North Region Respiratory Care Conference April 11-13, 2016 Rochester MN. Improving COPD Outcomes by Improving Care Transition

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1 North Region Respiratory Care Conference April 11-13, 2016 Rochester MN Improving COPD Outcomes by Improving Care Transition Patrick J. Dunne, MEd, RRT, FAARC Fullerton, CA Disclosure Professional relationship with Monaghan Medical Corporation Mylan Pharmaceutical Career-long member/supporter of AARC State affiliates MSRC, WSRC 1

2 Objectives Review the clinical and economic impact of COPD and associated comorbidities; List the evidence-based care guidelines for the inpatient and outpatient treatment of COPD, and Describe strategies where RTs can help reduce all-cause 30-day COPD readmissions by improving care transition Now, About COPD.... Definition: A progressive, inflammatory chronic disease characterized by: Increasing airflow obstruction, Destruction of pulmonary gas exchange areas, and Clinically relevant extra-pulmonary effects secondary to systemic inflammation Prevalence is increasing 3 rd Leading cause of death (120,000/year) Since 2000, mortality greater in women 4 th Leading cause of recidivism (EXPENSIVE $$$$) Cost of hospital stay greater than reimbursement Primary cause: Long-term exposure to noxious inhalants A largely preventable disease 2

3 COPD Is a Significant Health Burden 24 million individuals with COPD 1 12 million with undiagnosed COPD 1 12 million diagnosed with COPD 1 66% * in commercial population not on maintenance therapy 2 34% in a commercial population on maintenance therapy 2 * Some of these patients may be candidates for maintenance therapy. 1. National Institutes of Health. New survey suggests growing awareness of COPD, nation's fourth leading killer htm. Published November 13, Accessed October 29, Make B et al. Int J Chron Obstruct Pulmon Dis. 2012;7:1 9. COPD Cost Impact is Significant $32.1 billion Cost of treating COPD in 2010 *, $49 billion Projected cost of treating in 2020 * * Total annual cost estimates were determined by combining the direct medical costs (attributable costs to COPD and its sequelae) with indirect medical costs (defined as costs due to absenteeism). Total US medical costs aributable to COPD and its sequelae were esmated at $32.1 billion. Total absenteeism costs were $3.9 billion, resulting in a total burden of COPD attributable costs of $36 billion. Ford ES et al. Chest. 2015;147(1):

4 COPD is a Multisystem Disease Lung Cancer Anxiety, Depression, Addiction Pulmonary Hypertension Cardiovascular Disease Anemia Peripheral Muscle Wasting & Dysfunction Osteoporosis Diabetes Metabolic Syndrome Peptic Ulcers GI Complications Cachexia Adapted from Kao C, Hanania NA. Atlas of COPD Hospital Readmissions Primary Contributing Factors for COPD Poorly coordinated transition of care Patients not prepared for continuing self-care responsibilities Gaps in disease knowledge; Consequences of non-compliance Incorrect medication regimens; Access issues Unaware of early warning symptoms of relapse Failure to make/keep follow-up appointments 3 of 4 re-admitted patients no follow-up MD visit Ideally seen within 5-7 days of discharge Poor application of evidence-based medical practice Especially maintenance therapy (GOLD Guidelines) 4

5 Inpatient COPD Care: The Evidence McCrory DC, et al. Chest; 2001 EFFICACY EVIDENCE EXISTS Chest radiography/abgs Oxygen therapy Bronchodilator therapy Systemic steroids Antibiotics Ventilatory support (as required) EFFICACY EVIDENCE LACKING Sputum analysis Acute spirometry Mucolytic agents Chest physiotherapy Methylxanthine bronchodilators Leukotrine modifiers; Mast cell stablizers Level 1-2 evidence of efficacy = Recommended care Insufficient efficacy evidence = Non-recommended care Non-recommended care = Unnecessary care Under-treatment of COPD Record review: 69,820 records from 360 hospitals Lindenauer PK, et al. Ann Intern Med; June % received all of recommended care; 45% received at least one non-recommended care; Only 30% received Ideal Care We identified widespread opportunities to improve quality of care and to reduce costs... by reducing variation in practice Claims data review: 42,565 commercial, 8,507 Medicare Make B, et al. Int J Chron Obstruct Pulmon Dis; January 2012 No pharmacotherapy 60% commercial, 70% Medicare No smoking cessation 82% commercial, 90% Medicare No influenza vaccination 83% commercial, 76% Medicare This study highlights a high degree of under treatment of COPD 5

