Gillis Darcy, Demmons Jillian, Rocker Graeme
Division of Respirology, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Nova Scotia Health Authority, Halifax, NS, Canada.
Division of Respirology, Nova Scotia Health Authority, Dalhousie University, Halifax, NS, Canada.
Int J Chron Obstruct Pulmon Dis. 2017 May 29;12:1597-1604. doi: 10.2147/COPD.S136183. eCollection 2017.
The Halifax-based INSPIRED COPD Outreach Program™ is a facility-to-community home-based novel clinical initiative that through improved care transitions, self-management, and engagement in advance care planning has demonstrated a significant (60%-80%) reduction in health care utilization with substantial cost aversion. By assessing the feasibility of expanding INSPIRED into the emergency department (ED) we anticipated extending reach and potential for positive impact of INSPIRED to those with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who avoid hospital admission.
Patients were eligible for the INSPIRED-ED study if >40 years of age, diagnosed with AECOPD and discharged from the ED, willing to be referred, community dwelling with at least one of: previous use of the ED services, admission to Intermediate Care Unit/Intensive Care Unit, or admission to hospital with AECOPD in the past year. We set feasibility objectives for referral rates, completion of action plans, advance care planning participation, and reduction in ED visit frequency.
Referral rates were 0.5/week. Among eligible patients (n=174) 33 (19%) were referred of whom 15 (M=4, F=11) enrolled in INSPIRED-ED. Mean (SD) age was 68 (7) years, post-bronchdilator FEV 44.2 (15.5) % predicted, and Medical Research Council (MRC) dyspnea score 3.8 (0.41). We met feasibility objectives for action plan and advance care planning completion. Frequency of subsequent ED visits fell by 54%. Mean (SD) Care Transition Measure (CTM-3) improved from 8.6 (2.0) to 11.3 (1.3), =0.0004, and of 14 patients responding 12 (86%) found the program very helpful. An additional 34 patients were enrolled to our regular program from those referred but ineligible for INSPIRED-ED (n=27) or unwilling to participate (n=7).
INSPIRED-ED outcomes were generally positive, however referral and enrollment rates were lower than anticipated. Despite the potential of early self-management education, the ED may not be the ideal recruitment setting for home-based programs. Our findings underline the importance of conducting preliminary work to ascertain best settings for implementing new self-management education initiatives.
总部位于哈利法克斯的“激发慢性阻塞性肺疾病外展计划”（INSPIRED COPD Outreach Program™）是一项从医疗机构到社区的新型居家临床倡议，通过改善护理过渡、自我管理以及参与预先护理计划，已证明医疗保健利用率显著降低（60%-80%），并实现了可观的成本节约。通过评估将“激发计划”扩展到急诊科（ED）的可行性，我们期望将“激发计划”的覆盖范围和积极影响潜力扩大到那些避免住院的慢性阻塞性肺疾病急性加重（AECOPD）患者。
年龄大于40岁、被诊断为AECOPD且从急诊科出院、愿意接受转诊、居住在社区且满足以下至少一项条件的患者 eligible for the INSPIRED-ED study：既往使用过急诊科服务、入住过渡护理单元/重症监护病房、或在过去一年因AECOPD住院。我们设定了转诊率、行动计划完成率、预先护理计划参与率以及急诊科就诊频率降低方面的可行性目标。
转诊率为每周0.5例。在 eligible patients（n=174）中，33例（19%）被转诊，其中15例（男性4例，女性11例）enrolled in INSPIRED-ED。平均（标准差）年龄为68（7）岁，支气管扩张剂后FEV占预计值的44.2（15.5）%，医学研究委员会（MRC）呼吸困难评分为3.8（0.41）。我们实现了行动计划和预先护理计划完成方面的可行性目标。后续急诊科就诊频率下降了54%。平均（标准差）护理过渡指标（CTM-3）从8.6（2.0）提高到11.3（1.3），P=0.0004，在14例有回应的患者中，12例（86%）认为该计划非常有帮助。另外34例患者从被转诊但不符合INSPIRED-ED条件（n=27）或不愿意参与（n=7）的患者中纳入了我们的常规计划。
“激发计划”-急诊科的结果总体上是积极的，然而转诊率和参与率低于预期。尽管早期自我管理教育有潜力，但急诊科可能不是居家计划的理想招募场所。我们的研究结果强调了开展初步工作以确定实施新的自我管理教育倡议的最佳场所的重要性。
