MPH Thesis: Assesment Of A Case Manager Intervention To Reduce Readmissions On Chronic Lung Disease Patients

1. Combined case management and hospital day-care to treat chronic lung
disease
Authors:
Güell Viaplana, Francesc (MPH); Althaia Xarxa Assistencial de Manresa and
currently Servei Català de la Salut (Generalitat de Catalunya)
Address: Av.Lluis Companys, 44; Zip C: 08172 City: Sant Cugat del Vallès
(Barcelona, Spain)
Ph.Number: +34.657.387.047 Fax number: +34.675.54.05
E-mail: fguell@catsalut.cat (requests address)
Rodríguez Sanz, Maica2 (MPH); Agència de Salut Pública de Barcelona
Castells Oliveres, Xavier3 (PhD); Institut Municipal d’Assistència Sanitària.
Paper presented at the 22nd Conference of the Spanish Society of Public Health and
Health Administration (Sociedad Española de Salud Pública y Administración
Sanitaria - SESPAS) in Barcelona on June 21st, 2007.
Word count:
Title: 46 characters
Abstract: 247 words
Text: 2947 words
References: 23 references (646 words)
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2. ABSTRACT
BACKGROUND
Case management (CM) has became a new approach on the treatment of Chronic
Lung Diseases. The aim of the present study was to assess the impact of a
combined hospital-based CM and specialized day-care program on the number of
hospital admissions and number of days of hospital stay.
METHODS:
We used a quasi-experimental PRE–POST design to compare number of admissions
and days of stay among patients aged !15 years with chronic lung disease admitted
in the two hospitals of Manresa, Spain. One of these hospitals implemented the
combined intervention (intervention hospital) and the other did not (control hospital).
Two study periods were compared (1996-97, ‘PRE-intervention period’; 2001-02
‘POST-intervention period’) using generalized linear models adjusted by age, sex
and comorbidity.
RESULTS:
In the control hospital the number of admissions due to chronic lung disease during
the POST period increased by 23% with respect to the PRE period (p=0.011), while
in the intervention group decreased by 8% (p=0.168). Total number of days in
hospital changed significantly in both hospitals. Average length of stay increased by
2.54 days in the control group (p=0.003) and decreased by 3.16 days in the
intervention group (p<0.001).
CONCLUSION:
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3. The multidisciplinary nature of combined intervention in chronic lung diseases
improved the utilization of hospital services for patient care and for educating the
patient on how to self-manage the disease. This resulted in a decrease in the number
of hospital admissions, total number of days in hospital and the average length of
hospital stay.
KEY WORDS:
Chronic Obstructive Pulmonary Disease (COPD), Chronic lung disease, case
management, readmission, length of hospital stay, average length of hospital stay,
coordinated care.
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4. BACKGROUND
Lung diseases are the third most common cause of mortality and morbidity in Spain,
after cardiovascular disease and cancer[1]. Chronic Obstructive Pulmonary Disease
(COPD), asthma and other diseases characterised by chronic shortness of breath
are causes of disability, hospital admission and premature death[2,3]. COPD has an
important impact on the population over 40 years[4], and studies from various
regions of Spain estimate a prevalence of 9% in the population from 40 to 69 years of
age[5].
The burden of COPD on health care services is high: 40%-50% of COPD patients
discharged from hospital are re-admitted at least once within the following year[6];
COPD accounts for 10-12% of primary health care visits and 35-40% of pneumology
specialists’ workload[7]. In economic terms, COPD accounted for between 841 and
961 M Euros in health care expenditure in Spain in 1994, and hospitalization
represented the 36.3-43% of this amount[8,9].
In order to find better ways to deal with this problem, such as improving treatment
efficiency, encouraging coordinated care, promoting the efficient use of health care
services and reducing the need for hospital resources, since 1997 the “Sant Joan de
Déu de Manresa” Hospital has implemented a combination of hospital-based CM and
hospital day-care for patients with chronic lung disease.
Formal evaluations of CM experiences have not shown consistent results. While
some studies show benefits in terms of shorter length of stay, lower level of severity
at admission and fewer days of critical care[10], the effectiveness of the intervention
varied depending on the study design, the pathology treated, and the characteristics
and duration of the intervention[2,11,12].
