COPD is the chronic obstructive pulmonary disease occurring in people aged 70 or more. The aim of this research proposal is to find out the risks of the COPD admission and readmission of the elderly, different rates and variations and possible interventions to reduce the risk increase together with the levels of patient morbidity and mortality. This research proposal included ten specific articles under review to obtain information on COPD. Various data was presented according to the medical errors, COPD admission and readmission, the rates and costs of readmission in 15 states and the probable outcomes for the elderly people. It was found out that the risks of readmission of the aged individuals diagnosed with COPD are very high due to social, medical and self-management factors. What is more, hospitalsare at a significant minus considering readmissions, as they require more financial support. Risks that the elderly COPD patients suffer from being readmitted to the hospital include medical neglect of patient needs, illness relapse and poor self-management due to limited movability. Therefore, much of the patients who were unattended at their primary hospitalization are being treated for the second time within the period of a month.
Keywords: COPD, hospitalization, readmission, risks, statistic data
Risk Factors of Hospitalization and Readmission of Elderly Patients with COPD
Chronic obstructive pulmonary disease (COPD) is the illness demonstrating respiratory symptoms like chronic cough, shortness of breath, and physical activity limitations (Taffet, Dobohue, & Altman, 2014). It prevails in older people, mainly active smokers and those, who have a history of smoking.
Annually, COPD remains one of the leading causes of morbidity and mortality all around the world. Nowadays, it is a major health problem to the world population. According to the prognosis, by the year 2020, COPD will be the third most common cause of death and the fifth disease with multiple complications for both women and men (Chan et al., 2011). The most common reason for hospital admission and readmission is the acute exacerbation of COPD. From 1991 to 2000, the COPD admission rates in the United Kingdom doubled. Each year, the European Union allocates 6% of the health care budget towards respiratory disease prevention and treatment. Here, 56% of the costs (USD 53.9 billion) from the total healthcare budget are spent on COPD (Chan et al., 2011). In the United States, the cost of the COPD treatment was $18 billion in 2002, and they are growing every year (Chan et al., 2011).
The data from 2003 2004 shows that 22.6% of patients were admitted to the hospital with COPD, and, due to the COPD exacerbation, readmitted within 30 days (Elixhauser, Au, & Podulka, 2011). The same percentage was observed in 2008 in fifteen states (42% of the total U.S. population), when patients aged forty and older were readmitted to the hospital with previous diagnosis of COPD (Elixhauser et al., 2011). According to the latest estimates, the prevalence of COPD in the United States of America is approximately 10% among people aged 75 years and more (Taffet et al., 2014).
Between 2005 2015, the risk for repeat acute care encounters was significantly increased in the very old (age ? 80), individuals with dual Medicare and Medicaid eligibility, and long term oxygen use (Berry, and Kalhan, 2015). In addition, such pulmonary conditions as pneumonia, pulmonary hypertension, asthma, lung cancer, and pulmonary fibrosis were regular to COPD cases.
The reasons for unplanned readmissions vary. For instance, the most prevalent causes are the social factor, the clinical factor and the patient factor. The first aspect occurs when there is a gap between hospital and community connectivity, poor social support and premature discharge (diagnosis made without specific testing). The second factor is based on the relapse of the illness with multiple complications or parallel development of the other disease. The third aspect grounds on poor self-management and problems with medication intakes. To some extent, early readmission means that the quality of care was poor and insufficient at the very beginning, and brought to the worsening of the clinical condition. Notwithstanding the difference of the factors, they have the same outcome morbidity or, in the worst case scenario, mortality.
The excessively high rates of readmissions (which vary without any particular pattern) indicate problems in transitions of care and outpatient management following discharge (Elixhauser et al., 2011). Addressing this inability to avoid hospital readmissions is one of the most important objectives of the Affordable Care Act and different healthcare organizations, which are accountable to it.
Therefore, it is of great importance to investigate what are the causes and the risks of hospitalization and early readmission of the elderly patients diagnosed with COPD. Moreover, as the most vulnerable group consists of the elderly population, it is necessary to understand why older generation is undertreated in clinical conditions and, as a result, is readmitted feeling worse as compared to their initial (first) admission to the hospital. In addition, it is preferable to find out how patient self-management is carried out and whether it contributes to the early readmission of the elderly citizens.
