Article Text
Abstract
Background Chronic obstructive pulmonary disease (COPD) accounts for 10% of emergency hospital admissions in the UK annually. Nearly 33% of patients are readmitted within 28 days of discharge. We evaluated the effectiveness of implementing standardised packages of care called ‘care bundles’ on COPD readmission, emergency department (ED) attendance, mortality, costs and process of care.
Methods This is a mixed-methods, controlled before-and-after study with nested case studies. 31 acute hospitals in England and Wales which introduced COPD care bundles (implementation sites) or provided usual care (comparator sites) were recruited and provided monthly aggregate data. 14 sites provided additional individual patient data. Participants were adults admitted with an acute exacerbation of COPD.
Results There was no evidence that care bundles reduced 28-day COPD readmission rates: OR=1.02 (95% CI 0.83 to 1.26). However, the rate of ED attendance was reduced in implementation sites over and above that in comparator sites (implementation: IRR=0.63 (95% CI 0.56 to 0.71); comparator: IRR=1.12 (95% CI 1.02 to 1.24); group–time interaction p<0.001). At implementation sites, delivery of all bundle elements was higher but was only achieved in 2.2% (admissions bundle) and 7.6% (discharge bundle) of cases. There was no evidence of cost-effectiveness. Staff viewed bundles positively, believing they help standardise practice and facilitate communication between clinicians. However, they lacked skills in change management, leading to inconsistent implementation.
Discussion COPD care bundles were not effectively implemented in this study. They were associated with a reduced number of subsequent ED attendances, but not with change in readmissions, mortality or reduced costs. This is unsurprising given the low level of bundle uptake in implementation sites, and it remains to be determined if COPD care bundles affect patient care and outcomes when they are effectively implemented.
Trial registration number ISRCTN13022442.
- copd exacerbations
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Footnotes
Contributors MC, SJ, AS, WH, CM, JB, JC and SP were responsible for drafting the original study protocol and securing funding for the research. All authors contributed to the delivery of the study and analysis and interpretation of data. KM and AK collected data from sites. SJ led on patient and public involvement. KM and SP wrote the original draft of the manuscript. All authors contributed to and approved the final manuscript on behalf of the wider research team.
Funding This work was supported by the National Institute for Health Research (NIHR) Health Services and Delivery Research (HS&DR) Programme, project number 12/130/53. The research was hosted by NHS Bristol and was designed and delivered in partnership with the Bristol Randomised Trials Collaboration (BRTC), a UK Clinical Research Collaboration (UKCRC) registered Clinical Trials Unit (CTU). The views expressed are those of the authors and not necessarily of the NHS, the NIHR or the Department of Health and Social Care.
Competing interests SP is a general practitioner, and JB and JC are hospital consultants working in the fields of emergency care and respiratory medicine, respectively. All have endeavoured to ensure that their input to the research has not been biased by their own clinical practice. JC worked with colleagues at the British Thoracic Society to design and evaluate care bundles as an intervention to improve outcomes in a number of different respiratory conditions, including chronic obstructive pulmonary disease, pneumonia and asthma. SP is a member of the National Institute for Health Research (NIHR) Health Services and Delivery Research Researcher-led Panel, from 2017 to date. WH is a member of the NIHR Health Technology Assessment Clinical Trials Board. SJ runs an independent consultancy for public and charitable sector clients, providing strategy and organisation development, leadership coaching and facilitation.
Patient consent for publication Not required.
Ethics approval Ethical approval was given by the South West (Frenchay) Research Ethics Committee (study reference 14/SW/1057).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.