title: Factors contributing to high-cost hospital care for patients with COPD.
abstract: Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital admission, the fifth leading cause of death in North America, and is estimated to cost $49 billion annually in North America by 2020. The majority of COPD care costs are attributed to hospitalizations; yet, there are limited data to understand the drivers of high costs among hospitalized patients with COPD. In this study, we aimed to determine the patient and hospital-level factors associated with high-cost hospital care, in order to identify potential targets for the reorganization and planning of health services. We conducted a retrospective cohort study at a Canadian academic hospital between September 2010 and 2014, including adult patients with a first-time admission for COPD exacerbation. We calculated total costs, ranked patients by cost quintiles, and collected data on patient characteristics and health service utilization. We used multivariable regression to determine factors associated with highest hospital costs. Among 1,894 patients included in the study, the mean age was 73±12.6 years, median length of stay was 5 (interquartile range 3-9) days, mortality rate was 7.8% (n=147), and 9% (n=170) required intensive care. Hospital spending totaled $19.8 million, with 63% ($12.5 million) spent on 20% of patients. Factors associated with highest costs for COPD care included intensive care unit admission (odds ratio [OR] 32.4; 95% confidence interval [CI] 20.3, 51.7), death in hospital (OR 2.6; 95% CI 1.3, 5.2), discharge to long-term care facility (OR 5.7; 95% CI 3.5, 9.2), and use of the alternate level of care designation during hospitalization (OR 23.5; 95% CI 14.1, 39.2). High hospital costs are driven by two distinct groups: patients who require acute medical treatment for severe illness and patients with functional limitation who require assisted living facilities upon discharge. Improving quality of care and reducing cost in this high-needs population require a strong focus on early recognition and management of functional impairment for patients living with chronic disease.
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute; Department of Medicine, University of Ottawa, Ottawa, ON.
authors.forename: Sunita
authors.initials: S
authors.lastname: Mulpuru
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute.
authors.forename: Jennifer
authors.initials: J
authors.lastname: McKay
authors.affiliation: Department of Community Health Sciences, University of Calgary, Calgary, AB.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Ronksley
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute; Institute of Clinical and Evaluative Sciences, Toronto; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Kednapa
authors.initials: K
authors.lastname: Thavorn
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute; Department of Medicine, University of Ottawa, Ottawa, ON.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Kobewka
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute; Department of Medicine, University of Ottawa, Ottawa, ON.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Forster
mesh_terms: D000046:Academic Medical Centers / Q000191:economics*; D000368:Aged; D000369:Aged, 80 and over; D040561:Assisted Living Facilities / Q000191:economics; D003422:Critical Care / Q000191:economics; D018450:Disease Progression; D005260:Female; D006295:Health Resources / Q000191:economics* / Q000706:statistics & numerical data; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000191:economics; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D015999:Multivariate Analysis; D009864:Ontario; D010343:Patient Admission / Q000191:economics*; D010351:Patient Discharge / Q000191:economics; D017064:Process Assessment, Health Care / Q000191:economics*; D029424:Pulmonary Disease, Chronic Obstructive / Q000191:economics* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
keywords: chronic obstructive pulmonary disease; cost analysis; frailty; functional limitation