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Despite COPD being a common and one of the most lethal diseases, studies on the risk factors of hospitalizations and readmissions of the COPD patients are still limited. Therefore, the problem raised in the current research proposal can be addressed from different angles. First, it is essential to find out the causes and the risks patients obtain being diagnosed with COPD. Second, it is required to understand the methods of the disease treatment. Third, it is necessary to investigate the reasons of early discharge and readmission of patients with COPD. According to Chan et al. (2011), there is no definition of unplanned readmission that has been standardized. However, the most common and optimal scenario of re-hospitalization occurs within a duration of a month (30 days).
Thus, the purpose of this study is to investigate the risks of readmission for elderly patients diagnosed with COPD, why the very re-hospitalization occurs in the first place, and its causes and consequences for the older generation.
Research Picot Question
Population: elderly people (aged ?75) with limited movement.
Intervention: COPD treatment of the elderly with specific testing for the particular diagnosis (accurate diagnosis statement), which aims to cure the established disease without possible readmissions. What is more, social, clinical and patient treatment factors are taken into account.
Comparison: COPDtreatment of the elderly without specific testing (only symptomatic examination), which leads towards inadequate patient treatment and early readmission. Such treatment factors as social, clinical and patient are not being considered.
Outcome: When the medical diagnosis is erroneous, the treatment and care are inappropriate or lack sufficient quality and management, and patients are being discharged underserved and undertreated with high risks of further early readmission and serious health deterioration.
Time: 30 days after discharge and the period of readmission.
PICOT Question: What are the risks of re-hospitalization of the elderly population diagnosed with COPD within the 30 days after they have been discharged due to the lack of appropriate care, misinterpreted symptoms of recovery and medical neglect?
The number of people readmitted within thirty days will decrease if appropriate medical services for the elderly patients are provided, the pre-discharge education and distant monitoring by the assigned nurse is carried out, and prevention of the older generation from the risks of re-hospitalization is ensured.
The most common readmissions occur in the period of thirty days after the premature discharge. Out of 190,700 index of admissions with COPD, 7.1% of them had one readmission within 30 days and were diagnosed again with COPD (Table 1).
The 30Day Readmission among COPD Patients (40 Years and Older) in 15 States
(Elixhauser et al., 2011).
When COPD was taken as any diagnosis, the rates dramatically increased. It means that the very diagnosis could have been set erroneously. For instance, from 7.1% the numbers increased to 17.3% and 20.5%, followed by readmission within a month.
Inevitable in the causes of readmission are patient characteristics (Table 2). As COPD was taken as the principal diagnosis, readmissions occurred about 15% higher (7.8% index) than among the elderly (6.8% index). What is more, males tended to be more prone to readmission within 30 days than females.
Forty-Year and Older Patient Characteristic of a 30-Day Readmission for COPD (15 States)
(Elixhauser et al., 2011).
Ethnicity and race were also the contributing factor in the statistical scale of readmissions. For instance, the highest index of re-hospitalization was present in the Black population.
Another statistical evidence of massive readmission occurrence can be traced with the help of hospital costs spent on disease management (Table 3).
Hospital Costs in 15 States Concerning Patients with COPD (40 Years and Older)
(Elixhauser et al., 2011).
From Table 3 above it is noticeable that the costs were significantly higher for readmission treatment than for primary admission of the patient diagnosed with COPD. Therefore, to some extent, medical workers are guilty of their low quality work performance. From the diagnosis settlement and up to discharge, the patient should be monitored by observation, running tests and communication. However, most of the nurses lack the abilities to engage into the treatment and support patients as much as possible.
Definition of Terms
- Chronic obstructive pulmonary disease (COPD) is the illness based on the age-factor and physiological changes, due to which the impairment of pulmonary function increases. The changes of a kind include a progressive reduction in compliance of the chest wall, reduction in strength of the respiratory muscles, and anatomical changes to the lung parenchyma and peripheral airways (Taffet et al., 2014). What is more, osteoporosis and kyphosis contribute to the transformations in the shape of the thorax and result in the malfunction of the chest wall mechanics. The consequences of these changes can be expressed as the decreased peak inspiratory and expiratory airflows, vital capacity, and efficiency of gas exchange (Taffet et al., 2014).
