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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The respiratory community is failing people living with chronic obstructive pulmonary disease &#40;COPD&#41; by not addressing the problem of high re-admission rates following hospital treatment for exacerbations of COPD&#46; This failure is not because of inadequate data describing the scale of the problem&#46; In the UK national audit&#44; 43&#37; of 74&#44;645 patients had been re-admitted by 90 days and this figure had increased over time&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> 35&#37; of 15&#44;191 patients in the European COPD Audit were re-admitted by 90 days&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> A US database of 1&#44;055&#44;830 index admissions had a re-admission rate of 19&#46;2&#37; at 30 days&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> which compares to 24&#37; at 30 days in the UK&#58; remarkably similar re-admission rates are seen across diverse health settings&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our failure to address re-admissions in COPD is also not due to a lack of evidence explaining their causes&#44; and risk factors&#46; The commonest cause of re-admissions are respiratory-related&#44; COPD and pneumonia for example&#44; accounting for 52&#37; in the US study referred to above&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> A recent systematic review of risk-factors for all-cause readmissions highlighted co-morbidities&#44; previous exacerbations and hospitalisation&#44; and increased length of stay as significant risk factors for all-cause readmission&#46; In particular&#44; heart failure&#44; renal failure&#44; depression and alcohol use were all associated with an increased risk of 30-day re-admission&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The significant impact of re-admissions on patients is clear&#46; In a systematic review of how people living with COPD value COPD outcomes&#44; exacerbations and hospitalisations due to exacerbation were the outcomes rated most important&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> Moreover&#44; patients with COPD and frequent hospital admissions are at significant risk of increased mortality with a survival rate of only 20&#37; at five years&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Our failure to address re-admissions in COPD occurs despite evidence that exacerbations&#44; particularly hospitalised exacerbations cause much of the health-care burden and costs associated with COPD&#58; the cost of a severe &#40;hospitalised&#41; exacerbation being eight times the cost of a community treated event&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Thus&#44; hospitalised COPD exacerbations are important to payers and patients&#44; there is abundant evidence from diverse health care systems highlights the scale of the problem&#44; and the causes and risk-factors appear well understood&#46; What has gone wrong&#63; It must be time to think again about this problem&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">First&#44; understanding risk-factors for&#44; and causes of re-admission following hospital treatment for an exacerbation of COPD is not the same as having evidence-based interventions to mitigate this risk&#46; The likely candidates of supported self-management and &#8216;Discharge Bundles&#8217; have had disappointing results in clinical trials&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> likely because they are complex interventions requiring input from several individuals thus making it difficult to implement them effectively&#46; Although only applicable to a minority of the sickest patients with hypercapnoea&#44; domiciliary NIV is an example of an intervention where there is high quality trial evidence of benefit in reducing the risk of re-admission &#40;and death&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Evidence is emerging on the benefits of post-exacerbation pulmonary rehabilitation &#40;PR&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> but access to PR in general is limited<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> and implementation of post-exacerbation PR would require significant additional resource&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is clearly need for more work to understand the mechanisms of re-admissions and exacerbation recurrence&#44; and find better ways to prevent exacerbations&#46; These concepts were both identified as top-ten research priorities in a shared patient-clinician research prioritisation exercise for exacerbations of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> In the meantime&#44; practical advice for front-line clinicians must be to identify and optimise common co-morbidities&#44; and deploy evidence-based interventions to reduce COPD exacerbations&#46; Importantly&#44; for pharmacotherapy&#44; this includes not just using the right drugs but selecting the optimal device&#58; patients with severe COPD&#44; and those recovering from severe exacerbations may not generate sufficient inspiratory flow to activate dry-powder inhalers&#44; and critical inhaler errors are associated with increased risk of hospital care for COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> A reduction in admissions for COPD exacerbations in association with COVID-19 restrictions has highlighted the potential value of respiratory viral infection control measures to reduce exacerbations&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> but these have yet to be recommended in guidelines&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">An important question is to what extent re-admission reflect a failure of care&#46; Financial penalties to reduce reimbursement for re-admissions assume this to be the case&#46; However&#44; there is evidence that people with COPD are at highest risk for a recurrent exacerbation in the period immediately following a first exacerbation&#44; even when that first event has completely recovered&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> It may be time to add a paradigm of &#8216;high risk time-periods&#8217; when considering exacerbation risk&#44; to the familiar strategy of identifying high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Financial incentives might better focus on care quality&#44; as has been implemented with the UK national COPD audit&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Discharge from hospital care back to the community represents a vulnerable time for our sickest patients and it is incumbent on us all to ask if the communication and care we provide and receive at this time is optimal&#46; Early re-admissions&#44; therefore&#44; may be different from late re-admissions&#44; and may require different strategies to mitigate them&#46; We are not alone in facing these challenges&#58; 30 day re-admissions for heart failure are similar to those for COPD&#44; and there is a similar strategy to better implement effective therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">To conclude&#44; COPD re-admissions are a challenging problem&#46; We don&#8217;t yet have all the answers to provide a solution&#46; The minimum we can currently achieve is to optimise COPD care and co-morbidity prior to discharge&#44; and ensure effective transfer of care across hospital-based and community teams&#46; Ultimately&#44; we need further prospective research in this area&#44; to identify novel and simple interventions that are effective and implementable at scale&#46; Only by doing this can we reduce the burden of COPD re-admissions&#46; Our patients deserve nothing less&#46; They are waiting for us to act&#46;</p></span>"
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Editorial
The Impact of Re-Admissions in COPD
El impacto de los reingresos en la EPOC
Jaber S. Alqahtani
Corresponding author
j.hurst@ucl.ac.uk

Corresponding author.
