Evaluation of 'care bundles' for patients with chronic obstructive pulmonary disease (COPD): a multisite study in the UK.

Background

Chronic obstructive pulmonary disease (COPD) accounts for 10% of emergency hospital admissions in the UK annually. Nearly 33% of patients are readmitted within 28 days of discharge. We evaluated the effectiveness of implementing standardised packages of care called 'care bundles' on COPD readmission, emergency department (ED) attendance, mortality, costs and process of care.

Methods

This is a mixed-methods, controlled before-and-after study with nested case studies. 31 acute hospitals in England and Wales which introduced COPD care bundles (implementation sites) or provided usual care (comparator sites) were recruited and provided monthly aggregate data. 14 sites provided additional individual patient data. Participants were adults admitted with an acute exacerbation of COPD.

Results

There was no evidence that care bundles reduced 28-day COPD readmission rates: OR=1.02 (95% CI 0.83 to 1.26). However, the rate of ED attendance was reduced in implementation sites over and above that in comparator sites (implementation: IRR=0.63 (95% CI 0.56 to 0.71); comparator: IRR=1.12 (95% CI 1.02 to 1.24); group-time interaction p<0.001). At implementation sites, delivery of all bundle elements was higher but was only achieved in 2.2% (admissions bundle) and 7.6% (discharge bundle) of cases. There was no evidence of cost-effectiveness. Staff viewed bundles positively, believing they help standardise practice and facilitate communication between clinicians. However, they lacked skills in change management, leading to inconsistent implementation.

Discussion

COPD care bundles were not effectively implemented in this study. They were associated with a reduced number of subsequent ED attendances, but not with change in readmissions, mortality or reduced costs. This is unsurprising given the low level of bundle uptake in implementation sites, and it remains to be determined if COPD care bundles affect patient care and outcomes when they are effectively implemented.

Trial registration number

ISRCTN13022442.

Déclaration de conflit d'intérêts

Competing interests: SP is a general practitioner, and JB and JC are hospital consultants working in the fields of emergency care and respiratory medicine, respectively. All have endeavoured to ensure that their input to the research has not been biased by their own clinical practice. JC worked with colleagues at the British Thoracic Society to design and evaluate care bundles as an intervention to improve outcomes in a number of different respiratory conditions, including chronic obstructive pulmonary disease, pneumonia and asthma. SP is a member of the National Institute for Health Research (NIHR) Health Services and Delivery Research Researcher-led Panel, from 2017 to date. WH is a member of the NIHR Health Technology Assessment Clinical Trials Board. SJ runs an independent consultancy for public and charitable sector clients, providing strategy and organisation development, leadership coaching and facilitation.