- Risk factors are the numerous aspects, which might contribute to the health status by means of its deterioration. Risk factors predict readmission and are the key drivers of the unscheduled hospital care (Coventry, Gemmell, & Todd, 2011). Such aspects can be social, clinical, self-made and others.
- Spirometry testingthis is the testing for COPD and it is required to make a confident diagnosis and can be used to classify the severity of airflow limitation (Saffel, 2012). Its main goals are to determine the disease severity, airflow limitation severity, its impact on the patients health condition, the risk of possible exacerbations, future readmissions or even death. Correct and confident diagnosis based on spirometry is the first guide towards regular and effective treatment.
- Hospital readmission is the re-hospitalization of patients with the same diagnosis as their initial hospitalization (Amalfitano, 2013) after a short or long period.
- Recommended treatment is the kind of treatment based on a measure of the impact of the patients symptoms and an assessment of the patients risk of having a serious adverse health event in the future (Saffel, 2012). Treatments predispose medical interventions in the form of pills, inhalers, injections and other means.
The theoretical framework of this research proposal is guided by a theory proposed by Ida Jean Orlando, which is the nursing process discipline theory. The aim of this model is to show that the role of the nurse is to find out and meet the patients immediate needs for help (Nursing Process Theory, n.d.). Professional nursing functions normally only if it has an element of organization. Orlando claims nursing is responsive to individuals, who suffer, or who anticipate a sense of helplessness (Nursing Process Theory, n.d.). Therefore, the model presented focuses on the process of care with an immediate response (help) to the patient to retrieve him/her from this state of helplessness. As a result, if the patient has a need for help immediately, and the nurse manages to provide the kind of help in no time, then the purpose of nursing is accomplished.
The assumptions made by Orlandos model are:
- inability to cope with problems on ones own make patients distressed;
- nursing practice is intertwined with health, environment and people, which are its central concepts;
- patients tend to conceal their true needs and feelings;
- the nurse-patient relationship is dynamic: both actions and reactions are affected by both parties;
- nurses should be concerned with the patients needs and make efforts to meet them as soon as possible;
- and others.
The nursing process, according to Orlando, includes assessment, planning, implementation and evaluation (Nursing Process Theory, n.d.). The theory centers on the communication between the nurse and the patient, validation of perception, and the usage of nursing process for better outcomes and patient health improvement.
In this research proposal, Orlandos nursing process discipline theory is applicable as it addresses the questions posed from both sides. That is, the model reflects on the roles of the medical worker and the patient and their relationship and interconnection in order to promote patient well-being (discharge). When an elderly patient has symptoms of COPD, he/she is immediately hospitalized. Despite COPD being a curable illness, it requires obligatory admission, running tests and special medical support. What is more, old patients need twice as much nursing care and daily treatment, because they are too old and rather unable to provide treatment for themselves or tell the nurse what they feel or need.
Different risks, which are the factors to which each patient is vulnerable, might occur while hospitalization. These may be socio-communicative (poor medical and social support and premature discharge), unexpected exacerbation (illness relapse or the appearance of an additional disease, except COPD), and insufficient self-management (the clients are not educated on how to provide self-care and intake medicine or are too old to do so). The first risk happens when physicians tend to make diagnosis without specific instrumental help such as blood testing or any other hard evidence of the illness present except symptomatic information told by the patient. It is highly advisable that COPD should be diagnosed with the help of spirometry testing. This test has been designed to show the potential level of severity of the disease. However, some of the elderly patients cannot go through the spirometry testing adequately. The reasons for their inability lie in cognitive impairment, movement limitations, sedation or vigorous respiratory efforts (Taffet et al., 2014). Therefore, the elderly patients need more qualified and painstaking work of the medical personnel to conduct a spirometry test. Second, the older adults tend to be vulnerable to infections and other diseases, especially if they have not fully recovered from COPD. This way, a relapse happens with the new illness layered across the old symptoms. Here, the elderly patients need a sophisticated nursing care to get well as soon as possible without any lethal consequences. Third, the older generation cannot be discharged without specific education according to the medical intake or a home nurse responsible for monitoring and guiding this process.
