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

• Main Authors: Katherine Morton, Emily Sanderson, Padraig Dixon, Anna King, Sue Jenkins, Stephanie J MacNeill, Alison Shaw, Chris Metcalfe, Melanie Chalder, William Hollingworth, Jonathan Benger, James Calvert, Sarah Purdy
• Format: Article
• Language: English
• Published: NIHR Journals Library 2019-06-01
• Series: Health Services and Delivery Research
• Subjects: CHRONIC OBSTRUCTIVE PULMONARY DISEASE; CARE BUNDLES; QUALITY OF CARE; QUALITY IMPROVEMENT; DELIVERY OF CARE; ADMISSION AVOIDANCE; OBSERVATIONAL STUDIES
• Online Access: https://doi.org/10.3310/hsdr07210
• ISSN: 2050-4349; 2050-4357

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.