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Virtual Mentored Implementation to Improve Care Transitions in Chronic Obstructive Pulmonary Disease: Protocol for a
Cathryn T Lee1, Leah Traeger1, Mahima Akula1
1Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL, United States.
JMIR Research Protocols
|January 13, 2026
Summary
This study investigates effective transition of care (TOC) interventions for chronic obstructive pulmonary disease (COPD) to reduce hospital readmissions. The Reduce REVISITS trial evaluates implementation strategies across multiple sites to improve patient outcomes.
Area of Science:
- Implementation science
- Health services research
- Pulmonary medicine
Background:
- Chronic obstructive pulmonary disease (COPD) significantly impacts US adults, leading to frequent emergency department (ED) visits and hospitalizations.
- The transition of care (TOC) from inpatient to outpatient settings for COPD patients is under-researched, despite its importance.
Purpose of the Study:
- To assess COPD TOC interventions using implementation science.
- To conduct a cluster randomized trial of COPD TOC bundles over one year.
- To monitor the sustainment of these interventions over two years across 20 healthcare sites.
Main Methods:
- A pragmatic, multisite hybrid type II effectiveness-implementation design.
- Cluster randomization of 20 sites into four groups based on delivery method (in-person/virtual) and implementation strategy (mentored/co-design).
- Evaluation of clinical and implementation outcomes, with primary effectiveness outcome as COPD-specific acute healthcare use within 30 days of discharge.
Main Results:
- 21 sites completed contextual assessments and implementation plans.
- Site randomization is complete; baseline and implementation-phase data collection are nearing completion.
- Manuscript submission for primary implementation-phase findings is anticipated in December 2025.
Conclusions:
- The Reduce REVISITS study employs implementation science and human-centered design to test COPD TOC interventions.
- The goal is to reduce COPD hospital readmissions and improve outcomes for high-risk patients.
- Evaluating evidence-based programs across diverse healthcare settings will enhance patient care.
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