Intensive Intervention to Improve Outcomes for Patients With COPD.

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic conditions contributing to morbidity andmortality. In 2016, it was the third leading cause of years of life lostanddiasbility-adjusted life-years in theUnitedStates, with an estimated 164 000 deaths. Even with aggressive inpatient management, patientswho are hospitalized for COPDoften experience a recurrent cycle of rehospitalizations, resulting in reductions in overall health andquality of life (QOL).Tohelp interrupt this cycle, the Centers for Medicare &Medicaid Services incorporated COPD into the Hospital Readmission Reduction Program, which financially penalizes hospitals with high riskadjusted readmissions. The ensuing interest in COPD readmissionshas generatednumerous clinical trials that have examined different readmission reduction strategies, although this research has often produced conflicting results, andmany studies have failed to demonstrate benefit of transitional care or chronic disease self-management programs. Clinicians and health systems are left with limited guidance for how to manage this common disease. In this issue of JAMA, Aboumatar and colleagues report findings from a single-site randomized clinical trial of a tailored 3-month intervention that integrated transitional care support and chronic disease self-management. Compared with patients who received usual care (n = 120), patients who received the intervention (n = 120) had a robust reduction in subsequent COPD-related acute care events (hospitalization and emergency department visits at 6 months: mean of 1.4 events vs 0.72 events per patient in the usual care and intervention groups, respectively) and mitigation of declining health-related QOL (worsening of 5.44 points in the usual care group vs improvement of 1.53 points in the intervention group). One explanation for the improvement in QOL outcomes was that these were mediated through prevention of acute care events. The secondary outcome of all-cause acute care events was also significantly lower among patients in the intervention group compared with patients in the control group at longer follow-up periods (mean of 2.43 events vs 1.94 events per patient), although the differences in 30-day all-cause readmission (a common focus for hospital readmission reduction efforts) were not statistically significant. Given these encouraging results, clinical and administrative leaders may wonder whether the intervention should be adopted in their hospitals. Several relevant questionsmay inform this decision, including: “Why was this intervention so effective, when other COPD trials have inconsistently shown benefit, andsomehaveeven increased the riskofharm?”“How similar are the patient population and clinical setting of this study to local contexts?” “Do the costs associatedwith the intervention provide sufficient value in terms of future health care resource utilization and quality of life?” Unique characteristics of the study by Aboumatar et al may have contributed to the success of the intervention. The study combined COPD transitional care support and longterm self-management. Hospitalizations represent a vulnerable event for patients and caregivers, who may be more receptive to educational and behavioral interventions. In this sense, transitional care support may be an important factor that engages patients as they develop lifestyle changes that reinforce appropriate disease management. For instance, study nurses with special training in supporting patients delivered the intervention, which emphasized essential elements of COPD care, such as inhaler education, smoking cessation, breathing techniques, and developing an action plan to address signs and symptoms of exacerbations. However, the self-management intervention did not include provision of antibiotics or steroids for self-medication of exacerbations, a practice that in one prior study increased the risk for mortality. Rather, patients were instructed to contact clinicians when they developed respiratory symptoms. The authors attribute the success of the intervention to intensive features that differentiate this study from other studies, including engaging patients during hospitalization, providing continuity with the nurse across the continuum of care, and offering home or telephone outreach. These characteristics may have helped the intervention succeed, but the result can be time and resource intensive. Patients in the intervention group had a mean of 6 sessions with a study nurse that lasted more than 20 minutes each. No costeffectiveness analysis accompanied this study, although a less-intensive COPD intervention was estimated to cost $250000 per hospital to pay for nurse staffing, physician support, and patient outreach materials. Existing financial incentives from the Hospital Readmission Reduction Program are focused on addressing all-cause 30-day readmissions, an outcome that was not significantly affected by the study intervention. A shift from fee-for-service to valuebased care payment models, such as those integrated into accountable care organizations and risk-based commercial contracts, may encourage some health systems to adopt costly interventions that prevent health care utilization, although administrators will need to consider the specific cost-benefit trade-offs for their system. Related article page 2335 Opinion