4

5. In COPD specifically, some studies assessed self-management education
strategies[2,13] in the context of schemes aimed at replacing acute hospital care with
home-based care for patients with exacerbation[14,15,16], showing substantial
reductions in readmissions[6] and average length of stay[17] in some cases, although
very few of these studies used CM approaches and none were carried out in the
context of the Spanish or Catalan Health Care Systems. Nonetheless, at international
level assessments of CM programs for the treatment of COPD have shown
significant improvements on self-management of the disease, clinical
symptomatology, anxiety and depression, patient’s perceived support, quality of life,
a reduction in unplanned readmissions and more effective use of
medication[15,18,19]. Even though randomized controlled trial designs were the most
frequently used, the short duration of the intervention, the short period of its
consolidation, and the small sample sizes available may lead to unreliable
results[19,20].
The objective of this study was to assess the impact of a combined CM and day-care
hospital for patients admitted to the “Sant Joan de Déu de Manresa” Hospital with
chronic lung disease between November 1st, 1997 and October 31st, 2002, in terms
of clinical results (number of readmissions for the same problem) and resource
burden (length of stay). These results were compared to those from a control hospital
where this care scheme was not implemented (“Centre Hospitalari de Manresa”
Hospital).
METHODS
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6. Study Design and Patient Selection
A retrospective quasi-experimental design was used to evaluate both clinical and
health care services outcomes before and after the CM intervention, comparing
results for a hospital where this intervention was implemented with one where it was
not. The response outcomes measured in the “PRE-” and “POST-” intervention
periods were: average number of admissions per patient due to an exacerbation;
total number of days in hospital per patient due to an exacerbation; and average
number of days per admission due to an exacerbation. Results were adjusted for
sex, age (years), and comorbidity, measured using the Charlson Comorbidity Index.
The intervention began on November 1st, 1997: evaluation of the outcomes was
performed at two different hospitals in Manresa (Spain) during the “PRE” period, from
January 1st, 1996, to October 31st, 1997, and the “POST” period, from January 1st,
2001, to October 31st, 2002. In the Sant Joan de Déu de Manresa Hospital the
intervention was conducted systematically on all adults admitted due to an
exacerbation in chronic lung disease, while at the Centre Hospitalari de Manresa
Hospital all the patients with chronic lung disease were given the usual care. Both
hospitals were of similar size, being General Hospitals with 240-250 beds, and
shared their catchment area.
The study population comprised patients with chronic lung disease over 18 years
admitted to one of the two hospitals due to an exacerbation of their condition.
Medical diagnoses included in the study were: COPD (Chronic Bronchitis and Lung
Emphysema), Asthma with and without chronic limitation of air flow, Bronchiectasia,
Lung Fibrosis, Fibrothorax post Tuberculosis and Sleep Apnea Syndrome with and
without associated COPD.
Description of the Intervention
6

7. The intervention was a combination of case management and hospital day care
directed at patients with chronic lung disease patients. In the admissions section, the
case manager nurse performed a baseline evaluation of the patient’s health self-
management and education, and requested a medical evaluation by the internal
medicine/pneumology departments, and an evaluation of social and functional status
by the hospital social worker and physiotherapist respectively. At this point the
multidisciplinary team set objectives for the care of the patient and estimated a
discharge day. This team re-evaluated the case daily during admission, and
communicated with the community health support services (Primary Health Care
Domiciliary Support Team) on a weekly basis after discharge to address the patient’s
needs. During the admission, common medical practices were followed and self-
management strategies were taught to the patient by the case management nurse.
After discharge, the patient attended a series of medical, physiotherapy and nurse
visits, delivered by the same multidisciplinary team that treated the case during the
hospital stay. To ensure systematic care coordination, a report of every visit was
communicated to the Primary Health Care services. The Hospital also implemented a
Day Care Hospital Service, where the patient urged to use in order to receive prompt
medical and nursing care in cases of the emergence of signs or symptoms of
exacerbation. As the multidisciplinary team was the same during the hospital stay as
in the day care hospital, the patient was treated according to the same medical
guidelines.
Pneumologists at the intervention hospital also conducted teaching activities in all
Primary Health Care Centers in the hospital’s catchment area, to inform primary
health care physicians of the main guidelines for autonomously treating non-severe
exacerbations.
7

8. In the control hospital the health care delivered to chronic lung disease patients
admitted following exacerbation consisted of an interdisciplinary approach where
each professional (e.g. medical doctor, nurse, physiotherapist) carried out their tasks
with monitoring from the internal medicine physician and/or pneumologist responsible
for the case, supported by micromanagement from ward nurses. Under this system,
patients may not have received care according to consistent medical guidelines, and
management of their case could be affected by fragmentation of the care.
