COPD Performance Improvement Teleconference. Participants in the Program. Outcomes. 227 people registered. 61 finished baseline chart review

Transcription

1 COPD Performance Improvement Teleconference Lara Zisblatt, MA Assistant Director Continuing Medical Education Boston University School of Medicine Boston, Massachusetts 1 Participants in the Program 227 people registered 61 finished baseline chart review 35 submitted their Action Plans 6 completed the program 2 Outcomes Measure Initial Spirometry Repeat Spirometry Queried about Smoking Smoking Intervention Oxygen Saturation Assessed Inhaled Bronchodilators Prescribed Influenza Vaccination % Improvement 42% 129% 12.5% 8.5% 8.5% 3.1% 11.8% 3

2 4 Chart Review Challenge Biggest Challenge = Time Ways to overcome this barrier: Lowered the requirement from 10 charts to 5 charts for review Ask support staff to review patients seen in past month with any ICD 9 code for COPD and pull charts or review EMR Complete the chart review with another member of your team Make a plan to complete this chart review Schedule 2 one-hour sessions over the next week using administrative time or your lunch hour Performance Improvement Enrolling in this PI program is the 1 st step in improving care for your patients Key component to improvement is chart review Simple way to look at baseline measures of your practice The very act of reviewing charts can be illuminating 5 COPD Project Make a commitment to yourself and to your patients to work toward improving care! Complete the chart review as soon as possible as your first step toward improvement If you are having trouble completing the chart reviews, please let us know. We can help! Janet Schuldiner, PA, is our program coach. She will be calling you to offer help If you have any questions, please us at mentorqi@bu.edu or call us at

3 Pulmonary Rehabilitation in COPD Claire Murphy, NP-C Instructor of Medicine Pulmonary Nurse Practitioner Boston University School of Medicine 7 Faculty Disclosure Information Claire Murphy, NP-C, has no financial relationship with the grantor and/or any commercial interest 8 Learning Objectives Identify criteria for patient referral to pulmonary rehabilitation Describe how pulmonary rehabilitation optimizes body systems to ease extrapulmonary manifestations of COPD Explain how pulmonary rehabilitation affects patient outcomes in 3 definitive areas 9

4 10 COPD Overview Did you know: There are approximately 12 million people diagnosed with COPD, and ANOTHER 12 million may have COPD but remain undiagnosed COPD is the 4 th leading cause of death, projected to slide into 3 rd place by 2020 There is a 5.1% increase in mortality for COPD ( ), while the mortality for HD and CA declines Cigarette smoking is the most common risk factor COPD = chronic obstructive pulmonary disease; HD = heart disease; CA = cancer. But first Remember that 58-year-old female you inherited, whose medical record you reviewed during COPD Virtual Communities of Practice, and you: Accurately diagnosed COPD through spirometry Obtained a smoking-cessation referral Started her on appropriate inhaled medications, ie: Long-acting bronchodilator (beta 2 -agonist, anticholinergics, ICS, etc) Brought her immunizations up to date (influenza, pneumococcal) But something s missing ICS = inhaled corticosteroid. 11 On her most recent visit She tells you she is still experiencing dyspnea on exertion She is no longer going out to the shopping mall as much, because she gets tired more quickly she must just be getting old Her weight has increased ~20 lb since she really avoids walking along the beach her legs hurt too much She can tell you the Monday-Friday lineup of the new TV shows on cable, since that is her only source of entertainment these days 12

5 13 On physical examination Spirometry shows a moderate obstructive pattern Auscultation of breath sounds reveals mild, prolonged end-expiratory breath sounds decreased in the bases EKG obtained in office R/R/R? Maybe a stress test might not be a bad idea to rule out cardiac ischemia.. What about pulmonary rehab??? Know that. Although the lung function is most severely impacted: Skeletal muscle (esp. those of the lower extremities) = increase in lactic acid production = decrease in exercise tolerance Dyspnea from hyperinflation of the lungs as a result of increased ventilatory demand with little time for expiration Increased anxiety and depression Nici L, et al. Am J Respir Crit Care Med. 2006;173: Casaburi R, et al. Am Rev Respir Dis. 1991;143: Pulmonary rehab will Not directly improve lung function, but rather will minimize its DYSFUNCTION through: Moderating lactic acid levels through exercise Exercise combined with decreased levels of lactic acid will improve ventilatory demand, thus Resulting in a slowing of expiratory rate with diminishing dyspnea and... Antidepressant effect of exercise combined with social interaction Casaburi R, et al. Exercise training in chronic obstructive lung disease. In: Casaburi R, Petty TL, eds. Principles and Practice of Pulmonary Rehabilitation. Philadelphia, PA: WB Saunders; 1993, pp

