Retrospective Assessment of Home Ventilation to Reduce Rehospitalization in Chronic Obstructive Pulmonary Disease

Abstract

Background: Healthcare systems are attempting to reduce hospital readmissions due to chronic obstructive pulmonary disease (COPD).

Methods: A retrospective study of a quality improvement (QI) program performed at a single center whose multifaceted intervention included nocturnal administration of advanced positive airway pressure (PAP) modality (or noninvasive positive pressure ventilation [NIPPV]) called averaged volume assured pressure support (AVAPS-AE) initiation by a respiratory therapist (RT), medication reconciliation by a pharmacist, adequate provision of oxygen, and ongoing RT-led care. In this QI program, consecutive patients who had been hospitalized twice in a single year with an acute COPD exacerbation underwent such interventions after they met specific selection criteria.

Results: Three-hundred ninety-seven consecutive patients were eligible for the program because they had two or more hospitalizations in the previous year. The proportion of patients who were readmitted on two or more occasions decreased from 100% (397 of 397) in the year prior to initiation of intervention to 2.2% (9 of 397) in the following year (χ(2) = 758, p < 0.0001). Seventy patients died over the one year following initiation of the multifaceted intervention. A composite outcome of rehospitalization and death was associated with inhaled steroids (adjusted odds ratio [adjOR] of 2.13; 95% confidence interval [CI] 1.09, 4.17; p = 0.02), whereas inhaled antimuscarinics tended to be associated with less risk for rehospitalization or death (adjOR 0.56; 95% CI 0.34, 1.03; p = 0.06).

Conclusion: In a retrospective cohort study of a QI initiative undertaken at a single center, we have observed that a multifaceted intervention that involved initiation of nocturnal advanced PAP (NIPPV) modality, RT-led respiratory care, medication reconciliation, appropriate oxygen therapy initiation, and patient education led to significant reduction in rehospitalization.

Keywords: Intermittent Positive-Pressure Ventilation; chronic obstructive pulmonary disease; hospitalization; positive airway pressure; readmission.

Figure 1. Unadjusted odds ratios of determining variables with a composite dependent variable of rehospitalization and death (dependent variable) are shown.

Increased risk for hospitalization and death is towards the right and reduced risk is depicted by the arrow towards the left of the vertical dashed line which indicates an odds ratio of 1.0. *p value < 0.05. ^#p value < 0.10. PAP therapy, positive airway pressure therapy; CAD, coronary artery disease; HF, heart failure; DM, diabetes mellitus; HTN, hypertension; SABA, short acting β-agonists; LABA, long acting β-agonists. Please see Table 3 for more details.

Figure 2. Adjusted odds ratios of determining variables with a composite dependent variable of rehospitalization and death (dependent variable) are shown.

Increased risk for hospitalization and death is towards the right and reduced risk is depicted by the arrow towards the left of the vertical dashed line which indicates an odds ratio of 1.0. *p value < 0.05. ^#p value < 0.10. PAP therapy, positive airway pressure therapy; CAD, coronary artery disease; HF, heart failure; DM, diabetes mellitus; HTN, hypertension; SABA, short-acting β-agonists; LABA, long-acting β-agonists. Please see Table 4 for more details.