Factors contributing to high-cost hospital care for patients with COPD

Figures & data

Table 1 Demographics, characteristics, and costs among patients with index hospitalization for COPD exacerbation between 2010 and 2014

	Total N=1,894	Low cost (Q1, bottom 20%) N=379	Middle cost (Q2–Q4, middle 60%) N=1,136	High cost (Q5, top 20%) N=379	P-value
Age in years, mean ± SD	73.4±12.6	72.2±13.2	73.6±12.4	73.8±12.5	0.126
Age >80 years, n (%)	627 (33.1%)	127 (29.6%)	365 (32.1%)	135 (35.6%)	0.209
Male, n (%)	877 (46.3%)	188 (49.6%)	502 (44.2%)	187 (49.5%)	0.078
Elixhauser score, median (IQR)	8.00 (3.00–13.00)	3.00 (3.00–10.00)	8.00 (3.00–13.00)	8.00 (3.00–15.00)	<0.001
Baseline risk of death at admission, median (IQR)	0.08 (0.04–0.15)	0.05 (0.03–0.12)	0.08 (0.04–0.15)	0.11 (0.06–0.18)	<0.001
pCO2 (mmHg),a mean ± SD	56.38±23.82	46.36±14.35	55.18±22.36	62.62±27.46	<0.001
LAPS score,b mean ± SD	39.74±23.80	31.65±20.14	38.69±22.46	50.98±26.87	<0.001
ALC status,c n (%)	123 (6.5%)	0 (0.0%)	23 (2.0%)	100 (26.4%)	<0.001
ICU admission, n (%)	170 (9.0%)	≤5 (0.3%)	35 (3.1%)	134 (35.4%)	<0.001
Use of isolation precautions, n (%)	1,040 (54.9%)	164 (43.3%)	635 (55.9%)	241 (63.6%)	<0.001
Length of stay, median (IQR)	5.00 (3.00–9.00)	1.00 (1.00–2.00)	5.00 (3.00–7.00)	17.00 (12.0–28.0)	<0.001
Mortality, n (%)	147 (7.8%)	7 (1.8%)	67 (5.9%)	73 (19.3%)	<0.001
Transferred to long-term care, n (%)	184 (9.7%)	20 (5.3%)	87 (7.7%)	77 (20.3%)	<0.001
Discharged home with support, n (%)	451 (23.8%)	48 (12.7%)	296 (26.1%)	107 (28.2%)	<0.001
30-Day readmission rate,d n (%)	201 (11.8%)	34 (9.5%)	130 (12.3%)	37 (12.6%)	0.26
Cost per case, median (IQR)	5,121 (2,853–10,731)	1,716 (1,179–2,101)	5,121 (3,619–7,712)	24,399 (16,896–35,627)	<0.001
Total cost for cases	19,776,824	609,732	6,717,670	12,449,422	<0.001
Total cost (%)	n/a	3.1	34	62.9	n/a

Notes: Costs are given in Canadian dollars.

a Arterial partial pressure of carbon dioxide (pCO₂ in mmHg).

b Laboratory-based acute physiology score (LAPS) is a point score based on 14 laboratory tests obtained in the 24 h preceding hospitalization.

c Alternate level of care (ALC), which is the designation used when a patient is medically stable but cannot be discharged home, and therefore must stay in hospital.

d Readmission rates exclude the patients who died during index admission (30-day readmissions/eligible patients for readmission).

Abbreviations: COPD, chronic obstructive pulmonary disease; ICU, intensive care unit; IQR, interquartile range; SD, standard deviation; n/a, not applicable.

