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Assesment Of A Case Manager Intervention To Reduce Readmissions On Chronic Lung Disease Patients


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MPH Thesis: Assesment Of A Case Manager Intervention To Reduce Readmissions On Chronic Lung Disease Patients

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Assesment Of A Case Manager Intervention To Reduce Readmissions On Chronic Lung Disease Patients

  1. 1. Combined case management and hospital day-care to treat chronic lung disease Authors: Güell Viaplana, Francesc (MPH); Althaia Xarxa Assistencial de Manresa and currently Servei Català de la Salut (Generalitat de Catalunya) Address: Av.Lluis Companys, 44; Zip C: 08172 City: Sant Cugat del Vallès (Barcelona, Spain) Ph.Number: +34.657.387.047 Fax number: +34.675.54.05 E-mail: (requests address) Rodríguez Sanz, Maica2 (MPH); Agència de Salut Pública de Barcelona Castells Oliveres, Xavier3 (PhD); Institut Municipal d’Assistència Sanitària. Paper presented at the 22nd Conference of the Spanish Society of Public Health and Health Administration (Sociedad Española de Salud Pública y Administración Sanitaria - SESPAS) in Barcelona on June 21st, 2007. Word count: Title: 46 characters Abstract: 247 words Text: 2947 words References: 23 references (646 words) 1
  2. 2. ABSTRACT BACKGROUND Case management (CM) has became a new approach on the treatment of Chronic Lung Diseases. The aim of the present study was to assess the impact of a combined hospital-based CM and specialized day-care program on the number of hospital admissions and number of days of hospital stay. METHODS: We used a quasi-experimental PRE–POST design to compare number of admissions and days of stay among patients aged !15 years with chronic lung disease admitted in the two hospitals of Manresa, Spain. One of these hospitals implemented the combined intervention (intervention hospital) and the other did not (control hospital). Two study periods were compared (1996-97, ‘PRE-intervention period’; 2001-02 ‘POST-intervention period’) using generalized linear models adjusted by age, sex and comorbidity. RESULTS: In the control hospital the number of admissions due to chronic lung disease during the POST period increased by 23% with respect to the PRE period (p=0.011), while in the intervention group decreased by 8% (p=0.168). Total number of days in hospital changed significantly in both hospitals. Average length of stay increased by 2.54 days in the control group (p=0.003) and decreased by 3.16 days in the intervention group (p<0.001). CONCLUSION: 2
  3. 3. The multidisciplinary nature of combined intervention in chronic lung diseases improved the utilization of hospital services for patient care and for educating the patient on how to self-manage the disease. This resulted in a decrease in the number of hospital admissions, total number of days in hospital and the average length of hospital stay. KEY WORDS: Chronic Obstructive Pulmonary Disease (COPD), Chronic lung disease, case management, readmission, length of hospital stay, average length of hospital stay, coordinated care. 3
  4. 4. BACKGROUND Lung diseases are the third most common cause of mortality and morbidity in Spain, after cardiovascular disease and cancer[1]. Chronic Obstructive Pulmonary Disease (COPD), asthma and other diseases characterised by chronic shortness of breath are causes of disability, hospital admission and premature death[2,3]. COPD has an important impact on the population over 40 years[4], and studies from various regions of Spain estimate a prevalence of 9% in the population from 40 to 69 years of age[5]. The burden of COPD on health care services is high: 40%-50% of COPD patients discharged from hospital are re-admitted at least once within the following year[6]; COPD accounts for 10-12% of primary health care visits and 35-40% of pneumology specialists’ workload[7]. In economic terms, COPD accounted for between 841 and 961 M Euros in health care expenditure in Spain in 1994, and hospitalization represented the 36.3-43% of this amount[8,9]. In order to find better ways to deal with this problem, such as improving treatment efficiency, encouraging coordinated care, promoting the efficient use of health care services and reducing the need for hospital resources, since 1997 the “Sant Joan de Déu de Manresa” Hospital has implemented a combination of hospital-based CM and hospital day-care for patients with chronic lung disease. Formal evaluations of CM experiences have not shown consistent results. While some studies show benefits in terms of shorter length of stay, lower level of severity at admission and fewer days of critical care[10], the effectiveness of the intervention varied depending on the study design, the pathology treated, and the characteristics and duration of the intervention[2,11,12]. 4
  5. 5. In COPD specifically, some studies assessed self-management education strategies[2,13] in the context of schemes aimed at replacing acute hospital care with home-based care for patients with exacerbation[14,15,16], showing substantial reductions in readmissions[6] and average length of stay[17] in some cases, although very few of these studies used CM approaches and none were carried out in the context of the Spanish or Catalan Health Care Systems. Nonetheless, at international level assessments of CM programs for the treatment of COPD have shown significant improvements on self-management of the disease, clinical symptomatology, anxiety and depression, patient’s perceived support, quality of life, a reduction in unplanned readmissions and more effective use of medication[15,18,19]. Even though randomized controlled trial designs were the most frequently used, the short duration of the intervention, the short period of its consolidation, and the small sample sizes available may lead to unreliable results[19,20]. The objective of this study was to assess the impact of a combined CM and day-care hospital for patients admitted to the “Sant Joan de Déu de Manresa” Hospital with chronic lung disease between November 1st, 1997 and October 31st, 2002, in terms of clinical results (number of readmissions for the same problem) and resource burden (length of stay). These results were compared to those from a control hospital where this care scheme was not implemented (“Centre Hospitalari de Manresa” Hospital). METHODS 5
