Care Quality for Patients with Chronic Obstructive Pulmonary Disease in the Readmission Penalty Era

Abstract

Rationale: Chronic obstructive pulmonary disease (COPD) is the fifth-leading cause of admissions and third-leading cause of readmissions among U.S. adults. Recent policies instituted financial penalties for excessive COPD readmissions. Objectives: To evaluate changes in the quality of care for patients hospitalized for COPD after implementation of the Hospital Readmissions Reduction Program (HRRP). Methods: We conducted a retrospective cohort study of patients older than 40 years of age hospitalized for COPD across 995 U.S. hospitals (Premier Healthcare Database). Measurements and Main Results: Quality of care before and after HRRP implementation was measured via adherence to recommended inpatient care treatments for acute exacerbations of COPD (recommended care, nonrecommended care, "ideal care" [all recommended and no nonrecommended care]). We included 662,842 pre-HRRP (January 2010-September 2014) and 285,508 post-HRRP (October 2014-December 2018) admissions. Recommended care increased at a rate of 0.16% per month pre-HRRP and 0.01% per month post-HRRP (P < 0.001). Nonrecommended care decreased at a rate of 0.15% per month pre-HRRP and 0.13% per month post-HRRP. Ideal care increased at a rate of 0.24% per month pre-HRRP and 0.11% per month post-HRRP (P < 0.001). Conclusions: The pre-HRRP trends toward improving care quality for inpatient COPD care slowed after HRRP implementation. This suggests that financial penalties for readmissions did not stimulate higher quality of care for patients hospitalized with COPD. It remains unclear what policies or approaches will be effective to ensure high care quality for patients hospitalized with COPD exacerbations.

Keywords: chronic obstructive pulmonary disease; health policy; patient readmission; quality of health care.

Figure 1.

Definitions of ideal care, recommended care, and nonrecommended care. Quality of care was evaluated by comparing the treatment of patients with chronic obstructive pulmonary disease with the 2017 Global Initiative for Chronic Obstructive Lung Disease guidelines and guidelines established by the American College of Physicians and the American College of Chest Physicians in 2017.

Figure 2.

Flow diagram for the Premier Healthcare Database to identify pre- and post-HRRP COPD inpatient admissions. *COPD admission is inpatients older than 40 years of age admitted with an International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification, code with a primary diagnosis of COPD or a primary diagnosis of respiratory failure with a secondary code for COPD. **Exclusions based on patients with incomplete demographic information and patients with a secondary diagnosis of pneumonia. COPD = chronic obstructive pulmonary disease; HRRP = Hospital Readmissions Reduction Program.

Figure 3.

Interrupted time series analysis for chronic obstructive pulmonary disease quality of care from 2010 through 2018. This figure depicts segmented regression for ideal care, recommended care, and nonrecommended care from January 2010 through September 2014 and October 2014 through December 2018. The dotted vertical line in the graph depicts the month in which the Hospital Readmissions Reduction Program implemented a penalty for excessive readmission of patients with chronic obstructive pulmonary disease.

Figure 4.

Trends in chronic obstructive pulmonary disease (COPD) treatment from 2010 through 2018. Each panel in this figure depicts the trend in administration of a defined element of COPD care from 2010 through 2018. The dashed line in each panel represents the implementation of the Hospital Readmissions Reduction Program penalty for COPD readmissions (October 2014).