Teamwork and Adherence to Recommendations Explain the Effect of a Care Pathway on Reduced 30-day Readmission for Patients with a COPD Exacerbation

Figures & data

Figure 1. Overview mediation analysis.

Table 1. Patient and hospital characteristics.

	Intervention group (n=145)	Control group (n=112)	P-value^a
Individual patient level
Age (years)	69.5 (10.8)	70.2 (9.7)	0.337
Sex			0.773
Men	97 (66.9%)	73 (65.2%)
Women	48 (33.1%)	39 (34.8%)
COPD severity at admission			0.031
GOLD I: mild	4 (2.8%)	7 (6.3%)
GOLD II: moderate	50 (34.5%)	22 (19.6%)
GOLD III: severe	60 (41.4%)	49 (43.8%)
GOLD IV: very severe	31 (21.4%)	34 (30.4%)
Smoking status			0.994
no smoker	9 (6.2%)	7 (6.3%)
ex-smoker	74 (51.0%)	57 (50.9%)
active smoker	62 (42.8%)	48 (42.9%)
Hospitalisation in the year before index admission^b			0.058
0	94 (66.7%)	61 (55.0%)
≥ 1	47 (33.3%)	50 (45.0%)
Unknown	4	1
Charlson comorbidity index			0.119
<=2	59 (40.7%)	35 (31.3%)
>2	86 (59.3%)	77 (68.8%)
Cardiac failure^c	45 (31.0%)	43 (38.4%)	0.218
Diabetes^d	18 (12.4%)	18 (16.1%)	0.402
BMI			0.059
<20	39 (26.9%)	19 (17.0%)
>=20	106 (73.1%)	93 (83.0%)
30-day readmission rate^e	15 (10.3%)	22 (19.6%)	0.042
Adherence	47.3 ± 32.6	24.8 ± 29.2	0.012
ABG measurement^f	21 (42.0%)	15 (39.5%)	0.825
Referral to pulmonary rehabilitation during last year	72 (42.9%)	50 (34.0%)	0.463
Nutritional assessment (BMI)	108 (64.3%)	28 (19.0%)	0.007
Nutritional assessment – underweight	10 (18.2%)	2 (5.7%)	0.233
Nutritional assessment - overweight	10 (37.0%)	2 (9.5%)	0.140
Hospital level
Teaching hospitals	5/10 (50.0%)	4/9 (44.4%)	0.809
>600 beds	2/10 (20.0%)	3/9 (33.3%)	0.509
>300 patients admitted with COPD exacerbation yearly	2/10 (20.0%)	1/9 (11.1%)	0.592
Dedicated caring wards for pneumology	1/10 (10.0%)	3/9 (33.3%)	0.213
Possibility for non-invasive ventilation	3/10 (30.0%)	4/9 (44.4%)	0.514

Notes: Data are mean (SD) or n/N (%). Abbreviations: BMI, body mass index; GOLD, Global Initiative for Obstructive Lung Disease.

^a Chi-square test, Mann-Whitney U-test and t-test for categorical, ordinal and continuous variables, respectively.

^b Index admission: first admission during the study, at point of inclusion.

^c Includes heart failure, arrhythmia, valvular disease, acute myocardial infarction, ischemic heart disease.

^d Includes diabetes uncomplicated and complicated.

^e Adjusted for COPD severity at admission, cardiac failure, diabetes, BMI and intervention-control group.

^f Arterial blood gas measurement 1 or 2 days prior to discharge in patients hypoxemic during COPD exacerbation.

Table 2. Team characteristics.

	Intervention group (n = 152)	Control group (n = 132)	P-value^a
Individual team level
Age of participating team members	20-29 = 32.9%	20-29 = 28.0%	0.434
(% within a given category)	30-39 = 24.3%	30-39 = 29.5%
	40-49 = 19.7%	40-49 = 20.5%
	50-59 = 23.0%	50-59 = 20.5%
	60-69 = 0.0%	60-69 = 1.5%
Sex (% within a given category): male team member	24 (15.8%)	35 (26.5%)	0.026
female team member	128 (84.2%)	97 (73.5%)
Average number of years of being team member (SD)	9.4 (8.4)	9.1 (9.6)	0.785
Mean years of experience with COPD patients (SD)	9.5 (8.4)	11.4 (10.5)	0.091
Team processes
Team climate for innovation	3.6 (0.6)	3.2 (0.7)	0.007
Team vision	3.8 ± 0.6	3.4 ± 0.7	0.004
Participative safety	3.7 ± 0.7	3.3 ± 0.8	0.019
Task orientation	3.4 ± 0.7	3.0 ± 0.8	0.027
Support for innovation	3.4 ± 0.7	2.9 ± 0.8	0.001
Team outcomes
Level of organized care	67.9 ± 14.1	60.1 ± 15.0	0.005
Patient focused organization	73.0 ± 15.3	65.8 ± 16.7	0.008
Coordination of care	69.7 ± 14.0	62.8 ± 15.9	0.013
Communication with patient and family	64.4 ± 19.3	56.3 ± 20.6	0.042
Collaboration with primary care	66.1 ± 17.3	62.0 ± 18.7	0.158
Follow up of care	64.4 ± 15.6	55.6 ± 18.3	0.005
Level of burnout
Emotional exhaustion	3.5 ± 1.7	4.1 ± 1.9	0.026
Level of competence	7.9 ± 1.4	7.5 ± 1.3	0.026
Mental detachment	3.3 ± 1.4	4.0 ± 1.6	0.027