  6. 6. Study Design and Patient Selection A retrospective quasi-experimental design was used to evaluate both clinical and health care services outcomes before and after the CM intervention, comparing results for a hospital where this intervention was implemented with one where it was not. The response outcomes measured in the “PRE-” and “POST-” intervention periods were: average number of admissions per patient due to an exacerbation; total number of days in hospital per patient due to an exacerbation; and average number of days per admission due to an exacerbation. Results were adjusted for sex, age (years), and comorbidity, measured using the Charlson Comorbidity Index. The intervention began on November 1st, 1997: evaluation of the outcomes was performed at two different hospitals in Manresa (Spain) during the “PRE” period, from January 1st, 1996, to October 31st, 1997, and the “POST” period, from January 1st, 2001, to October 31st, 2002. In the Sant Joan de Déu de Manresa Hospital the intervention was conducted systematically on all adults admitted due to an exacerbation in chronic lung disease, while at the Centre Hospitalari de Manresa Hospital all the patients with chronic lung disease were given the usual care. Both hospitals were of similar size, being General Hospitals with 240-250 beds, and shared their catchment area. The study population comprised patients with chronic lung disease over 18 years admitted to one of the two hospitals due to an exacerbation of their condition. Medical diagnoses included in the study were: COPD (Chronic Bronchitis and Lung Emphysema), Asthma with and without chronic limitation of air flow, Bronchiectasia, Lung Fibrosis, Fibrothorax post Tuberculosis and Sleep Apnea Syndrome with and without associated COPD. Description of the Intervention 6
  7. 7. The intervention was a combination of case management and hospital day care directed at patients with chronic lung disease patients. In the admissions section, the case manager nurse performed a baseline evaluation of the patient’s health self- management and education, and requested a medical evaluation by the internal medicine/pneumology departments, and an evaluation of social and functional status by the hospital social worker and physiotherapist respectively. At this point the multidisciplinary team set objectives for the care of the patient and estimated a discharge day. This team re-evaluated the case daily during admission, and communicated with the community health support services (Primary Health Care Domiciliary Support Team) on a weekly basis after discharge to address the patient’s needs. During the admission, common medical practices were followed and self- management strategies were taught to the patient by the case management nurse. After discharge, the patient attended a series of medical, physiotherapy and nurse visits, delivered by the same multidisciplinary team that treated the case during the hospital stay. To ensure systematic care coordination, a report of every visit was communicated to the Primary Health Care services. The Hospital also implemented a Day Care Hospital Service, where the patient urged to use in order to receive prompt medical and nursing care in cases of the emergence of signs or symptoms of exacerbation. As the multidisciplinary team was the same during the hospital stay as in the day care hospital, the patient was treated according to the same medical guidelines. Pneumologists at the intervention hospital also conducted teaching activities in all Primary Health Care Centers in the hospital’s catchment area, to inform primary health care physicians of the main guidelines for autonomously treating non-severe exacerbations. 7
  8. 8. In the control hospital the health care delivered to chronic lung disease patients admitted following exacerbation consisted of an interdisciplinary approach where each professional (e.g. medical doctor, nurse, physiotherapist) carried out their tasks with monitoring from the internal medicine physician and/or pneumologist responsible for the case, supported by micromanagement from ward nurses. Under this system, patients may not have received care according to consistent medical guidelines, and management of their case could be affected by fragmentation of the care. Statistical Analysis First, we described of the overall outcome in each hospital during the “PRE-" and “POST-“intervention periods. Second, we described the population in terms of sex, age, and comorbidity (measuring the Charlson Comorbidity Index[21]) in the two periods and for each hospital. Outcomes for the two periods and for each hospital were described using their means and 95% confidence intervals. We compared them using the Student T- and Mann-Whitney U-tests. Finally, we fitted generalized linear models adjusted by sex, age, and comorbidity to examine changes in the outcomes between periods in each hospital. To model the variables “average number of admissions per patient due to exacerbation” and “total number of days in hospital per patient due to an exacerbation” we used a Poisson distribution and logaritm as the link function to estimate the percentage change between periods (RR). For the variable “average number of days in hospital per admission due to exacerbation” we used a normal distribution and identity as the link function to estimate the difference in means between different periods (DM). RESULTS Baseline analysis 8
