Patient Care Transitions in COPD: Improving Collaboration Between Inpatient and Outpatient Providers to Reduce Readmissions Held in conjunction with Hospital Medicine 2017, SHM s Annual Meeting. Provided by Integrity Continuing Education, Inc. Supported by an educational grant from Sunovion Pharmaceuticals, Inc.
2 Faculty Panel Brian Carlin, MD, FCCP, MAACVPR, FAARC Sleep Medicine and Lung Health Consultants Pittsburgh, Pennsylvania Senior Staff Physician Pittsburgh Critical Care Associates Pittsburgh, Pennsylvania B. Justin Krawitt, MD Medical Director of Care Management and Clinical Documentation Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire Assistant Professor of Medicine Geisel School of Medicine Dartmouth College Hanover, New Hampshire
3 Faculty Disclosures Brian Carlin, MD Consulting fees: Monaghan Medical, Nonin Medical, Philips Respironics, Sunovion Pharmaceuticals, Inc. Speakers Bureau: Monaghan Medical, Philips Respironics, Sunovion Pharmaceuticals, Inc. B. Justin Krawitt, MD Consulting fees: Sunovion Pharmaceuticals, Inc.
4 Learning Objectives Describe long-term management strategies that may reduce COPDrelated hospital readmissions Review important comorbidities of COPD as part of a management strategy to reduce readmissions Incorporate physical and cognitive assessments over the course of the inpatient-to-outpatient transition to determine the appropriate device for patients with COPD Improve communication between inpatient and outpatient healthcare providers who manage patients with COPD to better coordinate care transitions
5 COPD Readmissions The Current Landscape
In-hospital Burden of COPD 1.1 million COPD-related ED visits 1 660,000 hospital discharges 2 $5.7 billion aggregate cost for hospital stays* 3 In-hospital mortality: 4 2.5% for AECOPD-related admissions Up to 28% for patients requiring mechanical ventilation *COPD and bronchiectasis. AECOPD, acute exacerbation of COPD; ED, emergency department. 1. Singh JA, et al. Respir Res. 2016;17:1; 2. Ford ES. Chest. 2015;147(4):989-998; 3. Pfuntner A, et al. HCUP Statistical Brief #168; 2013; 4. Perera PN, et al. J Chron Obstruct Pulmon Dis. 2012;9:131-141. 6
The Hospital Readmissions Reduction Program (HRRP) 2013 Acute MI HF Pneumonia 2015 COPD Total hip arthroplasty Total knee arthroplasty 2017 Aspiration pneumonia Sepsis coded with pneumonia CABG CABG, coronary artery bypass graft; HF, heart failure; MI, myocardial infarction. Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reductionprogram.html. 7
Hospitals Penalized (%) The Impact of HRRP Percentage of hospitals penalized has risen to 79% over the past 5 years Readmission penalties will rise from $108M (2016) to $528M (2017); fines will range from 1% to 3% of Medicare inpatient payments 78% of 2017 Medicare admissions will be in hospitals receiving penalties 64 66 Beneficiary readmission rates have continued to drop since 2012, after the HRRP was enacted by the ACA Hospitals with relatively higher shares of low-income beneficiaries and major teaching hospitals are more likely to incur penalties 78 78 79 ACA, Affordable Care Act; FY, Fiscal Year. Available at: http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/. 100 80 60 40 20 0 FY2013 FY2014 FY2015 FY2016 FY2017 8
Rate of Readmission (per 100 index stays) Readmission Rates of Four High-volume Conditions (2009 2013) 26 24 22 20 25.1 23.5 21.2 20.0 Congestive heart failure COPD Acute myocardial infarction Pneumonia Total index admissions for any cause 18 16 14 12 10 16.9 15.3 14.0 15.5 14.7 13.9 2009 2010 2011 2012 2013 Year Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb196-readmissions-trends-high-volume-conditions.jsp. 9
