Continuity of Care and Avoidable Hospitalizations for COPD
Continuity of Care and Avoidable Hospitalizations for COPD
Background Numerous studied suggest that better continuity of care could result in better health outcomes. However, few studies have examined the relationship between continuity of care and avoidable hospitalizations.
Methods A retrospective cohort study design was adopted. We used secondary data analysis based on claim data regarding health care utilization under a universal coverage health insurance scheme in Taiwan. The study population included 3,015 subjects who were newly diagnosed with chronic obstructive pulmonary disease (COPD) in 2006. The main outcome was COPD-related avoidable hospitalization, and the continuity of care index (COCI) was used to measure continuity of care. A logistic regression model was used to control for sex, age, low-income status, and health status.
Results With regard to the effects of continuity of care on avoidable hospitalizations, dose–response trends were observed. The logistic regression model showed that after controlling for covariables, subjects in the low COCI group were 129% (adjusted odds ratio, 2.29; 95% confidence interval, 1.26–4.15) more likely to undergo COPD-related avoidable hospitalizations than those in the high COCI group.
Conclusions Patients with COPD with higher continuity of care had a significantly lower likelihood of avoidable hospitalization. To prevent future hospitalizations, health policy stakeholders should encourage physicians and patients to develop long-term relationships to further improve their health outcomes.
Chronic obstructive pulmonary disease (COPD) is a major global public health problem. In 2011 COPD was the fourth leading cause of death worldwide, and in 2006 it was the fourth leading cause of death in the United States. According to World Health Organization estimates, 65 million people worldwide have moderate to severe COPD. Unless COPD receives increased attention and disease management improves, it will become the third leading cause of death worldwide in 2030.
COPD constitutes an increasing burden on society and has material effects on health care expenditure. The Global Burden Disease study showed that in 2000 COPD was the cause of more than 26 million disability-adjusted life years and ranked as the 10th leading cause of disease burden in the world. In 2007, the costs of COPD exceeded US$49.9 billion, with US$29.5 billion attributable to direct health care expenditures. Hospitalization is the largest contributor to the cost of COPD. The hospitalization expenditures among Medicare beneficiaries with COPD were 2.7 times those of the Medicare beneficiaries without COPD. An economic burden analysis of 7 countries in North America and Europe (Canada, France, Italy, the Netherlands, Spain, the United Kingdom, and the United States) suggested that hospitalization of patients with COPD comprised the majority (52% to 84%) of the direct costs of COPD in most countries. Acute exacerbations of COPD are a key driver of secondary care costs.Although COPD cannot be completely cured, the Global Initiative for Chronic Obstructive Lung Disease recommends regular and continuous medication and appropriate disease management to reduce the symptoms and frequency of exacerbations, as well as improve the quality of life of patients with COPD. However, previous studies have demonstrated that more than 50% of patients with COPD do not continuously receive prescribed medication.
Continuity of care (COC) is considered to be a core element of primary care. Continuity is generally regarded as having 3 aspects: informational continuity, management continuity, and relational continuity. For patients with chronic diseases, relational continuity is the most important. This continuity refers to the ongoing therapeutic relationship between a patient and care provider. This relationship is usually characterized by personal trust and responsibility. The patient trusts the physician on a personal basis, and the physician is responsible for the patient's overall health care. For chronic patients, a long-term physician–patient relationship could improve mutual communication. In addition, the care provider could help enhance the patient's understanding of his or her medical history. The relationship can contribute to effective management of a chronic condition and enable the development of a long-term disease monitoring mechanism. Previous studies suggest that better COC is associated with fewer hospitalizations, fewer emergency department (ED) visits, better chronic disease control, and better patient satisfaction. To the best of our knowledge, however, few studies have examined the relationship between COC and health outcomes in patients with COPD. Only 1 study examined the relationship between COC and hospital admission for patients with COPD in Korea (65–84 years old). The study indicated that elderly patients with COPD with better COC had fewer hospitalizations. A continuous relationship between patient and physician would be likely to reduce disease progression and reduce unnecessary hospitalization.
Avoidable hospitalizations are defined as conditions for which timely and appropriate ambulatory care can decrease the likelihood of future hospitalization. These conditions also are called ambulatory care–sensitive conditions that could be used to reflect the quality, access, and performance of ambulatory care. To date, many investigators and institutions have identified avoidable hospitalizations using a range of methods. Among these definitions, those defined by the Agency of Healthcare Research and Quality (AHRQ) and by Billings and colleagues were widely used by researchers. Moreover, both these definitions identified COPD as an ambulatory care–sensitive condition. Previous studies showed that personal socioeconomic status, health status, and health care access are associated with avoidable hospitalizations. To the best of our knowledge, however, few studies examined the relationship between COC and avoidable hospitalizations; the majority of these studies included several diseases, but only 1 study focused on diabetes.
Taiwan implemented a compulsory National Health Insurance (NHI) scheme in 1995. Approximately 99% of Taiwan's 23 million residents were enrolled in the NHI scheme. Under this scheme, health care facilities have to submit patient diagnoses and treatment plans to the NHI Administration (NHIA) to claim health care costs. Using the nationwide NHI database, this study aims to determine the relationship between COC and the risk of future hospitalization for patients with COPD.