, Swapna Mandal, John R. Hurst
UCL Respiratory, University College London, London, UK
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The respiratory community is failing people living with chronic obstructive pulmonary disease &#40;COPD&#41; by not addressing the problem of high re-admission rates following hospital treatment for exacerbations of COPD&#46; This failure is not because of inadequate data describing the scale of the problem&#46; In the UK national audit&#44; 43&#37; of 74&#44;645 patients had been re-admitted by 90 days and this figure had increased over time&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> 35&#37; of 15&#44;191 patients in the European COPD Audit were re-admitted by 90 days&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> A US database of 1&#44;055&#44;830 index admissions had a re-admission rate of 19&#46;2&#37; at 30 days&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> which compares to 24&#37; at 30 days in the UK&#58; remarkably similar re-admission rates are seen across diverse health settings&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our failure to address re-admissions in COPD is also not due to a lack of evidence explaining their causes&#44; and risk factors&#46; The commonest cause of re-admissions are respiratory-related&#44; COPD and pneumonia for example&#44; accounting for 52&#37; in the US study referred to above&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> A recent systematic review of risk-factors for all-cause readmissions highlighted co-morbidities&#44; previous exacerbations and hospitalisation&#44; and increased length of stay as significant risk factors for all-cause readmission&#46; In particular&#44; heart failure&#44; renal failure&#44; depression and alcohol use were all associated with an increased risk of 30-day re-admission&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The significant impact of re-admissions on patients is clear&#46; In a systematic review of how people living with COPD value COPD outcomes&#44; exacerbations and hospitalisations due to exacerbation were the outcomes rated most important&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> Moreover&#44; patients with COPD and frequent hospital admissions are at significant risk of increased mortality with a survival rate of only 20&#37; at five years&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Our failure to address re-admissions in COPD occurs despite evidence that exacerbations&#44; particularly hospitalised exacerbations cause much of the health-care burden and costs associated with COPD&#58; the cost of a severe &#40;hospitalised&#41; exacerbation being eight times the cost of a community treated event&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Thus&#44; hospitalised COPD exacerbations are important to payers and patients&#44; there is abundant evidence from diverse health care systems highlights the scale of the problem&#44; and the causes and risk-factors appear well understood&#46; What has gone wrong&#63; It must be time to think again about this problem&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">First&#44; understanding risk-factors for&#44; and causes of re-admission following hospital treatment for an exacerbation of COPD is not the same as having evidence-based interventions to mitigate this risk&#46; The likely candidates of supported self-management and &#8216;Discharge Bundles&#8217; have had disappointing results in clinical trials&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> likely because they are complex interventions requiring input from several individuals thus making it difficult to implement them effectively&#46; Although only applicable to a minority of the sickest patients with hypercapnoea&#44; domiciliary NIV is an example of an intervention where there is high quality trial evidence of benefit in reducing the risk of re-admission &#40;and death&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Evidence is emerging on the benefits of post-exacerbation pulmonary rehabilitation &#40;PR&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> but access to PR in general is limited<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> and implementation of post-exacerbation PR would require significant additional resource&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is clearly need for more work to understand the mechanisms of re-admissions and exacerbation recurrence&#44; and find better ways to prevent exacerbations&#46; These concepts were both identified as top-ten research priorities in a shared patient-clinician research prioritisation exercise for exacerbations of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> In the meantime&#44; practical advice for front-line clinicians must be to identify and optimise common co-morbidities&#44; and deploy evidence-based interventions to reduce COPD exacerbations&#46; Importantly&#44; for pharmacotherapy&#44; this includes not just using the right drugs but selecting the optimal device&#58; patients with severe COPD&#44; and those recovering from severe exacerbations may not generate sufficient inspiratory flow to activate dry-powder inhalers&#44; and critical inhaler errors are associated with increased risk of hospital care for COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> A reduction in admissions for COPD exacerbations in association with COVID-19 restrictions has highlighted the potential value of respiratory viral infection control measures to reduce exacerbations&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> but these have yet to be recommended in guidelines&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">An important question is to what extent re-admission reflect a failure of care&#46; Financial penalties to reduce reimbursement for re-admissions assume this to be the case&#46; However&#44; there is evidence that people with COPD are at highest risk for a recurrent exacerbation in the period immediately following a first exacerbation&#44; even when that first event has completely recovered&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> It may be time to add a paradigm of &#8216;high risk time-periods&#8217; when considering exacerbation risk&#44; to the familiar strategy of identifying high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Financial incentives might better focus on care quality&#44; as has been implemented with the UK national COPD audit&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Discharge from hospital care back to the community represents a vulnerable time for our sickest patients and it is incumbent on us all to ask if the communication and care we provide and receive at this time is optimal&#46; Early re-admissions&#44; therefore&#44; may be different from late re-admissions&#44; and may require different strategies to mitigate them&#46; We are not alone in facing these challenges&#58; 30 day re-admissions for heart failure are similar to those for COPD&#44; and there is a similar strategy to better implement effective therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">To conclude&#44; COPD re-admissions are a challenging problem&#46; We don&#8217;t yet have all the answers to provide a solution&#46; The minimum we can currently achieve is to optimise COPD care and co-morbidity prior to discharge&#44; and ensure effective transfer of care across hospital-based and community teams&#46; Ultimately&#44; we need further prospective research in this area&#44; to identify novel and simple interventions that are effective and implementable at scale&#46; Only by doing this can we reduce the burden of COPD re-admissions&#46; Our patients deserve nothing less&#46; They are waiting for us to act&#46;</p></span>"
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Article information
ISSN: 03002896
Original language: English
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