  9. 9. The number of patients admitted due to respiratory exacerbation decreased in both hospitals between the two study periods. In the control hospital the number of patients admitted decreased from 238 during the “PRE-intervention” period to 131 in the “POST-intervention” period, while in the intervention hospital this number decreased from 406 to 242 (Table 1), representing total reductions of 107 and 164, respectively. However, the average length of hospital stay decreased by 2.97 days in the intervention hospital, but increased by 2.16 days in the control hospital. Follow-up and Outcomes There were no significant differences between hospitals in terms of percentage of male and females in either of the study periods. An older age distribution was observed in the control hospital for both periods of study; the number of patients !80 years of age was higher and there were significantly fewer individuals in the younger age groups. Consequently, comorbidity was also significantly lower in the intervention hospital than in the control hospital, where an increase in the number of patients with the most severe comorbidities was observed (Table 2). In the control hospital, the number of patients admitted only once decreased and the number admitted more than once increased, as shown in Figure 1. The intervention hospital experienced a non-significant decrease in the number of patients with three or more admissions, and an increase in those with two admissions during the study period. The total number of days in hospital per patient and period decreased significantly in the intervention hospital –a decrease of the admissions over 22 days per patient was observed –, while in the control hospital this number increased despite a reduction in the number of shorter stays (0-7 days). The average length of stay per patient tended to decrease in the intervention hospital, as suggested by an increase in the number of patients with an average length of stay of >5 days, while in 9
  10. 10. the control hospital the opposite trend was observed, with an increase in the number of patients with stays of !10 days. In the bivariate analysis (Table 3), the control hospital experienced a significant increase in the number of re-admissions due to respiratory exacerbation, the total number of days in hospital, and consequently, the average length of stay, which increased from 8.8 to 11.8 days. In contrast, the number of readmissions did not change significantly in the intervention hospital, although the total number of days in hospital decreased significantly, and also, consequently, the average length of stay (10.13 to 7.22 days). The multivariate analysis (Table 4) confirmed the changes described above between the PRE- and POST-intervention periods. The total number of re-admissions due to respiratory exacerbation increased in the control hospital (RR=1.18; p=0.037) but did not change significantly in the intervention hospital (RR=0.92; p=0.168). In the control hospital, the number of re-admissions was higher among males, younger patients, and those with a higher comorbidity index, but did not vary significantly with age or sex in the intervention hospital. However, an association between higher number of re-admissions and higher comorbidity index was evident in the intervention hospital. The total number of days in hospital due to respiratory exacerbation showed a significant decrease of 36% in the intervention hospital, but a significant increase of 46% in the control hospital. In the control hospital this outcome was associated with males, younger ages and higher comorbidities; in the intervention hospital the increase was associated with females, older ages and higher comorbidity indexes. The average length of hospital stay decreased by 3.16 days in the intervention hospital (p<0.001), but increased by 2.54 days in the control hospital (p=0.003). While this outcome was associated with females and older age but not with 10
  11. 11. comorbidity in the intervention hospital, in the control hospital it was associated with females, but not with older age or higher comorbidity index. CONCLUSIONS The present study is one of the first formal assessments of the implementation of a hospital based case management program to evaluate health care services utilization and clinical outcomes in the Spanish health care system. A multidisciplinary approach was used to implement a multifaceted intervention, which included patient education on self-management and health services use. Furthermore, it standardized the delivery of hospital and primary health care through the use of specific health care guidelines. The aim of the study was to explore changes in the number of readmissions, total number of days in hospital and average length of hospital stay per patient as a result of the implementation of this health care model. The results obtained indicate that case management intervention stabilized the number of admissions (this number increased in the control group), reduced by 36% the total number of days in hospital per patient (this rate tended to increase in the control group) and significantly decreased the average length of hospital stay by 3.2 days (this increased by 2.5 days in the control hospital). Although the literature on case management and self-management programs is sparse, the results of this study contrast positively with previous studies, which found no significant evidence of reductions in readmissions, average length of hospital stay and total number of days in hospital[13,14,2,22]. The results of our study are comparable to only a small number of assessments such as: i) self-management intervention in COPD, which showed reductions in the total number of days in 11