Abstract and Introduction
Abstract
Background Numerous studied suggest that better continuity of care could result in better health outcomes. However, few studies have examined the relationship between continuity of care and avoidable hospitalizations.
Methods A retrospective cohort study design was adopted. We used secondary data analysis based on claim data regarding health care utilization under a universal coverage health insurance scheme in Taiwan. The study population included 3,015 subjects who were newly diagnosed with chronic obstructive pulmonary disease (COPD) in 2006. The main outcome was COPD-related avoidable hospitalization, and the continuity of care index (COCI) was used to measure continuity of care. A logistic regression model was used to control for sex, age, low-income status, and health status.
Results With regard to the effects of continuity of care on avoidable hospitalizations, dose–response trends were observed. The logistic regression model showed that after controlling for covariables, subjects in the low COCI group were 129% (adjusted odds ratio, 2.29; 95% confidence interval, 1.26–4.15) more likely to undergo COPD-related avoidable hospitalizations than those in the high COCI group.
Conclusions Patients with COPD with higher continuity of care had a significantly lower likelihood of avoidable hospitalization. To prevent future hospitalizations, health policy stakeholders should encourage physicians and patients to develop long-term relationships to further improve their health outcomes.
Introduction
Chronic obstructive pulmonary disease (COPD) is a major global public health problem. In 2011 COPD was the fourth leading cause of death worldwide, and in 2006 it was the fourth leading cause of death in the United States. According to World Health Organization estimates, 65 million people worldwide have moderate to severe COPD. Unless COPD receives increased attention and disease management improves, it will become the third leading cause of death worldwide in 2030.
COPD constitutes an increasing burden on society and has material effects on health care expenditure. The Global Burden Disease study showed that in 2000 COPD was the cause of more than 26 million disability-adjusted life years and ranked as the 10th leading cause of disease burden in the world. In 2007, the costs of COPD exceeded US$49.9 billion, with US$29.5 billion attributable to direct health care expenditures. Hospitalization is the largest contributor to the cost of COPD. The hospitalization expenditures among Medicare beneficiaries with COPD were 2.7 times those of the Medicare beneficiaries without COPD. An economic burden analysis of 7 countries in North America and Europe (Canada, France, Italy, the Netherlands, Spain, the United Kingdom, and the United States) suggested that hospitalization of patients with COPD comprised the majority (52% to 84%) of the direct costs of COPD in most countries. Acute exacerbations of COPD are a key driver of secondary care costs.Although COPD cannot be completely cured, the Global Initiative for Chronic Obstructive Lung Disease recommends regular and continuous medication and appropriate disease management to reduce the symptoms and frequency of exacerbations, as well as improve the quality of life of patients with COPD. However, previous studies have demonstrated that more than 50% of patients with COPD do not continuously receive prescribed medication.
Continuity of care (COC) is considered to be a core element of primary care. Continuity is generally regarded as having 3 aspects: informational continuity, management continuity, and relational continuity. For patients with chronic diseases, relational continuity is the most important. This continuity refers to the ongoing therapeutic relationship between a patient and care provider. This relationship is usually characterized by personal trust and responsibility. The patient trusts the physician on a personal basis, and the physician is responsible for the patient's overall health care. For chronic patients, a long-term physician–patient relationship could improve mutual communication. In addition, the care provider could help enhance the patient's understanding of his or her medical history. The relationship can contribute to effective management of a chronic condition and enable the development of a long-term disease monitoring mechanism. Previous studies suggest that better COC is associated with fewer hospitalizations, fewer emergency department (ED) visits, better chronic disease control, and better patient satisfaction. To the best of our knowledge, however, few studies have examined the relationship between COC and health outcomes in patients with COPD. Only 1 study examined the relationship between COC and hospital admission for patients with COPD in Korea (65–84 years old). The study indicated that elderly patients with COPD with better COC had fewer hospitalizations. A continuous relationship between patient and physician would be likely to reduce disease progression and reduce unnecessary hospitalization.
Avoidable hospitalizations are defined as conditions for which timely and appropriate ambulatory care can decrease the likelihood of future hospitalization. These conditions also are called ambulatory care–sensitive conditions that could be used to reflect the quality, access, and performance of ambulatory care. To date, many investigators and institutions have identified avoidable hospitalizations using a range of methods. Among these definitions, those defined by the Agency of Healthcare Research and Quality (AHRQ) and by Billings and colleagues were widely used by researchers. Moreover, both these definitions identified COPD as an ambulatory care–sensitive condition. Previous studies showed that personal socioeconomic status, health status, and health care access are associated with avoidable hospitalizations. To the best of our knowledge, however, few studies examined the relationship between COC and avoidable hospitalizations; the majority of these studies included several diseases, but only 1 study focused on diabetes.
Taiwan implemented a compulsory National Health Insurance (NHI) scheme in 1995. Approximately 99% of Taiwan's 23 million residents were enrolled in the NHI scheme. Under this scheme, health care facilities have to submit patient diagnoses and treatment plans to the NHI Administration (NHIA) to claim health care costs. Using the nationwide NHI database, this study aims to determine the relationship between COC and the risk of future hospitalization for patients with COPD.