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NIHR Signal Packages of care interventions ‘not effective’ to reduce repeat admissions for COPD

Published on 27 August 2019

doi: 10.3310/signal-000810

Care bundles for COPD are difficult to implement, and their introduction in NHS hospitals does not reduce repeat admissions, deaths or use of resources when used on or after admission.

Care bundles are packages of interventions which, in other situations, can improve care. COPD care bundles include:

  • checking inhaler technique and medication use
  • providing a written plan for COPD management and supply of emergency medicines
  • assessing willingness to stop smoking
  • assessing suitability for pulmonary rehabilitation
  • arranging for follow-up within two weeks of discharge

A large-scale study of 31 NHS hospitals over two years found that less than 30% of people admitted with COPD received all five interventions in the care bundle. The research found no evidence of benefit in terms of readmission rates, length of stay or costs.

The study suggests that very few tasks were delivered as planned. Finding out which components of care bundles for COPD are hard to implement and why is needed. Until this is understood they are unlikely to be cost-effective.

Share your views on the research.

Why was this study needed?

COPD is one of the most common respiratory diseases in the UK, affecting an estimated three million people. Around 90,000 hospital admissions in the UK each year result from COPD (around 10% of the total), and one-third of patients are re-admitted within 28 days of hospital discharge. Interventions to reduce the rate of hospitalisation and readmission could have a significant effect on NHS budgets.

Care bundles have been developed by the British Thoracic Society and others to bring together packages of evidence-based interventions to improve care for COPD patients. They are intended to be delivered during hospital stay (either at admission or before discharge) with the aim of improving outcomes.

Early assessment of pilot projects to introduce care bundles were positive, but this is the first large scale assessment of their use. The primary aim of the research was to find out whether care bundles reduce 28-day readmission rates.

What did this study do?

The researchers recruited 31 NHS sites, which decided whether to become care bundle implementation sites (19) or comparator sites (12). They collected data on adult COPD admissions over 12 months before the implementation of care bundles and 12 months after, in a controlled retrospective cohort study.

Comparator sites delivered care as usual, which may have included use of some or all of the care bundle interventions. Intervention sites had education and health improvement programmes to introduce the care bundles, either as admission or pre-discharge interventions.

Routinely-collected NHS data was used to compare outcomes, including 28-day readmission rates. A sub-sample of hospital sites also provided more detailed data, and the researchers carried out interviews with staff, patients and carers in some hospitals to provide more insight into the pathways or process of care and challenges of implementation.

What did it find?

  • Intervention and comparator sites had similar 28-day readmission rates. Intervention sites had an average monthly COPD readmission rate of 11.6% for the 12 months before the index date on which they introduced care bundles and 10.8% for the 12 months after the index date. Comparator sites had a readmission rate of 14.7% before and after the index date (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.79 to 1.20).
  • None of the other outcomes – readmission rates for any cause, in-hospital mortality, length of stay, total number of bed days, mortality and readmission in the 90 days after discharge – showed any significant differences between implementation sites and comparator sites.
  • Admission bundles were less well utilised than discharge bundles. Only 7.6% of patients in intervention hospitals received all five admission bundle elements, compared to 28.3% of patients in intervention hospitals who received all five discharge bundle elements.
  • Economic analyses showed no improvements in NHS resource use, NHS secondary care costs or cost-effectiveness at sites implementing care bundles.
  • Interviews showed that staff valued care bundles as a way to ensure consistency of care but that patients and carers at implementation and comparison sites experienced little difference in their perceived quality of care.

What does current guidance say on this issue?

The NICE guidance on the diagnosis and management of COPD, published in December 2018, does not make a recommendation about the use of care bundles. It does recommend actions to be taken in discharge planning, including “Assess all aspects of the routine care that people receive (including appropriateness and risk of side effects) before discharge.”

Guidance also recommends to “Give people (or home carers) appropriate information to enable them to fully understand the correct use of medications, including oxygen, before discharge.” The British Thoracic Society disseminates care bundles as part of its clinical resources programme.

What are the implications?

Despite the advantages perceived by staff in standardising good practice, the study does not support the roll-out of care bundles for patients with COPD admitted to hospital.

This may be because some of the comparator sites were also using interventions included in care bundle packages and because the intervention sites did not fully deliver the care bundles.

However, the study did make clear from qualitative research that patients need considerable support at admission and discharge, whether that support comes as part of a formal care bundle or not, and the challenges that are faced in a research study are likely to be present if implemented at scale too.

Citation and Funding

Morton K, Sanderson E, Dixon P et al. Care bundles to reduce re-admissions for patients with chronic obstructive pulmonary disease: a mixed-methods study. Health Serv Deliv Res. 2019;7(21).

The project was funded by the NIHR Health Services and Delivery Research Programme (project number 12/130/53).

Bibliography

BTS. COPD admission and discharge care bundles. London: British Thoracic Society (undated).

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

Why was this study needed?

COPD is one of the most common respiratory diseases in the UK, affecting an estimated three million people. Around 90,000 hospital admissions in the UK each year result from COPD (around 10% of the total), and one-third of patients are re-admitted within 28 days of hospital discharge. Interventions to reduce the rate of hospitalisation and readmission could have a significant effect on NHS budgets.

