Reducing the Number of Hospitalization Days for COPD: Setting up a Transmural-Care Pathway

Abstract

Background: Many patients with chronic obstructive pulmonary disease (COPD) experience exacerbations of symptoms, leading to a large burden on patients and the health system and costs to society. To address this burden, a 25% reduction in number of hospitalization days for COPD exacerbations was recently declared a national goal in the Netherlands, to be achieved in 5 years.

Methods: A national care pathway was designed following an established managed clinical pathway setup, which involved prior national surveys and the identification of ten key elements. The concept was discussed, made locally applicable, and finally tested in eight regions containing eleven hospitals and surrounding primary-care groups in a prospective cohort study. All patients were followed for 1 year, starting at hospitalization.

Results: In total, 752 patients gave informed consent and participated (mean age 70 years, 58% female). Of these, 120 (16%) died within a year. The median length of index hospitalization was 5 days, and 43% had at least one rehospitalization within 1 year (range 0-8). There was a 19.4% reduction in number of total hospitalization days, without a decrease in health-related quality of life or perceived quality of care. Elements that contributed significantly to the reduction were contact in the first week after hospitalization, and during the year of follow-up pharmacological and nonpharmacological smoking-cessation guidance, checks on inhalation technique, and discussion of lung-attack plan.

Discussion: With concerted action between patients and health workers in the hospital and in the community, a large reduction in number of hospitalization days can be achieved. The program was quite demanding for both patients and health workers. In our subsequent national implementation plan after this pilot study, we have named the major contributors to success and advocate the stepwise introduction of the elements in light of feasibility.

Keywords: COPD; National Action Program; hospitalization; managed-care pathway.

Figure 1

Number of days hospitalized in 1 year (including index hospitalization).

Figure 2

Number of hospitalizations in 1 year (including index hospitalization).

Figure 3

Variability in patient contact per region in the first week after discharge. Dark blue bars represent percentage of patients contacted in the first week after discharge, light blue percentage of patients for whom this contact was a home visit.

Figure 4

Overall change in COPD-admission days and COPD=readmission numbers between 2013 and 2018 per region and total. Dark blue bars represent percentage change in admission days; light blue percentage change in readmissions.