Table 2 Costs by hospital discharge location after index hospitalization for COPD between 2010 and 2014

	Died in hospital N=147	Discharged home N=1,029	Discharged home with support servicesa N=451	Transferred to long-term care facility N=184	Transferred to acute care N=57
Total cohort (%)	7.8	54.3	23.8	9.7	3
Cost per case, median (IQR)	12,895 (7,001–28,934)	3,759 (2,296–6,462)	6,582 (3,882–12,574)	10,177 (4,983–22,382)	13,267 (8,184–22,326)
Total cost	3,558,586	6,256,907	5,261,468	3,365,399	1,156,548
Total cost (%)	18.0	31.6	26.6	17.0	5.8

Notes: All costs are in Canadian dollars.

a Support services refer to home care, which could include any of physiotherapy, occupational therapy, personal care, and palliative care at home.

Abbreviations: COPD, chronic obstructive pulmonary disease; IQR, interquartile range.

Table 3 Characteristics by ALC status during index hospitalization for COPD exacerbation in the top cost quintile (Q5, n=379 patients), 2010–2014

Variable	ALC N=100	No ALC N=279	P-value
Cost per case, median (IQR)	29,422.78 (21,420.02–41,649.00)	22,166.20 (16,050.95–32,374.37)	<0.001
Total cost	3,762,454.71	8,686,967.41	n/a
ICU admission, n (%)	9 (9.0%)	125 (44.8%)	<0.001
ICU days, mean ± SD	1.12±4.22	4.37±8.29	<0.001
Length of stay, mean ± SD	40.85±31.98	16.95±10.27	<0.001
Mortality, n (%)	11 (11.0%)	62 (22.2%)	<0.001
Discharged home, n (%)	7 (7.0%)	84 (30.1%)	<0.001
Discharged with support services, n (%)	35 (35.0%)	72 (25.8%)	<0.001
Transferred to long-term care, n (%)	43 (43.0%)	34 (12.2%)	<0.001
Baseline risk of death at admission, median (IQR)	0.16 (0.09–0.21)	0.11 (0.06–0.18)	0.002
Elixhauser score, median (IQR)	8.00 (3.00–15.00)	8.00 (3.00–15.00)	0.902
Respiratory therapist cost per case, median (IQR)	141.93 (0.00–1,597.41)	1,706.98 (304.84–3,720.97)	<0.001
Total nursing cost per case, median (IQR)	15,241.73 (10,731.20–23,165.68)	20,619.69 (14,550.81–29,217.27)	<0.001
Allied health professional cost per case, median (IQR)	2,396.46 (1,341.16–4,588.22)	871.73 (208.12–2,018.54)	<0.001
Age in years, mean ± SD	78.31±10.75	72.21±12.72	<0.001
Age >80 years, n (%)	52 (52.0%)	83 (29.7%)	<0.001

Note: All costs are in Canadian dollars.

Abbreviations: ALC, alternate level of care; COPD, chronic obstructive pulmonary disease; ICU, intensive care unit; IQR, interquartile range; SD, standard deviation.

Figure 1 Relative contribution of hospital days spent under ALC status, acute care, and in ICU, to the mean total length of stay in hospital among middle (Q2–Q4) and top (Q5) cost quintiles.

Abbreviations: ALC, alternate level of care; ICU, intensive care unit.

Table 4 Adjusted odds ratios for factors contributing to high-cost hospitalizations (Q5) for patients hospitalized with COPD between 2010 and 2014

Variable	Adjusted odds ratio for high cost (95% CI)
Age >80 yearsa	0.89 (0.64–1.25)
Elixhauser scorea	1.04 (1.02–1.06)
ICU admission	32.4 (20.3–51.7)
LAPS	1 (0.99–1.01)
Home care on discharge	3.2 (2.2–4.7)
Long-term care after discharge	5.7 (3.5–9.2)
Death in hospital	2.6 (1.3–5.2)
ALC status during hospital stay	23.5 (14.1–39.2)

Notes:

a Continuous variables in the regression model. The other variables were treated as categorical variables.

Abbreviations: ALC, alternate level of care; CI, confidence interval; COPD, chronic obstructive pulmonary disease; LAPS, laboratory-based acute physiology score; ICU, intensive care unit.