Impact of pulmonary rehabilitation on hospitalizations for chronic obstructive pulmonary disease among members of an integrated health care system.

PURPOSE: The evidence regarding the effects of pulmonary rehabilitation (PR) on health care resource use remains limited. This retrospective study evaluated the effects of PR on the primary outcome of all-cause hospitalizations and secondary outcomes of other health care use, exercise capacity, health-related quality of life (HRQOL), and body weight in patients with chronic obstructive pulmonary disease (COPD) in a large integrated health care system. METHODS: The PR cohort included 558 patients with a COPD diagnosis, age ≥ 40 years, who were treated with a bronchodilator or steroid inhaler, participated in 1 of 13 PR programs between January 1, 2008, and August 1, 2013, and were continuously enrolled in the health plan ≥ 12 months prior to and after PR. Two non-PR control cohorts were assembled for comparison. Data were extracted from electronic health records. The 6-minute walk test and St. George's Respiratory Questionnaire results were available for a subset. RESULTS: The proportion of patients who were hospitalized 12 months post-PR was lower compared with the 12 months prior (37% vs 45%, P = .001) while emergency department use was not different (52% vs 54%). Patients who declined PR for logistical reasons had a 40% higher risk of hospitalization than PR participants (relative risk = 1.40, 95% CI: 0.96-2.06, P = .08). There were significant improvements in the 6-minute walk test distance (+43 m) and the St. George's Respiratory Questionnaire total score (-9.6 points) but minimal changes in weight. CONCLUSIONS: Our finding that participation in PR is associated with reductions in hospitalizations corroborates previous studies. A notable strength of this study is the capture of complete utilization data.

Functional status at discharge and 30-day readmission risk in COPD.

BACKGROUND: Efforts to reduce 30-day readmissions are resource intensive. Healthcare systems need to target interventions at patients with the highest risk. Information on physical functioning has been found to increase the performance of previously published risk prediction models. We examined whether functional status documented during routine nursing care in the 24 h prior to discharge was an independent predictor of 30-day readmission risk in patients with COPD. METHODS: Patients from a large integrated healthcare system were included in this retrospective cohort study if they were hospitalized for COPD and discharged between January 1, 2011, and December 31, 2012, age 40+, on a bronchodilator or steroid inhaler, alive at discharge, and continuously enrolled in the health plan 12 months prior to the index admission and at least 30-days post discharge. Our main outcome was 30-day all-cause readmission. Functional status was documented as part of routine nursing care within 24 h prior to discharge as follows: bed bound (Level I), able to sit (Level II), stand next to bed (Level III), walk <50 feet (Level IV), and walk >50 feet (Level V). RESULTS: The sample included 2910 patients (n = 3631 index admissions) with a mean age of 72 ± 11. The 30-day readmission rate was 19%. Multivariate analyses showed that patients who were non-ambulatory at discharge (Levels I-III) were more than twice as likely to be re-admitted within 30-days compared to patients who were able to walk more than 50 feet (RR: 2.14, 95% CI 1.62-2.84, p < .001). There was no significant difference in readmission risk between patients classified as Level IV or V (p > .05). CONCLUSION: Patients with COPD who were non-ambulatory within 24 h prior to discharge were at significantly greater risk of readmission compared to ambulatory patients. Functional status should be used to risk stratify patients for more intensive supportive interventions post discharge.

Brief report: airways abnormalities and rheumatoid arthritis-related autoantibodies in subjects without arthritis: early injury or initiating site of autoimmunity?

OBJECTIVE: To evaluate the presence of pulmonary abnormalities in rheumatoid arthritis (RA)-related autoantibody-positive subjects without inflammatory arthritis. METHODS: Forty-two subjects who did not have inflammatory arthritis but were positive for anti-cyclic citrullinated peptide antibodies and/or ≥2 rheumatoid factor isotypes (a profile that is 96% specific for RA), 15 autoantibody-negative controls, and 12 patients with established seropositive early RA (<1-year duration) underwent spirometry and high-resolution computed tomography (HRCT) lung imaging. RESULTS: The median age of autoantibody-positive subjects was 54 years, 52% were female, and 38% were ever-smokers; these characteristics were not significantly different from those of autoantibody-negative control subjects. No autoantibody-positive subject had inflammatory arthritis based on joint examination. HRCT revealed that 76% of autoantibody-positive subjects had airways abnormalities including bronchial wall thickening, bronchiectasis, centrilobular opacities, and air trapping, compared with 33% of autoantibody-negative controls (P = 0.005). The prevalence and type of lung abnormalities among autoantibody-positive subjects were similar to those among patients with early RA. In 2 autoantibody-positive subjects with airways disease, inflammatory arthritis classifiable as articular RA developed ∼13 months after the lung evaluation. CONCLUSION: Airways abnormalities that are consistent with inflammation are common in autoantibody-positive subjects without inflammatory arthritis and are similar to airways abnormalities seen in patients with early RA. These findings suggest that the lung may be an early site of autoimmune-related injury and potentially a site of generation of RA-related autoimmunity. Further studies are needed to define the mechanistic role of lung inflammation in the development of RA.

Palliative care in lung cancer.

Advancements in the surgical and medical treatment of lung cancer have resulted in more favorable short-term survival outcomes. After initial treatment, lung cancer requires continued surveillance and follow-up for long-term side effects and possible recurrence. The integration of quality palliative care into routine clinical care of patients with lung cancer after surgical intervention is essential in preserving function and optimizing quality of life through survivorship. An interdisciplinary palliative care model can effectively link patients to the appropriate supportive care services in a timely fashion. This article describes the role of palliative care for patients with lung cancer.