Reducing COPD Exacerbation Readmissions in a Community-Based Teaching Hospital

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1 Reducing COPD Exacerbation Readmissions in a Community-Based Teaching Hospital Dawn Waddell, PharmD, BCPS Clinical Pharmacy Manager Lisa Kingdon, PharmD, BCPS Clinical Pharmacy Specialist

2 Dawn Waddell Baptist Dawn WaddellMemorial Hospital - Memphis No Conflicts of Interest

3 Chronic Obstructive Pulmonary Disease (COPD) Affects close to 30 million Americans 3 rd leading cause of death in the US 30-day readmission rate remains at 20% across the country Respir Med 2017;131:6-10.

4 Objective Devise a multi-faceted, multi-disciplinary approach to reduce COPD readmissions Current 30-day readmission rate: 25-30% Average length of stay on readmission: ~9 days Inpatient COPD Exacerbation Management Smoking Cessation Counseling Disease State Education Inhaler Technique Education Improve Access to Outpatient Inhalers

5 Inpatient COPD Exacerbation Care Conducted a MUE to evaluate current inpatient prescribing patterns: Average length of steroid therapy: 3.9 days 45% IV Steroids 21% PO Steroids 15% both IV & PO Average amount received: 435 mg prednisone equivalents Average amount of prednisone equivalents/day: 109 mg/day

6 Inpatient COPD Exacerbation Care Conducted a MUE to evaluate current inpatient prescribing patterns: Average length of steroid therapy: 3.9 days 45% IV Steroids 21% PO Steroids 15% both IV & PO Guideline recommendation: Prednisone 40 mg PO daily x 5 days Average amount received: 435 mg prednisone equivalents Average amount of prednisone equivalents/day: 109 mg/day

7 Outpatient COPD Management 32% of patients discharged with systemic steroids Average length of steroid treatment: 12 days Average amount: 25 mg of prednisone equivalents per day 14% of patients were discharged on guidelinerecommended inhalers 15% of patients filled inhalers prescribed at discharge

8 New Inpatient Protocol Steroids: Old Protocol o Methylprednisolone 40 mg IV q8h o Prednisone 40 mg PO daily Steroids: New Protocol o Prednisone 40 mg PO daily for 5 days o Methylprednisolone 40 mg IV q8h for 72 hours then Prednisone 40 mg PO daily Consider for patients who are mechanically ventilated, critically ill, or receive systemic corticosteroids as an outpatient

9 Smoking Cessation Counseling Consults were being placed, but there was not any follow through Respiratory therapy (RT) designed a new workflow to incorporate counseling and documentation into the flowsheet Both physicians and pharmacists are able to place a RT Smoking consult

10 Disease State Education Non-adherence to inhaled and oral medications in COPD patients reported to be % Effective Interventions Brief counseling Monitoring & feedback about inhaler use Self-management of symptoms Cochrane Review evaluation of Action plans For every 19 provided action plans, one person would avoid a hospital stay for an exacerbation Respiratory Research. 2013;14(109): 1-8. Cochrane Database of Systematic Reviews. 2016;12: CD

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12 Inhaler Technique Training One page education sheets created Placebo inhalers obtained from drug representatives Education completed by the pharmacist with an observed teach back using the placebo inhaler

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15 Barriers to Outpatient Inhalers 14% of patients were discharged on guidelinerecommended inhalers 15% of patients filled inhalers prescribed at discharge Obstacle (n=32) N (%) No COPD discharge medications 5 (19%) Did not pick up medications 11 (41%) Expensive copay 7 (26%) Prior authorization needed 5 (19%) Prior authorization not completed 4 (15%)

16 Insurance Information 3% n=33 6% 91% Medicare/Medicaid Commercial No insurance Medicare/Medicaid Eligible only for free 30 day coupon card Unique formularies for each plan Commercial Insurance Eligible for all coupon cards No insurance Manufacturer assistance

17 Equivalence of Long Acting Inhalers Extensive literature search and critical evaluation of meta-analyses for LABA, LAMA, LABA/LAMA, and LABA/ICS inhalers Similar rates of exacerbation between all LABA inhalers Minimal variation found within LAMA inhalers No difference found within LABA/LAMA inhalers No difference found within LABA/ICS inhalers Int J Chron Obstruct Pulmon Dis. 2017;12: Int J Chron Obstruct Pulmon Dis. 2015;10: Int J Chron Obstruct Pulmon Dis. 2015;10: Int J Chron Obstruct Pulmon Dis. 2014;9:

18 P&T Approval Proposal: Pharmacists can complete an automatic inhaler switch within same medication class to patient s outpatient insurance formulary Approved!

19 Identification of Patients Daily list of admitted patients Includes ~100 patients with COPD on problem list Ideal for intervening on readmitted patients Goal: identify patients on principal admission Collaboration with clinical documentation improvement (CDI) nurses who place a working DRG and ICD-10 code for all Medicare inpatients Request to Epic Build Team to allow this field to be viewed by pharmacists and physicians

20 ICD-10 CM Codes for COPD Code Description J42 Unspecified chronic bronchitis J Emphysema J Chronic obstructive pulmonary disease exacerbation Codes included in cohort if combined with secondary diagnosis of J44 J Acute respiratory failure R09.2 Respiratory arrest Reviewing patients by their ICD-10 CM codes decreased the 100 patients/day to a more accurate patients/month with a true COPD exacerbation.

21 Review of Patients on Principal Admission

22 Process of Interventions Patient Identification by Working DRG Daily evaluation by a pharmacist Patient evaluation Medication history Disease state education RT consult for smoking cessation Ensure fill of outpatient inhalers or change to formulary product Inhaler education with placebo Medication in hand prior to discharge

23 Full Interventions Beginning Mar 2018 COPD ObservedReadmission Rate 30% 25% 20% 15% 10% 16.8% 25.0% 8.6% 27.6% 21.9% 15.4% 12.1% 18.9% 19.0% 18.5% 14.6% 13.8% 13.6% 5% 0% JUN 2017 JUL 2017 AUG 2017 SEP 2017 OCT 2017 NOV 2017 DEC 2017 JAN 2018 FEB 2018 MAR 2018 APR 2018 MAY 2018 Readmission Rate

24 Future Plans Continuation of interventions for patients admitted with COPD exacerbation Addition of a hour phone call to ensure understanding of inhalers, receipt of inhalers, and use of action plan for symptoms

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