In-hospital care pathways for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease: From statistical significance to clinically relevance

For the treatment of chronic obstructive pulmonary disease (COPD), an international widely accepted guideline, Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) is available. ¹ However, patients in different patient groups still receive suboptimal care, and studies showed that teams can enhance their interprofessional collaboration and coordination. To improve the care for patients with a COPD exacerbation, the European Pathway Association (www.E-P-A.org) launched the European Quality of Care Pathways (EQCP) study. This study started in 2007 and included hospitals from Belgium, Italy and Portugal. The aim of this study was to evaluate the impact of care pathways (CPs) on variation in care, adherence to guidelines, patient outcomes and teamwork for patients admitted with a COPD exacerbation. CPs are defined as ‘complex interventions for the mutual decision making and organization of predictable care for a well-defined group of patients during a well-defined period’. ² In general, this EQCP study learned us two things regarding the reduction in length of stay and readmission rates for patients with a COPD exacerbation.^3,4

First, the implementation of this in-hospital CP led to significantly reduced 30-day readmission rates (in the CP group, 9.7% of the patients were readmitted within 30 days, while in the control group, 15.3% were readmitted). The CP had no significant impact on length of stay (12.0 days in the CP group compared to 12.4 days in the control group) or on six-month readmission rate (27.3% in the CP group compared to 33.0% in the control group). This significant reduction in 30-day readmission rates is important for hospitals, as based on the worldwide data of the World Health Organization, this effect is expected to lead to a reduction of approximately four million readmissions. ⁴

Second, although a golden standard is available, a significant number of patients still receive underuse. This was visualized by an importance-performance analysis. ³ In importance-performance analysis, the importance rate, based on guidelines or international Delphi results, is plot against the performance rate, measured as process indicators on adherence to guidelines. Care activities with high importance but low performance are high priorities for hospitals. Based on the EQCP data before the implementation of our CP, hospitals should have five high priorities, these priorities are performed in less than 20% of the patients, and are (i) smoking cessation intervention in active smokers at admission, (ii) adequate discharge management, (iii) performance of revalidation tests during the past year, (iv) education regarding inhaler therapy in patients for whom inhaler therapy is prescribed and (v) education regarding home oxygen therapy in patients for whom home oxygen is prescribed. ³ The impact of these care activities on COPD is not only a direct effect but mainly an indirect effect. To improve the care patients receive, behavioural change by both the patient and the interprofessional team is needed. Receiving adequate information and advice is a first step in behavioural change and self-management of the patient. These educational and self-management interventions can lead not only to lower hospitalization but also to improved health status. ¹ However, if we looked at our data after the implementation of a CP, we found that the implementation of our CP led only to significantly higher education regarding inhaler therapy in patients which inhaler therapy is prescribed (35.3% in the CP group compared to 9.1% in the control group) and higher nutritional assessment (63.8% in the CP group compared to 17.9% in the control group) ⁴ but had no significant impact on the other suggested priorities. We can conclude that the identified high priorities are still high priorities even after the implementation of a CP.

Based on the results of the EQCP study, we hypothesize that the effect of our CP on 30-day readmission rate is not only a direct effect but is also influenced by adherence to guidelines, as described above, as well as by team and organizational aspects. The fact that CPs have an impact on team aspects was already found in previous studies, showing that after the implementation of a CP, perceived level of organized care was significantly higher. ⁵ This was confirmed by the Belgian results on teamwork and adding a CP also led to significantly better team climate for innovation and lower risk of burnout. Lower risk of burnout was concluded from the fact that emotional exhaustion was significantly lower together with significant higher level of competence. ⁶

A limitation of this EQCP study is that the aim was to evaluate the in-hospital care. Through this limitation, the effect of our CP on long-term outcomes is limited. Cross boundary CPs, taken into account the patient centredness, should be developed and implemented to achieve results on long-term outcomes and increase the sustainability of the results. The focus of future research should be to increase the evidence of all the care activities involved in the care process, going from diagnostic phase until advance care planning and palliative care, as this may have an impact on short but also on long-term outcomes. By increasing the evidence, the care activities which lead to better care and patient outcomes can be identified, and organization can take actions to implement and sustain these care activities. To achieve better patient care, patient outcomes, and to improve and sustain integrated in-hospital care, the involved healthcare professionals, inside and outside hospital care, need to be identified and involved. We can conclude that through the implementation of our CP, the 30-day readmission rate was significantly reduced. The active components of our CP were feedback regarding the actual organization of care and teamwork, set of evidence-based key interventions and training in how to develop and implement CP based on the seven-phase methodology.^4,7 However, full implementation of a CP, containing all the needed care activities, for the in-hospital management for patients admitted with an acute COPD exacerbation was not possible due to the fact that hospitals can only focus on a few care activities to improve and the evidence, content of the CP, which change. Thus, the implementation of a CP is a continuous process and standing still means practically going behind. Hospitals should continue to take actions to improve the patient care. The content of the CP should be evaluated every six months and the performance rate at least once a year. ⁷ To reduce the readmission rate and apply an appropriate length of stay, not only one care activity is responsible for this effect. We suggest that hospitals need to (1) support the team members in following the agreed standards of care and (2) launch initiatives on a combination of evidence-based care activities to improve the care patients receive, to better follow-up these care activities and to continue to reduce the short-term and long-term readmission rates. These initiatives will depend on the care activity itself and on the context of the organization. For some of the care activities, the perceived organization of care or team climate for innovation should be improved which can result in improving lower performed care activities. For other care activity, including an additional professional group can increase the performance rate for that care activity. For example, if the smoking cessation is low performed, the inclusion of a tabacologist can help to improve this performance rate for this care activity.

In general, hospitals should evaluate the care process at regular time moments but should not expect to achieve results on patient outcomes immediately. First the adherence to guidelines should be improved, by improving the fidelity regarding following the guidelines, and then the relevant patient outcomes can be improved. This was confirmed by the results of this study where we showed that the implementation of this CP for patients admitted with an acute exacerbation of a COPD exacerbation reduced the 30-day readmission rate only due to the fact that the CP improved the adherence to guidelines, on its own, reduced 30-day readmission rate. ⁸