10 Index Hospitalization Stabilization of the Patient with an Exacerbation
11 Case Study: Patient Background 65-year-old female with COPD (previously confirmed with spirometry) Presents to ED experiencing an exacerbation for the second time in less than 3 weeks Social history: Widowed in the past year Currently lives with son who travels frequently for business Former smoker with a 40 pack-year history
Case Study: Patient Background (Cont d) Medical history: Current diagnosis of GOLD Group B Chronic HF Arthritis Poor vision Mild, but increasing, memory loss over past several months Current medications: Lisinopril Carvedilol Furosemide Nebulized SABA LAMA DPI (admits sporadic use because of difficulty with the device) DPI, dry powder inhaler; GOLD, Global Initiative for Chronic Obstructive Lung Disease; LAMA, long-acting muscarinic antagonist; SABA, short-acting beta 2 -agonist. 12
Case Study: Presentation and Exam Presentation: Shortness of breath Cough accompanied by significant sputum Dyspnea: trouble walking across the room Chest tightness Accessory muscle use Difficulty completing sentences Physical exam: Wheezing and decreased breath sounds Temperature: 100.2 HR: 70, regular rate, no murmurs RR: 24 BP: 130/72 SpO 2 : 86% BP, blood pressure; HR, heart rate; RR, respiration rate; SpO 2, oxygen saturation as measured by pulse oximetry. 13
Initial Treatment of an Exacerbation Bronchodilator therapy Increase doses/frequency of SABA therapy Combine SABAs with anticholinergics Use spacers or air-driven nebulizers Corticosteroids Antibiotics O 2 therapy Adjunctive therapies Noninvasive or invasive mechanical therapies Global Strategy for the Diagnosis, Management and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available at: http://goldcopd.org. 14
5-day Course of Corticosteroids Preferred for COPD Exacerbations Patients Without Exacerbation (%) GOLD Stage 3-4 FEV 1 ~31% predicted Randomized to 5 days or 14 days of prednisone (40 mg) 100 75 50 Short-term group (5 days) Conventional group (14 days) 5-day regimen noninferior to 14-day regimen Average hospital stays 1 day shorter with 5-day regimen 25 0 0 50 100 150 200 Time From Inclusion (days) FEV 1, forced expiratory volume in 1 second. Leuppi JD, et al. JAMA. 2013;309(21):2223-2231. 15
Discussion 16
17 Case Study: Hospital Admission The patient is admitted to the hospital based upon the following factors: Exacerbation history Age Concerns about home care environment
Guiding Principles I: Stabilization of the Patient with an Exacerbation 18 Management should be targeted at minimizing the negative impact of the current exacerbation and preventing the occurrence of future exacerbations and disease progression.
Inpatient Management 19
Comorbidities Associated with Increased Risk of Disease Progression and Future Exacerbations CHF OSTEOPOROSIS SKELETAL MUSCLE WEAKNESS COPD PROGRESSION AND FUTURE EXACERBATION LUNG CANCER ANXIETY DEPRESSION CHF, congestive heart failure. 20
