JMIR Publications

ABSTRACT

Background:

Chronic Obstructive Pulmonary Disease (COPD) affects more than 16 million U.S. adults, many of whom experience high rates of acute care revisits (emergency department [ED] and hospital) after initial hospitalization. These frequent exacerbations, often due to failures in transitions of care (TOC), lead to lung function decline and premature mortality. While effective interventions exist to reduce readmissions, wide-scale implementation of COPD TOC programs remains limited. The NIH-funded Reducing REVISITS study was designed to address this implementation gap by developing and implementing bundled COPD TOC programs across diverse U.S. hospitals.

Objective:

To conduct pre-implementation contextual assessments at U.S. hospitals to guide the development of site-specific, evidence-based COPD TOC programs.

Methods:

We conducted pre-implementation contextual assessments using a novel semi-structured interview format that integrated the Consolidated Framework for Implementation Research (CFIR) with human-centered design (HCD) approaches (ethnographic interviewing) to capture real-world experiences of COPD care across inpatient, outpatient, and home settings. Site leads, clinicians, organizational leaders, patients, and caregivers were interviewed. Interviews explored baseline COPD TOC practices, local resources, opportunities for improvement, as well as participant priorities from a menu of 12 evidence-based interventions (e.g., pulmonary rehabilitation, patient navigation, inhaler teaching). Rapid analysis methods identified intervention priorities across interviewee groups along with perceived barriers and facilitators to implementation. Findings were shared with site leads to help guide their development of tailored COPD TOC programs.

Results:

Among 194 participants from 21 sites (42 site leads, 29 organizational leaders, 105 clinicians, and 18 patients/caregivers), the highest priority interventions identified during interviews were post-ED follow-up visits, education (inhaler technique, disease management, action plan), and pulmonary rehabilitation. Reported barriers included clinician-level challenges (limited training, staffing, and time), patient-level challenges (social needs, physical burden of COPD), and system-level challenges (lack of standardization, limited resources, and cost). Key facilitators included the presence of dedicated staff and availability of pre-existing programs or infrastructure. The three most commonly chosen interventions for implementation were patient education (e.g., inhaler education, COPD action plans), medication reconciliation, and post-discharge care (e.g., post-discharge visits, pulmonary rehabilitation).

Conclusions:

This study demonstrates how the integration of implementation science (IS) and HCD approaches can yield valuable insights, beyond what either field could obtain separately, during the pre-implementation phase of COPD TOC program implementation development. Contextual assessments that capture diverse views are instrumental in designing feasible and relevant interventions. Future work will explore how pre-implementation insights relate to post-implementation outcomes across participating sites. Clinical Trial: NCT05568043