COPD: From Hospital to Home October 5, 2015 Derek Linderman, MD Associate Professor COPD Center Pulmonary Nodule Clinic
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1 COPD: From Hospital to Home October 5, 2015 Derek Linderman, MD Associate Professor COPD Center Pulmonary Nodule Clinic Learning Objectives Know the adverse effects of COPD exacerbations Know mainstays of treatment of COPD exacerbations including bronchodilators, antibiotics, steroids and oxygen/non- invasive ventilation Know medical and non- medical therapies that should help with the transition to home to help reduce likelihood of further exacerbations Know risk factors for readmission and data regarding prevention of readmission Outline Definitions and Statistics Inpatient treatment of acute exacerbations of COPD (AECOPD) Transition to home Readmissions
2 63 y/o WM presents with SOB GOLD grade 2 COPD, FEV1 58% predicted History of heart failure with severely reduced LV function on prior echo 5 days increased SOB and increased cough productive of green sputum Exam: tachypneic to 28, saturating 89% RA, diminished breath sounds and soft expiratory wheezes bilatrally, no LE edema CXR hyperinflated lungs but no opacities, chemistry panel and CBC unremarkable, BNP 120 Diagnosis? Definition of COPD Airflow limitation that is not fully reversible Usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases Exposure to known risk factor Smoking most common exposure in US Worldwide is burning of biomass fuels Not dependent on symptoms Definition of Acute Exacerbation of COPD An event in the natural course of the disease characterized by a change in the patient s baseline dyspnea, cough, and/or sputum that is beyond normal day- to- day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.
3 National Perspective COPD is the third leading cause of death in the U.S. Since 2000, deaths in women exceeded those of men Total medical costs attributable to COPD $32.1 billion in 2010 COPD caused 16.4 million days of absenteeism costing $3.9 billion in 2010 Exacerbations of COPD account for greatest portion of total healthcare burden of COPD In 2009 COPD cause of 8 million office visits 1.5 million emergency department visits 715,000 hospitalizations 133,965 deaths in the United States Consequences of AECOPD Accelerated loss in lung function Worsening symptoms and QOL Increased economic costs Increased mortality Consequences of COPD Exacerbations Risk of re- hospitalization after hospitalization for AECOPD 25% at 1 year 44% at 5 years Risk of death after hospitalization for AECOPD 21% at 1 year 55% at 5 years Increased age and prior hospitalizations independent predictors for both McGhan et al. Chest, 2007
4 Consequences of COPD Exacerbations For patients requiring mechanical ventilation In- hospital mortality 10% 40% 1 year mortality Connors et al. Am J Respir Crit Care Med, 1996 Up to 2/3 of exacerbations go unreported Langsetmo et al. Am J Respir Crit Care Med, Diagnosing AECOPD Clinical diagnosis based on change in symptoms Potential biomarker of exacerbation CRP one of best evaluated level 8mg/ml in combination with one symptom (increased SOB, sputum volume or purulence) is specific (95%) but not very sensitive (57%) Brightling. AnnalsATS 2013 Causes of AECOPD Infections Bacterial Viral Air Pollution Unknown cause (1/3 of cases) Pneumonia, PE, CHF, Pneumothorax may mimic or aggravate COPD symptoms
5 Inpatient Treatment of AECOPD Treatment of AECOPD Bronchodilators Probably no difference between inhaled and nebulized treatments Typically long- acting agents are withheld during phase Resume and/or modify home regimen as patient nears discharge Treatment of AECOPD Antibiotics Reduce the likelihood of treatment failure Recommended for: Mechanically ventilated patients (increased mortality and nosocomial pneumonia in ventilated patients not treated) Patients with 3 cardinal symptoms of SOB, increased sputum volume and purulence Patients with 2 cardinal symptoms if purulence is one Length of treatement 5-10 days, specific therapy determined by local resistance patterns Procalcitonin algorithms may help reduce or eliminate need for antibiotics Influenza/respiratory virus testing during peak seasons
6 Treatment of AECOPD Steroids Result in: shorter recovery time and hospital stay, Improved lung function and hypoxemia Reduced risk of treatment failure, early relapse Oral steroids equivalent to IV Prednisone mg per day probably adequate but optimal duration is unclear (10-14 days?) Treatment of AECOPD Oxygen Supplementation Supplemental oxygen reduces mortality chronic outpatient setting Titrate O2 to keep saturations 88-92% N.B. Likelihood of worsening hypercapnea with saturations >95% is low Titrate O2 at rest and with ambulation prior to discharge and arrange for home oxygen if needed Treatment of AECOPD Non- invasive ventilation Non- invasive ventilation (NIV) is beneficial for acute hypercapneic respiratory failure: Improves respiratory acidosis ( ph, PaCO2) Improves WOB Reduces hospital length of stay Reduces need for endotracheal intubation Reduced mortality
7 Treatment of AECOPD Mechanical Ventilation Mechanical ventilation if: failure or intolerance of NIV Severe refractory hypoxemia Massive aspiration Altered consciousness and/or hemodynamic instability Poorer outcomes for patients requiring mechanical ventilation Treatment of AECOPD Smoking Cessation Sustained abstinence from smoking reduces the rate of decline in lung function among other health benefits Smoking cessation counseling should be offered to active smokers admitted with AECOPD Nicotine replacement should be offered while inpatient If comprehensive smoking cessation program available, referral should be made during discharge planning Pharmacotherapy for Smoking Cessation? USA Today
8 Transitioning to Home Transitioning to Home Time for Discharge? Discharge is probably appropriate when Patient (and ABG s if tested) clinically stable hours Able to use long- acting inhalers Short- acting bronchodilator use q4 hours Appropriate follow up and home (or other) care arranged Patient, family and care providers feel discharge is appropriate Transitioning to Home Home Medical Regimen Patients should be transitioned to long- acting inhaler therapy while inpatient Most long- acting agents (LABA, ICS and LAMA) shown to improve symptoms reduce exacerbations reduce hospitalizations