Care bundles have been developed by the British Thoracic Society and others to bring together packages of evidence-based interventions to improve care for COPD patients. They are intended to be delivered during hospital stay (either at admission or before discharge) with the aim of improving outcomes.

Early assessment of pilot projects to introduce care bundles were positive, but this is the first large scale assessment of their use. The primary aim of the research was to find out whether care bundles reduce 28-day readmission rates.

What did this study do?

The researchers recruited 31 NHS sites, which decided whether to become care bundle implementation sites (19) or comparator sites (12). They collected data on adult COPD admissions over 12 months before the implementation of care bundles and 12 months after, in a controlled retrospective cohort study.

Comparator sites delivered care as usual, which may have included use of some or all of the care bundle interventions. Intervention sites had education and health improvement programmes to introduce the care bundles, either as admission or pre-discharge interventions.

Routinely-collected NHS data was used to compare outcomes, including 28-day readmission rates. A sub-sample of hospital sites also provided more detailed data, and the researchers carried out interviews with staff, patients and carers in some hospitals to provide more insight into the pathways or process of care and challenges of implementation.

What did it find?

  • Intervention and comparator sites had similar 28-day readmission rates. Intervention sites had an average monthly COPD readmission rate of 11.6% for the 12 months before the index date on which they introduced care bundles and 10.8% for the 12 months after the index date. Comparator sites had a readmission rate of 14.7% before and after the index date (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.79 to 1.20).
  • None of the other outcomes – readmission rates for any cause, in-hospital mortality, length of stay, total number of bed days, mortality and readmission in the 90 days after discharge – showed any significant differences between implementation sites and comparator sites.
  • Admission bundles were less well utilised than discharge bundles. Only 7.6% of patients in intervention hospitals received all five admission bundle elements, compared to 28.3% of patients in intervention hospitals who received all five discharge bundle elements.
  • Economic analyses showed no improvements in NHS resource use, NHS secondary care costs or cost-effectiveness at sites implementing care bundles.
  • Interviews showed that staff valued care bundles as a way to ensure consistency of care but that patients and carers at implementation and comparison sites experienced little difference in their perceived quality of care.

What does current guidance say on this issue?

The NICE guidance on the diagnosis and management of COPD, published in December 2018, does not make a recommendation about the use of care bundles. It does recommend actions to be taken in discharge planning, including “Assess all aspects of the routine care that people receive (including appropriateness and risk of side effects) before discharge.”

Guidance also recommends to “Give people (or home carers) appropriate information to enable them to fully understand the correct use of medications, including oxygen, before discharge.” The British Thoracic Society disseminates care bundles as part of its clinical resources programme.

What are the implications?

Despite the advantages perceived by staff in standardising good practice, the study does not support the roll-out of care bundles for patients with COPD admitted to hospital.

This may be because some of the comparator sites were also using interventions included in care bundle packages and because the intervention sites did not fully deliver the care bundles.

However, the study did make clear from qualitative research that patients need considerable support at admission and discharge, whether that support comes as part of a formal care bundle or not, and the challenges that are faced in a research study are likely to be present if implemented at scale too.

Citation and Funding

Morton K, Sanderson E, Dixon P et al. Care bundles to reduce re-admissions for patients with chronic obstructive pulmonary disease: a mixed-methods study. Health Serv Deliv Res. 2019;7(21).

The project was funded by the NIHR Health Services and Delivery Research Programme (project number 12/130/53).

Bibliography

BTS. COPD admission and discharge care bundles. London: British Thoracic Society (undated).

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

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

Published on 11 July 2019

Morton K, Sanderson E, Dixon P, King A, Jenkins S, MacNeill S J, Shaw A, Metcalfe C, Chalder M, Hollingworth W, Benger J, Calvert J & Purdy S.

Health Services and Delivery Research Volume 7 Issue 21 , 2019

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. 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.

Expert commentary

This study compared the rate of readmission to hospital a month after discharge between hospitals that implemented care bundles and those that didn’t. There was no difference in this outcome, though the care bundle group did have fewer A&E attendances.

Importantly, the actual level of delivery of the care mandated by the bundles was very incomplete and did not differ that much from what was being done in the non-care bundle hospitals.

The key message is that care bundles are only likely to work if they are actually implemented, and this is likely to require additional resources and additional prioritisation of care for this group of patients.

Nick Hopkinson, Reader in Respiratory Medicine, Imperial College London; Honorary Consultant Chest Physician, The Royal Brompton Hospital.

The commentator declares no conflicting interests

Expert commentary

The current study looked at clinically important outcomes but found no difference in the metrics in hospitals where care bundles were used.

Why the negative result and what are the future implications for care bundles? Despite attempting to control for many factors the landscape of care was evolving quickly with many hospitals having some sort of ‘supported discharge’ team for COPD. While they may not have delivered a bundle they would have discussed key aspects of care, improving outcomes in general.

Care bundles are a major aspect of care for respiratory patients (COPD, asthma, pneumonia) together with other conditions, so are here to stay, despite the apparently negative results.

Martin Allen, Consultant Physician, University Hospitals of North Midlands

The commentator declares no conflicting interests