What concerns the COPD treatment, its goal is to maximize the pulmonary function in order to prevent exacerbations. To meet the particular objective, the pharmacological means primarily employed are inhaled medications including short-acting and long-acting beta2-selective adrenergic agonists, short-acting and long-acting cholinergic antagonists, and corticosteroids (Taffet et al., 2014). Three types of devices the pressurized metered dose inhalers (MDIs), dry powder inhalers (DPIs) or nebulizers (Taffet et al., 2014), are administered for the COPD treatment. However, this process should be also monitored by the medical worker as treatment is the special need of the elderly patients, and a nurse has to meet this need to achieve patient recover (as in the model introduced by Orlando).
Patient recovery and discharge should be based on the following principles:
- cognitive status;
- activity level and functional status;
- the nature of the patient’s current home and suitability for the patient’s conditions;
- availability of family or companion support;
- ability to obtain medications and services;
- availability of transportation from hospital to home and for follow-up visits;
- availability of services in the community to assist the patient with ongoing care (Alper, O’Malley, & Greenwald, 2016).
Only by meeting the following needs, the nurse can ensure that the patient is appropriately helped and the readmission rate might decrease.
In the article by George Taffet et al., Considerations for Managing Chronic Obstructive Pulmonary Disease in the Elderly (2014), the authors speak about COPD in older people, its occurrence and prevalence. What is more, they raise the question of treatment obstacles, the most common of which is the inability to use inhalers by the older generation. This article is significant for the current research proposal as it shows one of the most prevalent risks among patients diagnosed with COPD, who cannot have a self-managed treatment. This issue is very serious as, in most cases, wrong COPD treatment brings towards re-hospitalization in a short-term.
The article Risk Factors of Hospitalization and Readmission of Patients with COPD in Hong Kong Population: Analysis of Hospital Admission Records by Chan et al. (2011), dwells on the disease called COPD as well and its manifestation in Hong Kong. The work analyzes admission reports and calculates the number of unplanned readmissions of the Chinese population. Despite this article focusing only on Hong Kong, it also provides data concerning the COPD occurrence in the United States and the global perspective on the disease spread over time. Therefore, the given work is an informative source to this research proposal as it proposes information of the global importance such as the COPD admissions, treatment of unplanned readmissions and the declared risks.
Another article reflecting on COPD is Readmissions for Chronic Obstructive Pulmonary Disease by Anne Elixhauser et al. (2011). Here, the authors claim that unexpected readmissions and their variations without any logical pattern happen due to problematic patient and care management following premature discharge. The given work highlights readmissions and their causes. Thus, this article is relevant to the research proposal, as it proposes different causative factors of the COPD patient readmission (risks), calculations and concrete numbers with actual costs to treat the patients readmitted within 30 days.
The cohort study Psychosocial Risk Factors for Hospital Readmission in COPD Patients on Early Discharge Services: A Cohort Study by Coventry et al. (2011), focuses on hospital readmission for the COPD acute exacerbation. The study reveals numbers of readmission occurrences and their physiological risk factors. What is more, the article investigates whether psychosocial risk factors are the contributing force to the early readmission, and whether it is possible to eliminate these risks and predict the COPD readmission. This work corresponds to the current research proposal, as it shares the needed data and answers the same questions concerning risks of hospitalization of the elderly clients.
The Master of Nursing Arts thesis “Contributing Factors to Hospital Readmissions” by Susan Amalfitano (2013) investigates the reasons of discharge being unsuccessful and resulting in re-hospitalization. The population under study is also the elderly patients, who are more vulnerable to COPD then the younger generation. This thesis is relevant, because it searches for the reasons of readmission and exemplifies them. Therefore, it is a solid source of information dedicated to the matter of COPD in elderly patients.