Impact of Comorbidities on Risk for 30-day COPD-related Readmission Early COPD-related Rehospitalization Favors No COPD-related Favors COPD-related Yes No Odds Ratio Rehospitalization Rehospitalization (n=174) (n=3438) (95% CI) P value Anxiety 44 (25.3) 561 (16.3) 1.68 (1.17, 2.41).005 Asthma 71 (40.8) 1036 (30.1) 1.57 (1.14, 2.16).006 Congestive heart failure 45 (25.9) 811 (23.6) 1.19 (0.84, 1.70).322 Diabetes 73 (42.0) 1142 (33.2) 1.45 (1.06, 1.97).019 Depression 31 (17.8) 511 (14.9) 1.18 (0.79, 1.77).422 Dyspnea 122 (70.1) 2011 (58.5) 1.63 (1.17, 2.27).004 Hypertension 116 (66.7) 2131 (62.0) 1.27 (0.92, 1.75).150 Hypoxia 23 (13.2) 284 (8.3) 1.67 (1.06, 2.63).028 Ischemic heart disease 76 (43.7) 1115 (32.4) 1.73 (1.26, 2.38) <.001 Osteoporosis 15 (8.6) 328 (9.5) 1.03 (0.59, 1.79).915 Pneumonia: -30 to -1 days 14 (8.0) 174 (5.1) 1.62 (0.92, 2.86).095-90 to -1 days 15 (8.6) 190 (5.5) 1.65 (0.95, 2.85).077-180 to -91 days 16 (9.2) 175 (5.1) 1.84 (1.08, 3.16).026-270 to -181 days 18 (10.3) 223 (6.5) 1.66 (1.00, 2.76).049-360 to -271 days 24 (13.8) 321 (9.3) 1.53 (0.98, 2.39).063-360 to -1 days 54 (31.0) 701 (20.4) 1.75 (1.25, 2.43).001 Pulmonary vascular disease 15 (8.6) 283 (8.2) 1.06, 0.61, 1.82).843 Stroke 16 (9.2) 366 (10.6) 0.91 (0.53, 1.53).710 Charlson Index (weighted) 2.1 ± 1.2 2.1 ± 1.3 1.00 (0.89, 1.12).980 CI, confidence interval. Roberts MH, et al. BMC Pulm Med. 2016;16(1):68. 0.5 1 2 3 4 Odds Ratio (95% CI) 21
GOLD 2017: The Redefined ABCD Assessment Tool Spirometrically confirmed COPD Assessment of airflow limitation Assessment of symptoms/ risk of exacerbations Post-bronchodilator FEV 1 /FVC <0.7 GOLD FEV 1 (% predicted) 1 80 2 50 79 3 30 49 4 <30 Exacerbation History 2 or 1 leading to hospital admission 0 or 1 (not leading to hospital admission) CAT, COPD Assessment Test; FVC, forced vital capacity; mmrc, modified Medical Research Council Dyspnea Scale. GOLD 2017 Update. Available at: http://goldcopd.org. C A mmrc 0 1 CAT <10 Symptoms D B mmrc 2 CAT 10 22
Treatment Recommendations by GOLD Grade LAMA + LABA GROUP C LABA + ICS Consider roflumilast* GROUP D Further exacerbation(s) Consider macrolide Further exacerbation(s) LAMA GROUP A Continue, stop, or try alternative bronchodilator class LAMA + LABA + ICS Persistent symptoms/further Further exacerbation(s) exacerbation(s) LAMA LAMA + LABA LABA + ICS GROUP B LAMA + LABA Evaluate effect Persistent symptoms A bronchodilator LABA or LAMA *If FEV 1 is <50% predicted and patient has chronic bronchitis; In former smokers. GOLD 2017 Update. Available at: http://goldcopd.org. 23
Pharmacologic Options Bronchodilators Anti-Inflammatory Short-Acting Long-Acting Inhaled Anticholinergic (SAMA) Ipratropium β 2 -Agonists (SABA) Albuterol Levalbuterol Metaproterenol Pirbuterol SAMA + SABA Ipratropium + albuterol Anticholinergic (LAMA) Tiotropium Aclidinium Umeclidinium β 2 -Agonists (LABA) Salmeterol, or 2 -Agonists Formoterol, (LABA) or Arformoterol, Salmeterol, or Indacaterol, or Formoterol, Olodaterol or Arformoterol, or Indacaterol (ultra), or Olodaterol LAMA + LABA Tiotropium + olodaterol LAMA LABA Umeclidinium + vilanterol Tiotropium + olodaterol Glycopyrrolate + indacaterol Umeclidinium vilanterol Xanthine Derivative: Theophylline Xanthine Derivative: Theophylline ICS + LABA Fluticasone + salmeterol Budesonide + formoterol Fluticasone + vilanterol
25 Therapies on the Horizon Type Agent Delivery LAMA Glycopyrronium bromide Nebulizer MDI LABA/LAMA Aclidinium + formoterol DPI LABA/LAMA/ICS Glycopyrronium + formoterol + budesonide MDI
Discussion 26
Association Between Disease Control and One or More Critical Inhaler Errors* Odds Ratio 1.80 1.60 1.47 1.62 1.50 1.54 1.40 1.20 1.00 Hospital Admissions ED Visits Antimicrobial Courses Corticosteroid Courses *Data includes asthma and COPD patient populations. Dekhuijzen PNR, et al. Patient Prefer Adherence. 2016;10:1561-1572; Melani AS, et al. Respir Med. 2011;105(6):930-938. 27
