Effect of a Hospital-Initiated Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Patients Hospitalized With Chronic Obstructive Pulmonary Disease A Randomized Clinical Trial

被引：91

作者：

Aboumatar, Hanan ^{[1
,2
,3
,4
,5
]}

Naqibuddin, Mohammad ^{[1
]}

Chung, Suna ^{[1
]}

Chaudhry, Hina ^{[1
]}

Kim, Samuel W. ^{[1
]}

Saunders, Jamia ^{[1
]}

Bone, Lee ^{[3
,4
]}

Gurses, Ayse P. ^{[1
,6
,7
,8
]}

Knowlton, Amy ^{[3
]}

Pronovost, Peter ^{[1
,5
,6
]}

Putcha, Nirupama ^{[9
]}

Rand, Cynthia ^{[9
]}

Roter, Debra ^{[3
,4
]}

Sylvester, Carol ^{[10
]}

Thompson, Carol ^{[11
]}

Wolff, Jennifer L. ^{[5
]}

Hibbard, Judith ^{[12
]}

Wise, Robert A. ^{[9
]}

机构：

[1] Johns Hopkins Sch Med, Armstrong Inst Patient Safety & Qual, 750 E Pratt St,15th Floor, Baltimore, MD 21202 USA

[2] Johns Hopkins Sch Med, Dept Med, Div Gen Internal Med, Baltimore, MD USA

[3] Johns Hopkins Bloomberg Sch Publ Hlth, Dept Hlth Behav & Soc, Baltimore, MD USA

[4] Johns Hopkins Univ, Welch Ctr Prevent Epidemiol & Clin Res, Baltimore, MD USA

[5] Johns Hopkins Bloomberg Sch Publ Hlth, Dept Hlth Policy & Management, Baltimore, MD USA

[6] Johns Hopkins Sch Med, Dept Anesthesiol & Crit Care Med, Baltimore, MD USA

[7] Johns Hopkins Sch Med, Div Hlth Sci Informat, Baltimore, MD USA

[8] Johns Hopkins Univ, Whiting Sch Engn, Malone Ctr Engn Healthcare, Baltimore, MD USA

[9] Johns Hopkins Sch Med, Pulm & Crit Care Med, Baltimore, MD USA

[10] Johns Hopkins Bayview Med Ctr, Baltimore, MD 21224 USA

[11] Johns Hopkins Bloomberg Sch Publ Hlth, Johns Hopkins Biostatist Ctr, Baltimore, MD USA

[12] Univ Oregon, Hlth Policy Res Grp, Eugene, OR USA

来源：

JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2019年 / 322卷 / 14期

关键词：

UNITED-STATES; COPD; INTERVENTIONS; REHOSPITALIZATION; EXACERBATION;

D O I：

10.1001/jama.2019.11982

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

IMPORTANCE Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life. OBJECTIVE To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers can improve outcomes. DESIGN, SETTING, AND PARTICIPANTS Single-site randomized clinical trial conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016. INTERVENTIONS The intervention (n = 120) involved a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by nurses with special training on supporting patients with COPD using standardized tools. Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care. MAIN OUTCOMES AND MEASURES The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful). RESULTS Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; 61.7% women), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 62.3 (18.8) in the intervention group and 63.6 (17.4) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 1.40 (95% CI, 1.01-1.79) in the intervention group vs 0.72 (95% CI, 0.45-0.97) in the usual care group (difference, 0.68 [95% CI, 0.22-1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was 2.81 in the intervention group and -2.69 in the usual care group (adjusted difference, 5.18 [95% CI, -2.15 to 12.51]; P = .11). During the study period, there were 15 deaths (intervention: 8; usual care: 7) and 339 hospitalizations (intervention: 202; usual care: 137). CONCLUSIONS AND RELEVANCE In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly greater COPD-related hospitalizations and emergency department visits, without improvement in quality of life. Further research is needed to determine reasons for this unanticipated finding.

引用

页码：1371 / 1380

页数：10

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