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The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.

Background Although inhaled therapy reduces exacerbations among patients with COPD, the effectiveness of providing inhaled treatment per risk stratification models remains unclear. Research Question Are inhaled regimens that align with the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy associated with clinically important outcomes? Study Design and Methods We conducted secondary analyses of Long-term Oxygen Treatment Trial (LOTT) data. The trial enrolled patients with COPD with moderate resting or exertional hypoxemia between 2009 and 2015. Our exposure was the patient-reported inhaled regimen at enrollment, categorized as either aligning with, undertreating, or potentially overtreating per the 2017 GOLD strategy. Our primary composite outcome was time to death or first hospitalization for COPD. Additional outcomes included individual components of the composite outcome and time to first exacerbation. We generated multivariable Cox proportional hazard models across strata of GOLD-predicted exacerbation risk (high vs low) to estimate between-group hazard ratios for time to event outcomes. We adjusted models a priori for potential confounders, clustered by site. Results The trial enrolled 738 patients (73.4% men; mean age, 68.8 years). Of the patients, 571 (77.4%) were low risk for future exacerbations. Of the patients, 233 (31.6%) reported regimens aligning with GOLD recommendations; most regimens (54.1%) potentially overtreated. During a 2.3-year median follow-up, 332 patients (44.9%) experienced the composite outcome. We found no difference in time to composite outcome or death among patients reporting regimens aligning with recommendations compared with undertreated patients. Among patients at low risk, potential overtreatment was associated with higher exacerbation risk (hazard ratio, 1.42; 95% CI, 1.09-1.87), whereas inhaled corticosteroid treatment was associated with 64% higher risk of pneumonia (incidence rate ratio, 1.64; 95% CI, 1.01-2.66). Interpretation Among patients with COPD with moderate hypoxemia, we found no difference in clinical outcomes between inhaled regimens aligning with the 2017 GOLD strategy compared with those that were undertreated. These findings suggest the need to reevaluate the effectiveness of risk stratification model-based inhaled treatment strategies.

The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.

BACKGROUND Despite guideline recommendations, patients suspected of having COPD often are treated empirically instead of undergoing spirometry to confirm airflow obstruction (AFO). Accurate diagnosis and treatment are essential to provide high-quality, value-oriented care. We sought to identify predictors associated with AFO among patients with and treated for COPD prior to performance of confirmatory spirometry. METHODS We identified a cohort of veterans with spirometry performed at Pacific Northwest Department of Veterans Affairs medical centers between 2003 and 2007. We included only patients with empirically diagnosed COPD in the 2 years prior to spirometry who were also taking inhaled medication to treat COPD in the 1 year prior to spirometry. We used relative risk regression analysis to identify predictors of AFO. RESULTS Among patients empirically treated for COPD (N = 3, 209), 62% had AFO. Risk factors such as older age, prior smoking status, and underweight status were associated with AFO on spirometry. In contrast, comorbidities often associated with somatic symptoms were associated with absence of AFO and included congestive heart failure, depression, diabetes, obesity, and sleep apnea. CONCLUSIONS Comorbidities associated with somatic complaints of dyspnea were associated with a lower risk of having airflow limitations, suggesting that empirical diagnosis and treatment of COPD may lead to inappropriate treatment of individuals who do not have AFO.