The article by Saffel Managing COPD in Elderly Patients (2012) introduces information about such disease as COPD, its diagnosis and treatment procedures. The author also updates about GOLD (guidelines for obtrusive lung disease) and the risks of inadequate treatment, which are also relevant to this research proposal.
The study entitled Risk Factors and Mortality Associated with Hospitalized Chronic Obstructive Pulmonary Disease (COPD) … by Maselli et al. (2015), aims at investigating and comparing the incidence, reoccurrence, risk factors and the COPD patient mortality exacerbations, which resulted in admission compared to those that were not hospitalized during the period of three years. This article is relevant to this research proposal, as it investigates the risks and the causes of hospitalization based on the COPD detailed study.
The Nursing Process Theory by Ida Jean Orlando proposes a theory of nursing, which can be applicable to any nursing process. According to this theoretical model, a nurse and a patient have a special relationship, where the objective of the former is to satisfy the latter and provide him/her with as much care and support as needed. The concepts of caring and curing are central to the nurse and provide a background for his/her nursing practice. This article is relevant to the given research proposal, as it provides theoretical basis (principle) of the nursing work, the neglect of which leads towards serious consequences. Among the negative outcomes and possible risks of the medical neglect is readmission.
The article Chronic Obstructive Pulmonary Disease Rehospitalization. A Big Problem that Now Needs Solutions by Berry & Kalhan (2015), discovers and names the risks of the COPD readmission. These are the socioeconomic status or gender, comorbid cardiac disease, level of physical activity and others. Therefore, this study is relevant to the topic of the research proposal as it brings a new insight into the risks of readmission and the population targeted.
The article by Alper et al., Hospital Discharge and Readmission (2016) speaks about the complex process of discharging patients from hospitals. It presents data and costs concerning the unplanned readmissions. The aim of this article is to investigate how the discharge process is effective and what kind of means can prevent the unexpected exacerbation of the illness. Thus, this work is suitable for the proposal research due to its novelty and overview of the discharge process and interventions based on unplanned readmission reduction.
The purpose of this study is to explore the risks and causes that lead to hospital readmission of the elderly group of people and to investigate the premature reasons of discharge, which result in re-hospitalization within a month after the discharge.
The design of the research presupposes observation (literature review), description (discussion of the findings) and documentation (recording of the findings and highlighting the most important points). Therefore, data based on the risks of hospitalization, COPD symptoms, treatment, readmission rates and illness exacerbations will be obtained and analyzed.
The population used in the current study is the elderly people approximately of seventy and more years old. The sample is gathered from the statistical data present in the articles under review. The similarity between the populations is hospitalization and readmission processes with the diagnosis of COPD. The sample does not have any gender, ethnic or other preferences, only the age category ? 75 years.
The instruments used in the given research are the rating scales and different graphs. These tools will precisely show the quantity of readmissions and the number of risks present in this procedure.
Protection of Human Rights
The rights of patients to be protected concerning the topic of the research proposal are as follows: 1. the right to treatment (the treatment should be carried out adequately); 2. the right to refuse treatment (the patient can refuse to be treated if he/she believes that the kind of treatment is unnecessary); 3. the right to know (it is obligatory that the patient knows his/her diagnosis and the respective risks); 4. the right to be respected (every patient is a human and deserves quality care); 5. the right to complain (if the patient is dissatisfied with the work of the medical workers, he/she can complain); 6. the right for privacy (each patients personal diagnosis and medical data cannot be disclosed without his/her consent).
On reviewing the literary sources, it was found out that there are risks of readmission for the elderly patients diagnosed with COPD. Notwithstanding the findings and the high rates and costs of readmission, the kind of situation can be prevented. First of all, medical workers should be dedicated to their work and take solid care of their patients. This means that the diagnosis cannot be established only by means of visual observation. The nurse should not neglect the needs of his/her patients, and the client must not be discharged unless he/she is educated on possible ways and methods of home treatment. Therefore, it is important that the system of healthcare is re-organized and the number of risks (and re-hospitalizations) should be reduced. Patients, who suffer from COPD, are mostly the older generation with multiple disabilities, and they require constant treatment and support.
