INtegrating Care After Exacerbation of COPD (InCasE)

慢性阻塞性肺疾病(COPD)的恶化在入院的退伍军人中很常见 医院，导致与健康相关的生活质量下降，是医疗保健的重要驱动因素 支出。COPD恶化与慢性心力衰竭并列为医疗服务的第二大原因 退伍军人事务部内的放电。病情加重后的再住院率很高，多达一半的患者 要求在6个月内再次入院。与针对慢性心力衰竭再次住院的倡议相反， 慢性阻塞性肺病不存在类似的努力。我们的研究表明退伍军人管理局潜在地错失了 加强护理以应对COPD的恶化，尽管最近的一些研究表明 成功的干预措施可降低未来病情恶化的风险。需要采取干预措施改善慢性阻塞性肺疾病的护理， 不仅治疗慢性阻塞性肺疾病患者及其伴随的并发症，而且还重新设计护理服务 系统，例如在以患者为中心的护理团队(PACT)内治疗患者的专门机构。当前的系统 反映了基于按服务付费模式的流程，其中专家等待患者转诊，而不是 为一群病人的健康承担责任。专家在地理上也很集中 在文化上和身体上与患者的医疗中心分开的主要医疗中心。 确定如何使用以Pact资深人士为中心的方法部署现有专业对于改进 可获得性、及时性和护理质量。我们建议测试一种与退伍军人事务部一致的新型干预措施 业务目标，并寻求提高COPD患者的护理质量，改善他们的 生活，并减少他们的再次住院和死亡率。 我们的具体目标包括： 在COPD恶化出院的患者中： 1.评估旨在提高生活质量和降低住院率的多方面干预措施 慢性阻塞性肺疾病患者的再入院和死亡率。该干预利用退伍军人管理局的综合 医疗保健和信息系统，通过使用 多学科团队纵向支持出院和初级保健团队护理病人 最近因慢性阻塞性肺病加重出院。干预的目的也是为了提供关于 退伍军人管理局如何扩大专家的责任，以便在高危时期更好地支持患者。 我们假设干预将： 1A.提高患者的生活质量； 1B.减少COPD加重患者入院时的入院时间和死亡率。 次要目标 1.评估干预是否改善了COPD特定的护理流程； 2.评估干预是否提高了退伍军人对护理的满意度； 3.评估初级保健临床医生对干预措施的可接受性和满意度。

Chronic obstructive pulmonary disease (COPD) exacerbations are common among Veterans admitted to hospital, lead to decrements in health-related quality of life, and are important drivers of health care expenditures. COPD exacerbation rivals chronic heart failure as the second leading cause of medical service discharges within VA. The readmission rate after exacerbations is high with as many as half of patients requiring readmission within 6 months. In contrast to initiatives targeting readmission for chronic heart failure, similar efforts do not exist for COPD. Our research suggests that VA potentially misses opportunities to augment care in response to COPD exacerbations despite a number of recent studies that demonstrate successful interventions to decrease future exacerbation risk. An intervention to improve COPD care is needed, not only to treat patients for COPD and their accompanying comorbidities, but also to redesign the care delivery system, such as specialties treating patients within Patient Aligned Care Teams (PACT). The current system reflects a process that is based on a fee-for-service model where specialists wait for patient referrals and do not assume responsibility for the health of a population of patients. Specialists are also geographically concentrated at major medical centers that are culturally and physically separated from the patient's medical home. Determining how to deploy existing specialties using a PACT-Veteran-centric approach is important to improve access, timeliness, and quality of care. We propose to test a novel intervention that is aligned with VA operational goals, and seeks to improve the quality of care among patients with COPD, improve their quality of life, and reduce their hospital re-admissions and mortality. Our specific aims include: Among patients who were discharged from hospital with an exacerbation of COPD: 1. Evaluate a multifaceted intervention that seeks to improve quality-of-life and decrease rate of hospital readmission and mortality among patients with COPD. The intervention leverages the VA's integrated healthcare and informatics system to facilitate the transition from hospital to home by using a multidisciplinary team to longitudinally support discharge and primary care teams in the care of patients recently discharged with a COPD exacerbation. The intervention is also designed to provide evidence about how VA may expand the responsibilities of specialists to better support patients during high risk periods. We hypothesize that the intervention will: 1a. Improve patient quality of life; 1b. Decrease hospital admission and mortality after hospital admission for COPD exacerbation. Secondary Aims 1. Assess whether the intervention improves COPD specific processes of care; 2. Assess whether the intervention improves Veterans' satisfaction with care; 3. Assess acceptability and satisfaction of the intervention to primary care clinicians.