Factors Associated with Differential Readmission Diagnoses Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease
BACKGROUND: Readmissions after exacerbations of chronic obstructive pulmonary disease (COPD) are penalized under the Hospital Readmissions Reduction Program (HRRP). Understanding attributable diagnoses at readmission would improve readmission reduction strategies.
OBJECTIVES: Determine factors that portend 30-day readmissions attributable to COPD versus non-COPD diagnoses among patients discharged following COPD exacerbations.
DESIGN, SETTING, AND PARTICIPANTS: We analyzed COPD discharges in the Nationwide Readmissions Database from 2010 to 2016 using inclusion and readmission definitions in HRRP.
MAIN OUTCOMES AND MEASURES: We evaluated readmission odds for COPD versus non-COPD returns using a multilevel, multinomial logistic regression model. Patient-level covariates included age, sex, community characteristics, payer, discharge disposition, and Elixhauser Comorbidity Index. Hospital-level covariates included hospital ownership, teaching status, volume of annual discharges, and proportion of Medicaid patients.
RESULTS: Of 1,622,983 (a weighted effective sample of 3,743,164) eligible COPD hospitalizations, 17.25% were readmitted within 30 days (7.69% for COPD and 9.56% for other diagnoses). Sepsis, heart failure, and respiratory infections were the most common non-COPD return diagnoses. Patients readmitted for COPD were younger with fewer comorbidities than patients readmitted for non-COPD. COPD returns were more prevalent the first two days after discharge than non-COPD returns. Comorbidity was a stronger driver for non-COPD (odds ratio [OR] 1.19) than COPD (OR 1.04) readmissions.
CONCLUSION: Thirty-day readmissions following COPD exacerbations are common, and 55% of them are attributable to non-COPD diagnoses at the time of return. Higher burden of comorbidity is observed among non-COPD than COPD rehospitalizations. Readmission reduction efforts should focus intensively on factors beyond COPD disease management to reduce readmissions considerably by aggressively attempting to mitigate comorbid conditions.
© 2020 Society of Hospital Medicine
CONCLUSION
Our study highlights the importance of understanding comorbidity as a major determinant of readmissions following COPD exacerbations, particularly in distinguishing which patients will return for COPD versus non-COPD-related diagnoses. At the health system level, readmission programs should be designed with the multimorbid patient in mind. Engagement of care teams, facilitating communication, and shared decision making are strategies to mitigate readmission risk in addition to COPD-focused disease management.39 These data highlight the need to use risk prediction tools in assigning resources to reduce readmissions,45 as well as the need to move readmission reduction programs beyond COPD management alone. Developing such systems to prospectively identify which patients are at risk of returning for both COPD and non-COPD reasons may further elucidate readmission mitigation strategies and should be a subject of future prospective study.
Acknowledgments
Data were made available through the Agency for Healthcare Research and Quality’s Healthcare Utilization Project. A full list of partner organizations providing data for the Nationwide Readmission Database can be found at https://www.hcup-us.ahrq.gov/db/hcupdatapartners.jsp.
Prior Presentation
Portions of this work were presented in abstract form at the 2018 American Thoracic Society International Conference (May 2018, San Diego, CA). This manuscript is derived from the doctoral dissertation for the degree of PhD in Health Policy and Management of the corresponding author, conferred in June 2019.
Disclaimer
This article does not necessarily represent the views and policies of the Department of Veterans Affairs or the USPSTF.