Statistical Analysis
First, we described of the overall outcome in each hospital during the “PRE-" and
“POST-“intervention periods. Second, we described the population in terms of sex,
age, and comorbidity (measuring the Charlson Comorbidity Index[21]) in the two
periods and for each hospital. Outcomes for the two periods and for each hospital
were described using their means and 95% confidence intervals. We compared them
using the Student T- and Mann-Whitney U-tests. Finally, we fitted generalized linear
models adjusted by sex, age, and comorbidity to examine changes in the outcomes
between periods in each hospital. To model the variables “average number of
admissions per patient due to exacerbation” and “total number of days in hospital per
patient due to an exacerbation” we used a Poisson distribution and logaritm as the
link function to estimate the percentage change between periods (RR). For the
variable “average number of days in hospital per admission due to exacerbation” we
used a normal distribution and identity as the link function to estimate the difference
in means between different periods (DM).
RESULTS
Baseline analysis
8

9. The number of patients admitted due to respiratory exacerbation decreased in both
hospitals between the two study periods. In the control hospital the number of
patients admitted decreased from 238 during the “PRE-intervention” period to 131 in
the “POST-intervention” period, while in the intervention hospital this number
decreased from 406 to 242 (Table 1), representing total reductions of 107 and 164,
respectively. However, the average length of hospital stay decreased by 2.97 days in
the intervention hospital, but increased by 2.16 days in the control hospital.
Follow-up and Outcomes
There were no significant differences between hospitals in terms of percentage of
male and females in either of the study periods. An older age distribution was
observed in the control hospital for both periods of study; the number of patients !80
years of age was higher and there were significantly fewer individuals in the younger
age groups. Consequently, comorbidity was also significantly lower in the
intervention hospital than in the control hospital, where an increase in the number of
patients with the most severe comorbidities was observed (Table 2).
In the control hospital, the number of patients admitted only once decreased and the
number admitted more than once increased, as shown in Figure 1. The intervention
hospital experienced a non-significant decrease in the number of patients with three
or more admissions, and an increase in those with two admissions during the study
period. The total number of days in hospital per patient and period decreased
significantly in the intervention hospital –a decrease of the admissions over 22 days
per patient was observed –, while in the control hospital this number increased
despite a reduction in the number of shorter stays (0-7 days). The average length of
stay per patient tended to decrease in the intervention hospital, as suggested by an
increase in the number of patients with an average length of stay of >5 days, while in
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10. the control hospital the opposite trend was observed, with an increase in the number
of patients with stays of !10 days.
In the bivariate analysis (Table 3), the control hospital experienced a significant
increase in the number of re-admissions due to respiratory exacerbation, the total
number of days in hospital, and consequently, the average length of stay, which
increased from 8.8 to 11.8 days. In contrast, the number of readmissions did not
change significantly in the intervention hospital, although the total number of days in
hospital decreased significantly, and also, consequently, the average length of stay
(10.13 to 7.22 days).
The multivariate analysis (Table 4) confirmed the changes described above between
the PRE- and POST-intervention periods. The total number of re-admissions due to
respiratory exacerbation increased in the control hospital (RR=1.18; p=0.037) but did
not change significantly in the intervention hospital (RR=0.92; p=0.168). In the control
hospital, the number of re-admissions was higher among males, younger patients,
and those with a higher comorbidity index, but did not vary significantly with age or
sex in the intervention hospital. However, an association between higher number of
re-admissions and higher comorbidity index was evident in the intervention hospital.
The total number of days in hospital due to respiratory exacerbation showed a
significant decrease of 36% in the intervention hospital, but a significant increase of
46% in the control hospital. In the control hospital this outcome was associated with
males, younger ages and higher comorbidities; in the intervention hospital the
increase was associated with females, older ages and higher comorbidity indexes.
The average length of hospital stay decreased by 3.16 days in the intervention
hospital (p<0.001), but increased by 2.54 days in the control hospital (p=0.003).
While this outcome was associated with females and older age but not with
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11. comorbidity in the intervention hospital, in the control hospital it was associated with
females, but not with older age or higher comorbidity index.
CONCLUSIONS
The present study is one of the first formal assessments of the implementation of a
hospital based case management program to evaluate health care services utilization
and clinical outcomes in the Spanish health care system. A multidisciplinary
approach was used to implement a multifaceted intervention, which included patient
education on self-management and health services use. Furthermore, it standardized
the delivery of hospital and primary health care through the use of specific health
care guidelines.
