Care bundles to reduce re-admissions for patients with chronic obstructive pulmonary disease: a mixed-methods study

Abstract

Background Chronic obstructive pulmonary disease (COPD) is the commonest respiratory disease in the UK, accounting for 10% of emergency hospital admissions annually. Nearly one-third of patients are re-admitted within 28 days of discharge. Objectives The study aimed to evaluate the effectiveness of introducing standardised packages of care (i.e. care bundles) as a means of improving hospital care and reducing re-admissions for COPD. Design A mixed-methods evaluation with a controlled before-and-after design. Participants Adults admitted to hospital with an acute exacerbation of COPD in England and Wales. Intervention COPD care bundles. Main outcome measures The primary outcome was re-admission to hospital within 28 days of discharge. The study investigated secondary outcomes including length of stay, total number of bed-days, in-hospital mortality, 90-day mortality, context, process and costs of care, and staff, patient and carer experience. Data sources Routine NHS data, including numbers of COPD admissions and re-admissions, in-hospital mortality and length of stay data, were provided by 31 sites for 12 months before and after the intervention roll-out. Detailed pseudo-anonymised data on care during admission were collected from a subset of 14 sites, in addition to information about delivery of individual components of care collected from random samples of medical records at each location. Six case study sites provided data from interviews, observation and documentary review to explore implementation, engagement and perceived impact on delivery of care. Results There is no evidence that care bundles reduced 28-day re-admission rates for COPD. All-cause re-admission rates, in-hospital mortality, length of stay, total number of bed-days, and re-admission and mortality rates in the 90 days following discharge were similar at implementation and comparator sites, as were resource utilisation, NHS secondary care costs and cost-effectiveness of care. However, the rate of emergency department (ED) attendances decreased more in implementation sites than in comparator sites {implementation: incidence rate ratio (IRR) 0.63 [95% confidence interval (CI) 0.56 to 0.70]; comparator: IRR 1.14 (95% CI 1.04 to 1.26) interaction p < 0.001}. Admission bundles appear to be more complex to implement than discharge bundles, with 3.7% of comparator patients receiving all five admission bundle elements, compared with 7.6% of patients in implementation sites, and 28.3% of patients in implementation sites receiving all five discharge bundle elements, compared with 0.8% of patients in the comparator sites. Although patients and carers were unaware that care was bundled, staff view bundles positively, as they help to standardise working practices, support a clear care pathway for patients, facilitate communication between clinicians and identify post-discharge support. Limitations The observational nature of the study design means that secular trends and residual confounding cannot be discounted as potential sources of any observed between-site differences. The availability of data from some sites was suboptimal. Conclusions Care bundles are valued by health-care professionals, but were challenging to implement and there was a blurring of the distinction between the implementation and comparator groups, which may have contributed to the lack of effect on re-admissions and mortality. Care bundles do appear to be associated with a reduced number of subsequent ED attendances, but care bundles are unlikely to be cost-effective for COPD. Future work A longitudinal study using implementation science methodology could provide more in-depth insights into the implementation of care bundles. Trial registration Current Controlled Trials ISRCTN13022442. Funding This project was funded by the National Institute for Health Research Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 21. See the NIHR Journals Library website for further project information.

Observational Cost-Effectiveness Analysis Using Routine Data: Admission and Discharge Care Bundles for Patients with Chronic Obstructive Pulmonary Disease

“…We therefore estimated the cost effectiveness of both admission and discharge care bundles using observational patient-level data from 14 hospital sites located in England and Wales. This cost-effectiveness study was part of a wider project evaluating the effectiveness of care bundles for acute exacerbations of COPD [8][9][10].…”

Using and implementing care bundles for patients with acute admission for COPD: qualitative study of healthcare professionals’ experience in four hospitals in England

“…We undertook a multi-method evaluation to address this knowledge gap 10–12. Our quantitative findings indicated that admission and discharge bundles for COPD had little impact on patient outcomes, including readmissions and mortality or healthcare costs, although bundles did appear to be associated with a reduced number of subsequent attendances at the emergency department.…”

“…Our quantitative findings indicated that admission and discharge bundles for COPD had little impact on patient outcomes, including readmissions and mortality or healthcare costs, although bundles did appear to be associated with a reduced number of subsequent attendances at the emergency department. Variability in bundle structure and implementation create challenges in ascertaining the impact of COPD care bundles on patient outcomes 11 12. Within the evaluation, we conducted a qualitative study which examined how bundles were delivered and how staff perceived bundles to impact the process of patient care 10 12.…”

“…Variability in bundle structure and implementation create challenges in ascertaining the impact of COPD care bundles on patient outcomes 11 12. Within the evaluation, we conducted a qualitative study which examined how bundles were delivered and how staff perceived bundles to impact the process of patient care 10 12. This paper develops a subset of these qualitative data relating to barriers and facilitators to implementation of bundles.…”

“…In this paper, we elaborate how the bundles were used in different hospital settings, how they impacted care delivery from the perspective of healthcare professionals and factors experienced to help or hinder successful bundle use. These qualitative findings may help to explain why bundles were not found to enhance patient outcomes, given the challenges to their implementation 11 12…”