6 16 Exercise Training Targets in Pulmonary Rehab Program for COPD Patients Casaburi R, ZuWallack R. N Engl J Med. 2009;360: And there is always The promotion of self-management interventions as the patient becomes the manager of his/her disease Generates positive behaviors Increases adherence Early recognition of worsening symptoms Cost-effective Bourbeau J, et al. Arch Intern Med. 2003;163: Bourbeau J, et al. Chest. 2006;130: The evidence supports that Exercise capacity increases Severity of dyspnea decreases Quality of life improves 18

7 19 The evidence supports that (cont d) Lacasse et al in a recent meta-analysis of 31 randomized clinical trials reports: In 11 trials (n=618), improvement was demonstrated in 4 domains by CRDQ Dyspnea Fatigue Emotional function Mastery of disease Results support x the minimum of clinical difference in treatment vs. control group CRDQ = Chronic Respiratory Disease Questionnaire. Lacasse Y, et al. Cochrane Database Syst Rev Oct 18;4 CD The evidence supports that (cont d) In 16 trials (n=669) Demonstrated improvement of functional exercise capacity through 6-min walk test was 48 m Anticipated result: 50 m Lacasse Y, et al. Cochrane Database Syst Rev Oct 18;4 CD Efficacy of Pulmonary Rehabilitation Dyspnea (CRDQ Score) Walking Distance (m) Placebo Rehabilitation 0 Control Rehabilitation Baseline 6 wk 1 yr CRDQ = Chronic Respiratory Disease Questionnaire. Griffiths TL, et al. Lancet. 2000;355:

8 22 Components of a Pulmonary Rehabilitation Program Interdisciplinary team Exercise training Strength training Nutrition Occupational therapy Education/Self-management Psychological counseling Assess for depression Ries AL, et al. Chest. 2007;131:4S-42S. So who do YOU want to send to rehab? Symptomatic patients with an FEV 1 65% And even patients with lesser disease with poor exercise tolerance Resting (and exercise testing with) hypoxemia 90% Patients WITH SOME MOTIVATION Obstructive diseases Typically Stage 3/Stage 4 GOLD COPD/Per Asthma/Bronchiectasis/cystic fibrosis Restrictive diseases ILD (pulmonary fibrosis, sarcoidosis, scleroderma, chest wall diseases) Neuromuscular Lung cancer, pre- and post-transplant FEV 1 = forced expiratory volume in 1 second; GOLD = Global Initiative for Chronic Obstructive lung Disease; ILD = interstitial lung disease. 23 Pulmonary Rehab Yet Another Example of a Performance Improvement Goal Increase number of appropriate patients receiving pulmonary rehabilitation Obstacles: time, lack of referral sites, process Interventions Think about it!! Develop a process for referral Institute home program for home-bound patients Use flowsheet to track appropriate referrals Use check-off box in EMR EMR = electronic medical records. 24

9 25 It s Not Just About the Exercise Understanding COPD and coping strategies Bronchial hygiene Breathing from the abdomen Strategies to stop the panic when you feel you can t breathe In-home breathing exercises Using pulmonary rehab equipment to increase and bump up functional capacity Availability of community resources Support groups For That Home-Bound Patient, How About Some Home Work? Start with some easy coughing to clear your lungs of mucus Now let s practice relaxing and deep breathing for a few minutes Continue deep breathing for a few minutes Try to keep breathing out twice as long as you breathe in Count as you breathe Breathe in: 1-2. Breathe out: No breath holding American Lung Association, May Some Advice for the Patient Stretching and Reaching Movements Help You Warm Up and Get Ready to Exercise. Trunk Turning Sit in a straight-back chair with your shoulders relaxed, and breathe in As you breathe out slowly, turn your trunk to the left, and reach your arms over your left shoulder, as if you were reaching behind you Bounce your arms a few times. Rest, and repeat on the other side American Lung Association, May

10 28 Some Advice for the Patient (cont d) Start with a warm-up period, including stretching and reaching exercises If you feel tired or short of breath at any time while exercising, stop, take a break, and relax a few minutes; then start again Remember, being short of breath isn t bad it means your lungs are working harder than usual Always end your exercise with a cool-down period American Lung Association, May Some Advice for the Patient (cont d) Having a little trouble starting and keeping to that exercise plan? Try to pick an exercise or activity that you enjoy Not to worry...you most likely are already doing exercise like walking, dancing, or gardening Anything that keeps you up and about and active counts! American Lung Association, May The Role of Immunizations in Preventing COPD Exacerbations William C. Kohlhepp, DHSc, PA-C Associate Professor of Physician Assistant Education Quinnepiac University 30

11 31 Faculty Disclosure Information William C. Kohlhepp, DHSc, PA-C, has no financial relationship with the grantor and/or any commercial interest. Mr. Kohlhepp owns stock in Pfizer Inc. Learning Objectives Identify the ways that COPD exacerbations affect the health status of patients Describe the role of viruses and bacteria as COPD exacerbation triggers Explain the benefits of vaccinations against influenza and pneumococcal pneumonia in preventing COPD exacerbations Describe the barriers that prevent susceptible patients from receiving needed vaccines Identify strategies for improving our ability to successfully vaccinate patients with COPD 32 Vaccinations All patients with COPD should receive a pneumococcal vaccine if aged 65 yr All patients with COPD should receive an annual influenza vaccination Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated

