An Improvement Project!

A very well written article describes an improvement project in a hospital in Ohio.[1] The idea was to reduce readmissions of patients with chronic obstructive pulmonary disease COPD. The intervention was based on an in-house analysis of the quality of care, and was designed to improve care by remedying identified deficiencies. Many, but certainly not all, of these deficiencies related to use of inhalers. This was identified both by analysis of discharge prescriptions and testimony from patients themselves. Indeed, it is a nice example of patient participation in designing improved care models. The intervention was followed by, and likely caused, a sharp drop in the readmission rate. The reduction in the readmission rate for patients who received all five components of the care bundle was nearly 11%. I worry about “regression to the mean” in such single centre studies showing impressive improvements. However, the authors’ were aware of this risk and carried out a long-run time series showing that readmission rates had been stable for many years prior to the intervention. Furthermore, the individual components of the bundle were all evidence-based and relevant to identified problems in the index hospital. The other problem I have with improvement projects is that they show what can be done, rather than would be achieved by widespread adoption of the same method. That is to say, they are subject to publication bias. In this particular case, the findings are open to two different interpretations. The results could be interpreted to mean that other centres should follow the same overall development pathway, tailoring an intervention to problems identified in each particular hospital. Alternatively, the results could be interpreted to mean that the bundle could be used by other hospitals, on the basis of that, similar problems are likely to be ubiquitous.

I shall invite members of the Chronic Diseases theme of the CLAHRC WM to consider these two interpretations and perhaps consider a replication study locally.

— Richard Lilford, CLAHRC WM Director


  1. Zafar MA, Panos RJ, Ko J, et al. Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science. BMJ Qual Saf. 2017; 26: 908-18.

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