morgan, 2003).In a recent prospective study of COPD admissions in South Tyneside, 28% of patients had been seen by their GP within 72 hours of admission. This could be as a result of deterioration in the patient’s condition, or, perhaps, non-compliance by the GP with treatment guidelines.A study by the King’s Fund (2001) suggests that primary care should become proactive rather than reactive in managing these patients. It suggests that COPD patients should be identified in advance of the winter months, when there is more pressure on hospital beds. This would enable regular intervention by the primary health-care team, with weekly or fortnightly reviews if necessary to allow early intervention where appropriate.Despite the burden imposed upon the patient, the health service and society, COPD is not currently a priority in the national strategy for health. Although there is no National Service Framework (NSF) for COPD to guide those commissioning and providing respiratory services, nearly all of the patients would meet the criteria for the NSF for the Older Person (DoH 2001).A report by the Respiratory Alliance (2003) aims to encourage collaborative working between primary and secondary care to standardise care for COPD patients. It is hoped that this will enable real improvements by reducing the number of admissions and re-admissions as well as reducing health-care resource use.From a patient perspective, however, treatment success should not just be measured in relation to use of health-care resources but to overall quality of life, symptom control and mortality.Our study did not investigate outcomes which matter to patients and their care-givers. It has not taken into account the long-term effects an exacerbation can have on a patient’s quality of life and ability to perform activities of daily living.Self-care ability often reflects the severity of underlying disease (Lau et al, 2001). In one study 30% of patients had not been able to resume their normal mobility up to three months after discharge, and 65% of the patients were unable to do housework they could previously manage (Seemungal et al, 2000).This can place an added burden on families and carers, which may also have a bearing on the frequency of readmission (Osman et al, 1997; Lau et al, 2001; Willaert et al, 2002). Wives who are the care-givers of men with COPD have described feelings of anger, helplessness, guilt, depression and isolation (Bergs, 2002); 75% of all patients readmitted were male.Outcomes of the audit can be used in various ways - first, to improve the overall quality of care, and second, to improve the organisation of care. Findings should also be compared to national outcomes. We make a number of recommendations arising from our findings (Box 3).

Conclusion
A very few patients accounted for a disproportionately high readmission rate, despite good practice being followed. Importantly, there are no startling omissions in patient care to account for this.Six patients accounted for 70% of the readmissions. Identifiable risk factors for readmission such as age and severity of disease corresponded with previous findings. A greater understanding of the local COPD population has been achieved, which will inform future service developments.It may be that offering regular home visits to this small number of patients will result in an improvement in readmission rates for COPD within South Tyneside in the future. This practice has now started and will need evaluation.

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