The aim of the study was to explore changes in the number of readmissions, total
number of days in hospital and average length of hospital stay per patient as a result
of the implementation of this health care model. The results obtained indicate that
case management intervention stabilized the number of admissions (this number
increased in the control group), reduced by 36% the total number of days in hospital
per patient (this rate tended to increase in the control group) and significantly
decreased the average length of hospital stay by 3.2 days (this increased by 2.5 days
in the control hospital).
Although the literature on case management and self-management programs is
sparse, the results of this study contrast positively with previous studies, which found
no significant evidence of reductions in readmissions, average length of hospital stay
and total number of days in hospital[13,14,2,22]. The results of our study are
comparable to only a small number of assessments such as: i) self-management
intervention in COPD, which showed reductions in the total number of days in
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12. hospital and average length of hospital stay of 42.4%(6) and; ii) the early discharge
program in hospital- admitted COPD and asthma patients, which achieved significant
reductions in average length of hospital stay (7.8 days to 3.69 days) among patients
who received the intervention[15]. Similar results were obtained in our study.
Regarding the comparability of the study groups (intervention and control hospitals),
patients were generally older and more comorbid in the control group. Although the
analysis was adjusted for these factors, severity of chronic lung illness could be
greater in the control hospital than in the intervention hospital and not strictly
correlated to comorbidity or age. This is a minor limitation to be considered when
interpreting our results. Other aspects to be considered regarding comparability of
the groups were the size of the hospitals (both were a 240-250 bed hospital) and the
fact that the study groups pertained to the same time periods and resided in the
same hospital catchment area. This is expected to minimize confounding factors,
such as climate, socioeconomic status, and organization of territorial primary health
care services. Aspects of the study design such as the long period of time between
the implementation of the intervention and the POST-intervention evaluation period,
as well as the large sample size support the significance of our findings.
The main limitation of this study is the use of an administrative database consulted
retrospectively. As some studies have indicated, comorbidity data obtained from
minimum hospital databases may suffer from problems of under-declaration or
imprecision. Assessments of the quality of hospital administrative databases have
identified limitations in the registration of secondary diagnoses, in which physicians
and administrators tend to systematically substitute patients’ chronic diagnoses with
more severe diagnoses in patients with a highly comorbid process, resulting in under-
registration of chronic illnesses and consequently underestimated comorbidity(23). In
12

13. our study, this may influence the comorbidity index since the Hospital Minimum
Database Set systematically includes only the first four secondary diagnoses. This
may explain why we did not find any correlation between the average length of
hospital stay and the increase in the comorbidity index. The main limitation of using
an administrative database for this evaluation is the lack of a systematic register of
severity. Variables such as Forced Expiratory Volume (FEV) as a lung capacity
index, partial oxygen pressure (PO2), partial carbon dioxide pressure in arterial blood
(PaCO2), or current pharmacological treatment may have been useful as adjustment
variables.
We also explored potential contamination of each group with readmission of patients
initially belonging in the other group. The objective was to determine whether there
were differences in the number of patients belonging to the control hospital group
who were admitted and treated once or more at the intervention hospital and vice
versa. The results showed no significant differences between both groups.
Regarding the decrease in the number of admissions between study periods we
compared trends and the pattern of admission diagnosis in both hospitals between
PRE- and POST-. The decrease from the PRE- to POST-intervention periods was
similar in both groups (44.9% in the control group and 40.4% in the intervention
group) and there were no notable differences in the pattern of admissions diagnosis
profiles between periods or hospitals.
The results of the program implemented at Sant Joan de Déu Hospital are especially
relevant, since case management assessments have frequently failed to be
effective[11,22]. This program represents a successful experience that will help to
orient future strategies for specialized care of chronic lung disease, and
demonstrates the effectiveness of case management and hospital day care in
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14. treating patients with chronic lung disease within the Spanish health care system.
This study is the first part of a comprehensive assessment of case management
intervention in this disease. In addition to the results reported here for measures of
health care services burden, other measures, such as the use of community health
care services, self-perceived quality of life, other clinical outcomes and patient
satisfaction with the treatment received, will be assessed in future studies in order to
comprehensively evaluate the effects of the intervention.
To successfully introduce health care services programs such as the one described
here, the involvement and cooperation of hospital managers and health care
professionals is essential. Promoting collaboration between these professionals is
fundamental for achieving patient-centred care. On the basis of these principles, this
study shows that a case management approach, with care planning from admission
to discharge, improvement of self-management strategies and access to specialized
health care, and effective coordination with community health care services, can
result in a significant reduction in hospital admissions and days of acute care
required.
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