12 34 Role of Influenza and Pneumococcus Virus in Exacerbations Bacteria and viruses are thought to cause a substantial portion of COPD exacerbations Viral infection is thought to cause one-third of exacerbations Significant causative virus is influenza Impairment of host defense by influenza leads to colonization with bacteria Wongsurakiat P, et al. Chest Jun;125(6): Benefits of Vaccination Approach using prophylaxis is less effective due to growing pneumococcal resistance Influenza vaccine to chronic lung disease 52% reduction in hospitalizations 70% mortality reduction RCTs in COPD patients demonstrate that influenza vaccine is highly effective in prevention of acute respiratory infections related to influenza virus Pneumococcal (pneumonia) vaccine Conflicting evidence RCTs = randomized clinical trials. Niewoehner DE. Am J Med. 2006;119(10 Suppl 1): Inconsistent and Conflicting Evidence on Vaccine Benefit Pneumococcal vaccination studies: Few small, underpowered studies Retrospective studies, including other lung diseases Prospective study demonstrated reduction in CAP Influenza vaccination studies: Small, randomized, controlled trials Large retrospective studies, including other lung diseases Single Cochrane systematic review Effective and safe CAP = community-acquired pneumonia. Kunisaki KM, et al. Drugs Aging. 2007;24:

13 : Benefit for Influenza Vaccine, Not Pneumococcal Vaccine Study design Largest study of patients with COPD (N = 177,120) Retrospective, community-based population study Study results Influenza vaccine effective at decreasing all-cause mortality Unable to demonstrate similar benefit with pneumococcal vaccine Schembri S, et al. Thorax. 2009;64: Vaccination Rates for Age 65: Not Enough Vaccination Rates (%) 100 Healthy People 2010 Target 90% % 66.8% Influenza Vaccine Pneumococcal Vaccine BRFSS data, median percentage of adults 65 years who had received an influenza vaccine during the prior 12 months or ever received a pneumococcal vaccine, Behavioral Risk Factor Surveillance System (BRFSS), United States, MMWR. 2008;57(SS-7). 38 Vaccination Performance Improvement Goals Influenza vaccine prior to every flu season Pneumococcal vaccine for all COPD patients Intervention: Use a flowsheet in all charts of COPD patient, which includes vaccinations Use stickers on charts of COPD patients Hang a poster in your reception area Send patients postcard reminders 39

14 40 Medicare Beneficiary Study: Why Did You Not Get Vaccinated? Misconceptions about the vaccine Not clear if it is safe Can cause influenza Could have side effects Not clear if vaccine is effective in preventing influenza Lack of clinician recommendation Lack of knowledge about vaccine Concerns about cost MMWR October 8;48(39): Factors Increasing Likelihood of Pneumococcal Vaccine Patients consider themselves at high risk Discomfort or other side effects are limited Recommendation made by a clinician Patient previously heard of vaccine Siriwardena AN. Postgrad Med J Apr;75(882):: Importance of Other Perspectives in Patient s Vaccine Decision-Making Sought advice from others: Practice nurses (37%) Family and friends (27%) Practice receptionists (8%) Read brochure (98%) McDonald P, et al. BMJ. 1997;314:

15 43 Health Belief Model Provides Focus for Vaccine Efforts Patients are more likely to change health behavior if they understand: Perceived susceptibility Assessment of their risk of getting the condition Perceived severity Assessment of condition s seriousness and potential consequences Perceived barriers Assessment of the influences that facilitate or discourage adoption of the promoted behavior Perceived benefits Assessment of the positive consequences of adopting the behavior Strecher VJ, Rosenstock IM. The Health Belief Model. In Health Behavior and Health Education: Theory, Research, and Practice, eds. Glanz K, Lewis FM, Rimer BK. San Francisco: Jossey-Bass; Vaccination Strategies Opportunistic Vaccinate at time of routine visit Contact patients at risk Hand out leaflet with routine prescriptions (enlist pharmacist aid) Run a vaccine campaign 44 Vaccine Campaign: Support Materials Focus on practice clinicians and support staff Leaflet to brief professionals Clinical guidelines Agreed-upon practice guideline Patient identification forms Vaccine reminders on appointment lists Focus on patients Leaflet to brief patients Patient invitation letter Poster for year-round display McDonald P, et al. BMJ. 1997;314:

16 46 Vaccine Campaigns: A Successful Strategy Increase of pneumonia vaccine From 4% to 33% Increased clinician participation Ordering vaccine 17% to 96% Offering vaccine 16% to 81% McDonald P, et al. BMJ. 1997;314: Discussion/Questions 47