Notes: ^aChi-square test, Mann-Whitney U-test and t-test for categorical, ordinal and continuous variables, respectively.

Table 3. Simple and multiple multilevel regression analysis.

	Care Pathway				30-day readmission
	Estimate	Lower 2·5% CI	Upper 2·5% CI	P-value	Estimate	Lower 2·5% CI	Upper 2·5% CI	P-value
Model 2a: effect of CP on adherence (proposed mediator)
Adherence	14.449	3.240	25.658	0.012	—	—	—	—
Model 2b: effect of CP on TCI (proposed mediator)
TCI	0.365	0.108	0.621	0.005	—	—	—	—
Model 2c: effect of CP on level of organized care (proposed mediator)
Level of organized care	6.655	1.785	11.525	0.007	—	—	—	—
Model 2d: effect of CP on emotional exhaustion (proposed mediator)
Emotional exhaustion	−0.588	−1.319	0.142	0.115	—	—	—	—
Model 2e: effect of CP on level of competence (proposed mediator)
Level of competence	0.244	−0.205	0.692	0.287	—	—	—	—
Model 2f: effect of CP on mental detachment (proposed mediator)
Mental detachment	−0.675	−1.345	−0.005	0.048	—	—	—	—
Model 3a: effect of adherence (proposed mediator) on 30-day readmission
Adherence	—	—	—	—	−0.037	−0.053	−0.020	<0.001
Model 3b: effect of TCI (proposed mediator) on 30-day readmission
TCI	—	—	—	—	−0.827	−1.976	0.321	0.158
Model 3c: effect of level of organized care (proposed mediator) on 30-day readmission
Level of organized care	—	—	—	—	−0.024	−0.120	0.072	0.631
Model 3d: effect of emotional exhaustion (proposed mediator) on 30-day readmission
Emotional exhaustion	—	—	—	—	0.129	−0.366	0.623	0.609
Model 3e: effect of level of competence (proposed mediator) on 30-day readmission
Level of competence	—	—	—	—	−1.640	−2.899	−0.380	0.011
Model 3f: effect of mental detachment (proposed mediator) on 30-day readmission
Mental detachment	—	—	—	—	−0.027	−0.628	0.574	0.930
Model 4: effect of CP, adherence and level of competence (proposed mediators) on 30-day readmission
Care pathway	—	—	—	—	0.591	−0.865	2.047	0.426
Adherence	—	—	—	—	−0.039	−0.061	−0.016	0.001
Level of competence	—	—	—	—	−2.128	−0.213	−4.044	0.029

Notes: 30-day readmission was adjusted for COPD severity at admission, cardiac failure, diabetes and BMI.

Abbreviations: CI, Confidence Interval; BMI, Body Mass Index; GOLD, Global Initiative for Obstructive Lung Disease; TCI, Team Climate for Innovation.

Table 4. Parallel mediation analyses: estimating the mediating effect of adherence and teamwork in the association between CP implementation and 30-day readmission.

	30-day readmission				Level of competence				Adherence
		Lower	Upper			Lower	Upper			Lower	Upper
	Estimate	2·5% CI	2·5% CI	P-value	Estimate	2·5% CI	2·5% CI	P-value	Estimate	2·5% CI	2·5% CI	P-value
Model 5: mediation model assessing the mediating effect of adherence and level of competence in the association between CP and 30-day readmission
Care pathway	0.526	−0.880	1.931	0.464	0.163	−0.319	0.646	0.508	18.152	7.474	28.830	0.001
Adherence	−0.038	−0.060	−0.016	0.001	—	—	—	—	—	—	—	—
Level of competence	−2.044	−3.789	−0.298	0.022	—	—	—	—	—	—	—	—

Notes: 30-day readmission was adjusted for COPD severity at admission, cardiac failure, diabetes and BMI.

Abbreviations: CI, Confidence Interval; BMI, Body Mass Index; GOLD, Global Initiative for Obstructive Lung Disease; TCI, Team Climate for Innovation.