To conclude, chronic obstructive pulmonary disease (COPD) is the pulmonary illness with an obstruction to the airflow. The elderly group of people is more vulnerable to this disease as they are aged, their body functioning is partially impaired, and there are a number of limitations present. COPD is characterized with such symptoms like chronic cough, shortness of breath, and physical activity limitations. It prevails among older people, mainly active smokers and those, who have a history of smoking. COPD remains the leading cause of morbidity and mortality all around the world and is a major health problem to the world population nowadays. The annual admission and readmission of patients diagnosed with COPD is very high. Moreover, the costs of these readmissions are twice as higher. It is assumed that by the year 2020, the level of COPD within the elderly population will increase dramatically, with the highest risks being morbidity and mortality.
Therefore, the current proposal researched what were the risk factors of patient readmission. It was found that most of re-hospitalizations occur due to medical errors. For instance, a physician has two ways of establishing the COPD diagnosis (spirometry and observation). Most of doctors do not make their patient take the spirometry tests and base their diagnosis on symptomatic observation. This is unprofessional and causes that COPD may not be the real diagnosis. Moreover, nurses, who take care after the elderly, monitor their health condition and medicine intake, tend to neglect the needs of the patients and do not properly educate them on how to be home treated after discharge. Additionally, the patients ability to be self-treated is not examined, and a nurse is not appointed to pay the client the needed visits. Finally, as the elderly people have a vulnerable immune system, other diseases based on COPD may occur. If other illnesses appear, COPD relapses and worsens the health condition due to illness stratification and devastation of the old exhausted immune system.
Due to the risks described in the proposal, the rates of the COPD readmission are very high and happen within 30 days after discharge. What concerns the costs of these readmissions, they are the following: if COPD is a principal diagnosis and the admission is primary, its total is $7,100 and from $6,800 to $8,100 according to states hospital management respectively (Table 3). However, if COPD is a principal diagnosis within the 30 days after discharge, and the patient is readmitted with the same diagnosis, the total costs are $8,400 and $8,200 – $11,300 with regards to the state (Table 3). The all-cause readmissions total is $11,100, which is too high for any hospital.
In order to reduce the costs and the number of readmissions it is advisable to: 1. test the COPD diagnosis with the help of spirometry testing (if patients are not able to inhale and exhale, the other tests should be implied); 2. the medication prescribed should not be general, and the patient should be educated on how to use it correctly; 3. the nurse should be obliged to take care of the elderly, monitor their condition, meet the primary and secondary needs and educate them on their health status; 4. the elderly patient should be fully aware of the possible risks and ought to have knowledge on how to manage his/her treatment at home; 5. the discharge cannot be performed without primary blood test, symptomatic examination, and making sure that the patient will be surely treated at home. The theoretical model proposed by Orlando has all the steps a nurse should take to provide the patient with the maximum support and eliminate any possible risks.
As the data presented in the research proposal is limited, it is highly advisable to conduct further study and explore more articles to obtain the broader scope of the situation. What is more, it would be best to conduct a qualitative and quantitative research. The literary sources reviewed are mostly studies conducted in 2011, 2014 and 2015. The research is limited due to the locality and regions. Despite having various limitations, the studies propose full information about COPD, its symptoms, target population, treatment and risks.
This research proposal also expects to find out more types of risks that add to the COPD exacerbation, as not only social, medical and self-management risks are the basic causers of readmission. What is more, it is of great importance to understand whether the problem occurring is rather a medical error or patients non-awareness of the possible dangers. In addition, the interesting fact is that one of the reasons for the COPD readmission is smoking. I believe that this risk factor should be analyzed in more details as well as its contribution to the latter COPD problems. It would be best to conduct a real life survey based on the COPD readmission to achieve the latest data on the COPD annual distribution and management. Moreover, the treatment should also be investigated. By so far, the only treatment there is performed with the help of respiratory inhalators. Perhaps, the elderly people can be treated with other possible medicines that will be easier to intake.
Thus, the current research proposal is only the first step into the chronic obstructive pulmonary disease (found in the elderly patients) investigation. In order to get the full picture of COPD, its risks for the elderly and readmission rates, further analysis is required, and a greater amount of statistical data should be skimmed and scanned.