6 Under-treatment of COPD Summary COPD - an expensive, chronic condition Incidence is increasing Financial liability is escalating (CMS s HRRP) Diagnostic spirometry woefully under-used Use of evidence-based treatment guidelines low Failure to control symptoms a precursor to exacerbations COPD re-admissions largely preventable Chronic disease management strategies a necessity COPD Maintenance Treatment GOLD Guidelines (2014) FEV1 % PREDICTED (AIRFLOW LIMITATION) 80% MILD 50 80% MODERATE 30 50% SEVERE 30% VERY SEVERE EXACERBATION GRADE (RISK) A LOW B MEDIUM C HIGH D VERY HIGH TREATMENT CONSIDERATIONS Smoking cessation; Vaccinations; SABA prn Add to above: Nebulized LABA LAMA daily; Pulm Rehab; Exacerbation action plan Add to above: ICS for exacerbation prone; Referral to pulmonologist Add to above: long term oxygen therapy; Consider surgical options 6

7 Inhaler Misuse in COPD Patients Important Considerations Age related physical/mental deterioration Visual, hearing, tactile, memory Add disease related limitations Actuation/inhalation coordination issues Inability to alter breathing pattern Diminished PIFR capability due to low FEV 1 Physical Ability to Use a DPI Poor Use = Non-delivery of Medication Value of assessing peak inspiratory flow rate Not demanding but insightful maneuver Ability to generate PIFR L/min PIFR 35-40L/min candidate for nebulizer 7

8 Secretion Retention with COPD Exacerbation Can Contribute to Airflow Obstruction; WOB Chest physiotherapy An airway clearance technique (ACT) Secretion retention, ineffective cough problematic Trendelenburg position contraindicated in COPD Proven alternate ACT techniques in use for CF ACBT, AD, HFCWO, IPV, OPEP Which to consider for COPD? OPEP Rx a viable regimen Inexpensive, non-invasive Alone or in combo with SVN Role of Nebulized Therapy in COPD Dhand R, et al. COPD; Feb 2012 Recommendation: Many patients, especially elderly patients with COPD, are unable to use their pmdis and DPIs in an optimal manner. For such patients, nebulizers should be employed on a domiciliary basis... Nebulizers are more forgiving to poor inhalation technique, especially poor coordination with pmdis and the requirement to generate adequate peak inspiratory flows with DPIs. 8

9 Nebulized Therapy at Home Enabling Sustained Medication Adherence Ease of use; simple technique Effective, reliable drug delivery Use not limited by disease severity or mental acuity Inconvenience, IC issues addressed Device and unit dose meds covered under Medicare Part B Home Cleaning/Sterilizing Options AeroEclipse Reusable; Aerobika Infection Control Options Dishwasher safe Immersable in boiling water Microwave sterilizer 9

10 Improving COPD Care Outcomes Starting a New Approach to Care Practice evidence-based inpatient care It s best for patients, hospital, physicians & RTs! Facilitates interactive team care It s cost-effective, becoming linked to payment Important questions at hand-off (Talking points) What # admission? How long since last admission? Last MD visit? (PCP, Specialist?) Meds at home pre-admission? (Access, adherence?) Stage of disease severity? (Spirometry, mmrc, CAT?) Relevant comorbidities? ADL status? Smoking status? Immunizations? New Medicare Requirements Discharge Planning Formalized discharge planning for ALL patients Ensure ALL continuing care needs met PAC Must include relevant in-patient care providers Must take into account patient s goals/preferences Patient-centric care Process to begin within 24 hours of admission Must include complete medication reconciliation Formal, post-discharge follow-up process required 10

11 Medication Reconciliation Ensuring Symptom Control PAC Joint Commission definition: The process of comparing a patient s mediation order to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Medication Reconciliation Ensuring Symptom Control PAC Key Steps: On admission Obtain, verify, and document medication history Determine orders for hospital medication regimen At discharge: Determine post-discharge medication regimen Educate/instruct patient +/or caregiver Transmit medication list to care-team members Caveats: Not a straightforward process Traditionally 3 disciplines (MDs, RNs, PharmDs) Roles/responsibilities vary Patient input can be incomplete Comorbidities adds further complexity 11