28 Common Inhaler Devices DPI MDI SMI Nebulizer
Assessments to Aid in Device Selection Cognitive Any test for higher-level cognitive function Failure indicates MDI or DPI may be inappropriate Physical Validated teach-back methods for specific devices Check for inspiratory flow (eg, In-Check DIAL) Available at: http://www.alliancetechmedical.com/products/check-dial-training-device/. 29
Overcoming Cognitive and Physical Limitations Cognitive Physical Limitation Unable to coordinate breathing with device requirements Unable to remember instructions for device actuation Unable to keep track of doses Unable to generate adequate PIFR Impaired manual dexterity Pain or weakness from neuromuscular disease Potential Strategy Spacer, SMI, nebulizer Device with fewer steps, nebulizer Device with a dose counter SMI, nebulizer Nebulizer Nebulizer PIFR, peak inspiratory flow rate. Wise RA, et al. Chron Obstruct Pulmon Dis. 2017;4(1):13. Dhand R, et al. J Chron Obstruct Pulmon Dis. 2012;9(1):58-72; Nobles J, et al. Consult Pharm. 2014;29(11):753-756. 30
31 Case Study: In-hospital Care Patient is doing well with corticosteroid and antibiotic treatment Corticosteroids and antibiotics are continued Maintenance bronchodilator therapy is initiated
Hospital Stays for Exacerbations of COPD Following Initiation of LAMA Hospital Stay (± SD, days) 14 12 10 8 6 4 2 0 *P<.05 2004 2006 2004 2006 2004 2006 2004 2006 January February March Jan-Mar Combined * Early addition of tiotropium to a respiratory therapist-directed bronchodilator protocol for patients hospitalized for an exacerbation reduced hospital stays and costs with no safety concerns. SD, standard deviation. Drescher GS, et al. Respir Care. 2008;53(12):1678-1684. 32
Readmission Rate (%) Odds of Readmission 31% Lower When Nebulized LABA Initiated in Hospital 20 15 10 5 Neb-SABA Arformoterol P=.696 7.3 5.8 Overall, significantly lower (8.7% vs 11.9%) 30-day readmissions with arformoterol P=.867 8.9 9.3 P=.031 12.6 8.1 P=.028 17.5 9.9 0 Minor Moderate Major Extreme Severity of Illness Bollu V, et al. Int J Chron Obstruct Pulmon Dis. 2013;8:631-639. 33
DPI Handling Errors Are More Frequent with Greater COPD Severity Error Rate (%) 100 80 60 62 40 20 24 25 34 0 No COPD Mild Moderate Severe Severity of COPD Lareau SC, et al. J Am Acad Nurse Pract. 2012;24(2):113-120. Wieshammer S, et al. Respiration. 2008;75(1):18-25. 34
Inpatient Portable Spirometry Can Be Used to Identify Patients with COPD Obstructed on inpatient spirometry Obstructed on outpatient spirometry Unobstructed on outpatient spirometry Total 45 (75%) 15 (25%) 60 Unobstructed on inpatient spirometry 4 (28.6%) 10 (71.4%) 14 Total 49 25 74 Inpatient portable spirometry during AECOPD can predict airflow obstruction that persists after recovery. Note: Inpatient spirometry was a poor predictor of follow-up severity of obstruction. Loh C, et al. Am J Respir Crit Care Med. 2016;193:A1518. 35
Guiding Principles II: Considerations for Management of the Stable Inpatient 36 The diagnosis of COPD should be confirmed and the patient should be comprehensively assessed (ie, for extent of airflow limitation, symptom severity, and risk for future exacerbations) In addition, maintenance therapy regimens should be reevaluated, adjusted, and initiated during the hospital stay to insure that treatment is appropriate given the physiological and behavioral characteristics of the patient
37 Transitions of Care Opportunities to Reduce Readmissions
