Authors

1. Ersgard, Karen Bagger Dip, RN, MCN
2. Pedersen, Preben U PhD
3. Sorensen, Tina Brandt MD

Abstract

Review question/objective: This review aims to identify discharge interventions that can reduce readmission or prolong the time before the next readmission of patients with chronic obstructive pulmonary disease (COPD)

The specific review question is:

What is the impact of a structured planned discharge intervention for patients with chronic obstructive pulmonary disease after admission to hospital due to exacerbation in COPD.

Background: Chronic obstructive pulmonary disease is a preventable and treatable disease that is characterized by airflow limitation. Chronic obstructive pulmonary disease is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lungs to noxious particles or gases. Exacerbations and comorbidities are known to contribute to the overall severity in individual patients.1

Chronic obstructive pulmonary disease remains as a major public health problem worldwide. By 2020, it is projected that COPD will rank fifth globally in burden of diseases, according to a study published by the World Bank/World Health Organization.2

Depending on the stage of COPD, the illness will have a significant impact on the life of patients. Patients have to cope with physical symptoms such as breathlessness, reduced activity level and malnutrition. Patients often report isolation, loss of independence, reduced quality of life and depression.1 Additionally, COPD often coexists with other diseases that may have a significant impact on the prognosis.1

During the last 15 to 20 years, the development towards better treatment, rehabilitation, care and medication has taken massive steps forward, and the attitude towards this group of patients has changed: "a nihilistic attitude towards the patient with COPD is no longer justified".3^{(p 223)}. Instead, patients with COPD nowadays meet with well-informed, multidisciplinary and intersectional teams work together with the patient with the goal of helping and educating him/her to self-management, stable physical condition and to increase quality of life, as recommended by global initiative for chronic obstructive lung disease (GOLD).1

Many of these initiatives are based on the chronic care model (CMM) as defined by Wagner.4 The six components of this model are: organization of health care, self-management support, decision support, delivery system design, clinical information system, community resources and policies. The essential purpose of the model is to increase the quality of health care without increasing cost. The main issue is the patient-centered approach and then the model recommends systematic care planning, intersectional collaboration, patient empowerment, evidence-based care, and ongoing evaluation of humanistic, clinical and economic outcomes.4 In spite of these extensive efforts worldwide, patients are often readmitted after hospitalization due to acute exacerbations of COPD (AECOPD).

The number of AECOPD incidents has been estimated to be 0.6-3.5 per patient per year.5 A number of these patients have to be admitted/readmitted to hospital for instance because of the need for invasive or mechanical ventilation. The admission/readmission is necessary, despite the fact that admission caused by acute exacerbation has a negative impact on mortality, and a negative influence on the patients' quality of life and health care costs.5 The question of whether it is possible to prevent a number of the exacerbations and thereby some of the admissions remains. The focus of this study is on the effect of discharge initiatives as a preventing intervention.

Transition from hospital to home is not always easy, especially for elderly and chronically ill patients, and as the average length of hospital stay has decreased during the last decades,6 many initiatives are taken to meet this challenge. A preliminary literature search showed that there are a number of intervention studies, for example, on case management and action plans,7,8 that seem to have an impact on reducing readmission for patients with COPD. There was a systematic review concerning discharge interventions for mixed patient groups, which showed that combining discharge planning and discharge support tends to lead to the greatest effect on readmissions.6 A meta-analysis from Cochrane concluded that "The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in length of hospital stay and readmission rates for older people admitted to hospital with a medical condition".9^(p.14) Aside from the discomfort for the patient, the cost for hospitalization is greater than taking care of the patient at home. It is therefore vital to develop and implement an effective health care initiative that reduces both the negative impact from readmission for the patient with COPD at the individual level, as well as the overall cost for health care system.

An initial search on the databases of CINAHL, JBI COnNECT+, DARE, PubMed, Cochrane Library, TRIP and PROSPERO showed that no systematic review on this topic exists or in progress currently.

Definitions

Acute exacerbation of COPD (AECOPD) defined as an acute and sustained worsening of the patient's condition beyond normal day-to-day variations and requiring medical intervention. It is also a common complication of COPD.

Discharge interventions are defined as "in-hospital interventions or interventions after discharge performed (partly) by hospital-based professionals, explicitly targeted to smooth the transition from hospital to home or to prevent or diminish problems after hospital discharge".6^(p.2) The interventions can be divided into two groups: discharge preparation (pre-discharge) and discharge support/after care (post-discharge).6

Readmission is defined as hospitalization to the same or a different hospital due to AECOPD within the following year after discharge.