  12. 12. hospital and average length of hospital stay of 42.4%(6) and; ii) the early discharge program in hospital- admitted COPD and asthma patients, which achieved significant reductions in average length of hospital stay (7.8 days to 3.69 days) among patients who received the intervention[15]. Similar results were obtained in our study. Regarding the comparability of the study groups (intervention and control hospitals), patients were generally older and more comorbid in the control group. Although the analysis was adjusted for these factors, severity of chronic lung illness could be greater in the control hospital than in the intervention hospital and not strictly correlated to comorbidity or age. This is a minor limitation to be considered when interpreting our results. Other aspects to be considered regarding comparability of the groups were the size of the hospitals (both were a 240-250 bed hospital) and the fact that the study groups pertained to the same time periods and resided in the same hospital catchment area. This is expected to minimize confounding factors, such as climate, socioeconomic status, and organization of territorial primary health care services. Aspects of the study design such as the long period of time between the implementation of the intervention and the POST-intervention evaluation period, as well as the large sample size support the significance of our findings. The main limitation of this study is the use of an administrative database consulted retrospectively. As some studies have indicated, comorbidity data obtained from minimum hospital databases may suffer from problems of under-declaration or imprecision. Assessments of the quality of hospital administrative databases have identified limitations in the registration of secondary diagnoses, in which physicians and administrators tend to systematically substitute patients’ chronic diagnoses with more severe diagnoses in patients with a highly comorbid process, resulting in under- registration of chronic illnesses and consequently underestimated comorbidity(23). In 12
  13. 13. our study, this may influence the comorbidity index since the Hospital Minimum Database Set systematically includes only the first four secondary diagnoses. This may explain why we did not find any correlation between the average length of hospital stay and the increase in the comorbidity index. The main limitation of using an administrative database for this evaluation is the lack of a systematic register of severity. Variables such as Forced Expiratory Volume (FEV) as a lung capacity index, partial oxygen pressure (PO2), partial carbon dioxide pressure in arterial blood (PaCO2), or current pharmacological treatment may have been useful as adjustment variables. We also explored potential contamination of each group with readmission of patients initially belonging in the other group. The objective was to determine whether there were differences in the number of patients belonging to the control hospital group who were admitted and treated once or more at the intervention hospital and vice versa. The results showed no significant differences between both groups. Regarding the decrease in the number of admissions between study periods we compared trends and the pattern of admission diagnosis in both hospitals between PRE- and POST-. The decrease from the PRE- to POST-intervention periods was similar in both groups (44.9% in the control group and 40.4% in the intervention group) and there were no notable differences in the pattern of admissions diagnosis profiles between periods or hospitals. The results of the program implemented at Sant Joan de Déu Hospital are especially relevant, since case management assessments have frequently failed to be effective[11,22]. This program represents a successful experience that will help to orient future strategies for specialized care of chronic lung disease, and demonstrates the effectiveness of case management and hospital day care in 13
  14. 14. treating patients with chronic lung disease within the Spanish health care system. This study is the first part of a comprehensive assessment of case management intervention in this disease. In addition to the results reported here for measures of health care services burden, other measures, such as the use of community health care services, self-perceived quality of life, other clinical outcomes and patient satisfaction with the treatment received, will be assessed in future studies in order to comprehensively evaluate the effects of the intervention. To successfully introduce health care services programs such as the one described here, the involvement and cooperation of hospital managers and health care professionals is essential. Promoting collaboration between these professionals is fundamental for achieving patient-centred care. On the basis of these principles, this study shows that a case management approach, with care planning from admission to discharge, improvement of self-management strategies and access to specialized health care, and effective coordination with community health care services, can result in a significant reduction in hospital admissions and days of acute care required. REFERENCES 1. Ministerio de Sanidad y Consumo. Plan de Salud 1995. Centro de publicaciones. Secretaria General Te"cnica. Madrid: Ministerio de Sanidad y Consumo, 1995. 2. Dongbo F, Hua F, McGowan P, Yi- e S, Lihzen A, Huiqin Y, et al. Implementation and quantitative evaluation of chronic disease self -management programe in Shanghai, China: randomized controlled trial. Bulletin of the World Health Organization 2003;81(3)174 -182. 14
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