9 Transitioning to Home Home Medical Regimen LABA/ICS combination is better than either component alone (TORCH trial) Trend towards reduced mortality Increase in pneumonia with ICS GOLD guidelines recommended for FEV1 <50% and frequent exacerbations Tiotropium reduces symptoms, exacerbations and hospitalizations (UPLIFT trial) May be additive to LABA/ICS combination Meta- analyses raised concern for increased mortality with anticholinergic inhalers UPLIFT did not observe this in 4 year trial of tiotropium Transitioning to Home Additional Medical Therapies Macrolide antibiotic, azithromycin 250 mg daily increases time to next exacerbation Beware CV effects/qt prolongation Increased bacterial resistance but less likely to become colonized Phosphodiesterase- 4 inhibitor roflumilast 500 mcg daily reduces exacerbations in GOLD 3-4 patients with a history of exacerbations and chronic bronchitis GI symptoms particularly diarrhea and weight loss may lead to intolerance of medication Criner et al. Chest, 2015 Transitioning to Home Non- Medical Therapies Vaccinations Annual influenza vaccine recommended 23- valent pneumococcal vaccine recommended 65 or <65 if COPD 13- valent pneumococcal vaccine recommended for all patients 65 GOLD Guidelines 2013 Criner et al. Chest, 2015
10 Transitioning to Home Non- Medical Therapies All COPD patients benefit from regular physical activity and should be encouraged to remain active Pulmonary Rehabilitation Formalized program consisting of exercise training, nutritional counseling and disease education Improves exercise capacity and QOL Reduces SOB Reduces hospitalizations for exacerbations seen within 4 weeks of exacerbation Not widely available, not always covered by insurance GOLD Guidelines 2013 Criner et al. Chest, 2015 Transitioning to Home Non- Medical Therapies Assess needs and arrange home oxygen therapy if necessary Nocturnal NIV in patients with severe COPD (FEV1 <50% predicted) and chronic hypercarbic & hypoxic respiratory failure (PaCO2 >46 mmhg) Adjusted mortality (not crude) favored NIV over oxygen therapy alone (HR 0.63) No change in PaCO2 or hospitalization rates Disease- specific QOL not improved and certain elements worse with NIV McEvoy et al. Thorax, 2009 Preventing Readmissions
11 Why worry about readmissions? Morbidity and mortality effects of AECOPD ACA established the Hospital Readmissions Reduction Program (HRRP) For discharges starting 10/1/12, hospitals incurred a reduction in payment from CMS that had excess 30- day readmissions for acute MI, heart failure and pneumonia In late 2014 COPD and TKA/THA added to HRRP What we know about COPD readmissions 20% of patients admitted for AECOPD were readmitted in 30 days Highest readmission was day 1 post- discharge (6%) 60% of readmissions were within 15 days of discharge Readmitted patients more likely dually eligible and had longer LOS for index admission Shah et al. Chest, 2015 What we know about COPD readmissions Most common reasons for readmission: COPD (27.6%) Respiratory Failure Pneumonia CHF Asthma Respiratory causes accounted for only 50.6% of readmissions Shah et al. Chest, 2015
12 What we know about COPD readmissions Patients admitted with COPD who had co- existing psychological disorders more likely to be lower SES longer LOS during index admission less likely to follow up as outpatients (63% vs 74%) higher 30- day readmission rates (23.8% vs 16.3%) COPD most common reason for 30- day readmissions (31%) Singh et al. Chest, 2015 What we know about COPD readmissions Most common psychological disorders in readmitted patients Depression Anxiety Psychosis Alcohol abuse Drug abuse Singh et al. Chest, 2015 What we know about COPD readmissions Patients admitted for AECOPD Only 44% had follow up with a pulmonologist Those that did not follow up within 30- days of discharge OR 2.91 of readmission in 90 days OR 1.83 of additional hospitalization or death Gavish et al. Chest, 2015
13 Interventions to reduce readmissions Meta- analysis of 5 studies with interventions to attempt to reduce readmissions All programs involved disease- specific education and development of a disease management plan and some form of hotline for patients Heterogeneity in smoking cessation, pulmonary rehab, follow up with provider Evaluated 6-12 month readmissions, not 30- day 2/5 showed some reduction in readmissions Most showed no significant difference in mortality, except for the one performed in the US (Fan et al. Ann Intern Med, 2012) which was stopped early due to excessive deaths in the intervention group Prieto- Centurion et al. AnnATS, 2014 Interventions to reduce readmissions Hopkinson et al. implemented a discharge bundle incuding Disease specific education and management plan Smoking cessation counseling Referral to Pulmonary Rehab Follow up appointment with specialist Follow up phone call post- discharge These elements much more likely to be done after implementation of the bundle 30 day readmissions trended down but not statistically significant (10.8% vs 16.4%) Hopkinson et al. Thorax, 2012 Interventions to reduce readmissions Jennings et al. implemented a discharge bundle incuding Disease specific education Smoking cessation counseling Assessment of anxiety/depression Appropriate use of inhalers Follow up phone call post- discharge 30 day readmissions not statistically different between groups (22.8% vs 19.4%) and study stopped during year 3 interim analysis Jennings et al. Chest, 2015
14 COPD Readmissions Summary Readmissions within 30 days are fairly common Lower SES more likely to be readmitted, more likely for co- existing psychological disorders, and less likely to follow up Concern for safety net hospitals more likely to be penalized under HRRP and least able to afford it No interventions proven to reduce 30- day readmission rates Thank You Questions?
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