Most patients with a clinical diagnosis of COPD have not had spirometry to confirm airflow obstruction (AFO). Overweight and obese patients report more dyspnea than normal weight patients, which may be falsely attributed to AFO. We sought to determine whether overweight and obese patients who received a clinical diagnosis of COPD were more likely to receive a misdiagnosis (ie, lack of AFO on spirometry) and be subsequently treated with inhaled medications.The cohort comprised US veterans with COPD (International Classification of Diseases, 9th Revision, code; inhaled medication use; or both) and spirometry measurements from one of three Pacific Northwest Veterans Administration Medical Centers. The measured exposures were overweight and obesity (defined by BMI categories). Outcomes were (1) AFO on spirometry and (2) escalation or deescalation of inhaled therapies from 3 months before spirometry to 9 to 12 months after spirometry. We used multivariable logistic regression with calculation of adjusted proportions for all analyses.Fifty-two percent of 5,493 veterans who had received a clinical diagnosis of COPD had AFO. The adjusted proportion of patients with AFO decreased as BMI increased (P.01 for trend). Among patients without AFO, those who were overweight and obese were less likely to remain off medications or to have therapy deescalated (adjusted proportions: normal weight, 0.69 [95% CI, 0.64-0.73]; overweight, 0.62 [95% CI, 0.58-0.65; P = .014]; obese, 0.60 [95% CI, 0.57-0.63; P = .001]).Overweight and obese patients are more likely to be given a misdiagnosis of COPD and not have their inhaled medications deescalated after spirometry demonstrated no AFO. Providers may be missing potential opportunities to recognize and treat other causes of dyspnea in these patients.

Approximately 65% of elderly patients with lung cancer who are admitted to the ICU will die within 6 months. Efforts to improve end-of-life care for this population must first understand the patient factors that underlie admission to the ICU.We performed a retrospective cohort study examining all fee-for-service inpatient claims in the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry for elderly patients (aged65 years) who had received a diagnosis of lung cancer between 1992 and 2005 and who were hospitalized for reasons other than resection of their lung cancer. We calculated yearly rates of ICU admission per 1,000 hospitalizations via room and board codes or International Classification of Diseases, Ninth Revision, Clinical Modification and diagnosis-related group codes for mechanical ventilation, stratified the rates by receipt of mechanical ventilation and ICU type (medical/surgical/cardiac vs intermediate), and compared these rates over time.A total of 175,756 patients with lung cancer in SEER were hospitalized for a reason other than surgical resection of their tumor during the study period, 49,373 (28%) of whom had at least one ICU stay. The rate of ICU admissions per 1,000 hospitalizations increased over the study period from 140.7 in 1992 to 201.7 in 2005 (P.001). The majority of the increase in ICU admissions (per 1,000 hospitalizations) between 1992 and 2005 occurred among patients who were not mechanically ventilated (118.2 to 173.3, P.001) and among those who were in intermediate ICUs (20.0 to 61.9, P.001), but increased only moderately in medical/surgical/cardiac units (120.7 to 139.9, P.001).ICU admission for patients with lung cancer increased over time, mostly among patients without mechanical ventilation who were largely cared for in intermediate ICUs.

Background COPD and hypertension both increase the risk of congestive heart failure (CHF). Current clinical trials do not inform the selection of combination antihypertensive therapy among patients with COPD. We performed a comparative effectiveness study to investigate whether choice of dual agent antihypertensive therapy is associated with risk of hospitalization for CHF among patients with these two conditions. Methods We identified a cohort of 7,104 patients with COPD and hypertension receiving care within Veterans Administration hospitals between January 2001 and December 2006, with follow-up through April 2009. We included only patients prescribed two antihypertensive medications. We used Cox proportional hazard models for statistical analysis. Results Compared with β-blockers plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, patients prescribed a thiazide diuretic plus a β-blocker (adjusted hazard ratio [HR], 0.49; 95% CI, 0.32-0.75), a thiazide plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (adjusted HR, 0.50; 95% CI, 0.35-0.71), and a thiazide plus a calcium channel blocker (adjusted HR, 0.55; 95% CI, 0.35-0.88) had a significantly lower risk of hospitalization for CHF. After stratification by history of CHF, we found that this association was isolated to patients without a history of CHF. Adjustment for patient characteristics and comorbidities had a small effect on risk of hospitalization. Choice of antihypertensive medication combination had no significant association with risk of COPD exacerbation. Conclusions Among patients with comorbid hypertension and COPD requiring two antihypertensive agents, combination therapy that includes a thiazide diuretic was associated with a significantly lower risk of hospitalization for CHF among patients without a history of CHF.