12 COPD Care Transition Plan Coleman EA. Coleman s Four Pillars for effective care transition Medication management Red Flag warnings Follow-up MD appointment Written care plan COPD Care Transition Plan Coleman EA. Coleman s Four Pillars Medication management Proper meds (LABA, LAMA, OPEP, LTOT) Correct delivery devices (pmdi Spacer; Home nebulizer) Continued access, Basic troubleshooting, Infection control Red Flag warnings Increasing dyspnea, cough, or mucus alteration When/whom to call 12

13 COPD Care Transition Plan Coleman EA. Coleman s Four Pillars Follow-up appointments Primary care/specialist; Spirometry; Annual flu vaccination Written care plan Individualized; comorbidities addressed, tobacco cessation, daily activity/exercise regimen, comprehendible So, What s in a Name? AARC 2015 Summer Forum and Others COPD Patient Educator COPD Care Coordinator COPD Clinical Specialist COPD Care Navigator COPD Transition Coordinator COPD Case Manager COPD Disease Manager Pulmonary Disease Educator Chronic Care Coordinator Cardio Pulmonary Navigator 13

14 One Hospital s Journey AARC Times November 2015 One Hospital s Journey Brown, GA. AARCTimes; Nov audit of 244 COPD exacerbation pts. To determine: The degree to which evidence-based/recommended care is routinely prescribed, and The degree to which care lacking efficacy is prescribed Findings: RECOMMENDED CARE MEAN 1 Chest radiography 88% 96% Oxygen therapy 89% 95% Bronchodilators 93% 98% Systemic steroids 85% 86% Antibiotics 77% 86% 1. Lindenauer et al., Ann Intern Med, June

15 One Hospital s Journey Brown GA. AARCTimes; Nov 2011 Attributes of new COPD Program: Undertaken in 2008 to reduce cost of COPD care Hospital-wide performance improvement initiative Audits to determine degree of evidence-based care New, standardized admitting order set Training, deployment of RTs as COPD Clinical Specialists New, standardized RT-driven COPD medication protocol Monitoring of clinical, financial, patient satisfaction outcomes Bronchodilator Assessment Score Bronchodilator Therapy Assessment Score SCORE Breath sounds 0 Normal/Clear 1 End Expiratory Wheeze 2 Pronounced Expiratory Wheeze 3 Inspiratory & Expiratory Wheeze 4 Absent or Near Absent Dyspnea (SOB) 0 None 1 Slight 2 Mild 3 Moderate 4 Severe TOTAL SCORE: Total Score Frequency SABA Q4 hours PRN for increased shortness of breath; continue long acting bronchodilators SABA Q4 hours PRN for increased shortness of breath; start long acting bronchodilators SABA and Anticholinergic every 4 hours; consider starting long acting bronchodilators Every 2 hours; if on continuous, then wean SABA by 5 mg/hr as tolerated down to 5 mg/hr Every 1 hour up to 3 treatments, then start continuous SABA and Anticholinergic When SABA use Q4H, convert to long-acting bronchodilators; Reduce SABA to Q4H/prn; Assess peak inspiratory flow rate If 40 L/min Anoro DPI (umeclidinium/vilanterol) QD If 40 L/min Nebulized Perforomist BID; Ipatropium 0.5 mg/q6h 15

16 One Hospital s Journey Brown GA. AARCTimes; Nov 2011 Two years after implementation of COPD Inpatient Care Program ADDITIONAL COMPOSITE MEASURES 2008 N = N = N = 37 Recommended care 57% 71% 86% Length of stay 3.4 days 3.6 days 3.4 days 30-day readmission rate 28% 14% 6% Medicare margin -$613/pt $128/pt $699/pt Oral administration of antibiotics & steroids one-tenth cost of IV route; Pharmacy costs decreased by $52/patient/day; Respiratory care by $27/patient/day Financial Outcomes COPD (MS-DRG ); Margin/admission $2,500 $2,000 $1,500 $1,000 $500 $ $(500) Series1 Linear (Series1) 16

17 North Region Respiratory Care Conference April 11-13, 2016 Rochester MN Improving COPD Outcomes by Improving Care Transition Patrick J. Dunne, MEd, RRT, FAARC Fullerton, CA 17