38 Case Study: Patient Discharge Patient is symptomatically improved for 24 hours and is ready to return home Issues revealed by comprehensive assessment of the patient s psychosocial situation over the hospital stay are considered: Ability to obtain medications Access to transport Health literacy Insurance coverage of the patient s treatments
Discussion 39
Preparing Patients With COPD for Safe Transitions of Care Upon admission At discharge Postdischarge Initiate processes to reduce readmission risk factors Initiate processes to reduce readmission risk factors Educate patients and and caregivers caregivers in a patient-centered in a patient-centered manner manner Address key patient and caregiver concerns Address key patients and caregiver concerns Provide discharge instructions without without medical medical jargon using jargon teach using back teach back Communicate with with outpatient HCPs HCPs about about hospital hospital stay and stay ongoing and care ongoing care Provide a a complete discharge summary summary to outpatient to outpatient HCPs HCPs Complete medication reconciliation Coordinate outpatient outpatient follow-up follow-up visits visits Check in with patients for early warning signs of an adverse event Provide patient resources needed to handle events if disease worsens Promptly send completed discharge summaries to outpatient HCPs Connect patients to community resources Available at: http://www.hospitalmedicine.org/web/quality Innovation/Implementation_Toolkit/COPD/Best_Practices/transitions_pall.aspx. 40
Pulmonary Rehabilitation Programs in the US Available at: https://www.copdfoundation.org/learn-more/pulmonary-rehabilitation/find-a-pr-center-near-you.aspx. 41
The Pittsburgh Regional Health Initiative: A Case Study in Reducing Hospital Readmissions The Perfect Discharge Bundle Root cause analysis 30 minutes of patient education Pharmacist medication review Discharge action plan Note to physician within 72 hours following discharge Phone call to patient within 72 hours following discharge The Primary Care Resource Center: A New Model for Complex Patients. Available at: https://www.youtube.com/watch?v=mldf3h5fcsi. 42
Guiding Principles III: Care of the Patient at Discharge At discharge, the goals of care during and after the next 30 days should be discussed with patients Patients should receive education on device training, therapeutic expectations, medication adherence, and nonpharmacologic interventions Follow-up consisting of a home care visit or a call from the transition care team, and an appointment with a PCP should be scheduled PCP, primary care provider. 43
44 Audience Response Question Approximately what percentage of PCPs in the United States report being notified when a patient is discharged from the hospital or seen in an ED? A. 10% B. 30% C. 50% 8 0% 0% 0% A. B. C.
% of Cases Communication Between Inpatient and Outpatient Healthcare Providers 80 Notified of ED visit Notified of hospital discharge 60 40 20 0 68 69 56 48 49 37 38 32 32 31 32 29 31 29 27 20 18 18 6 8 NET NZ UK NOR US CAN SWIZ GER AUS SWE In the US, only one-third of PCPs reported being notified when a patient is discharged from the hospital or seen in an ED. 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Available at: http://www.commonwealthfund.org/publications/in-the-literature/2015/dec/primary-care-physicians-in-ten-countries 45
Discussion 46
Improving Communication Between Inpatient and Outpatient HCPs Employment of multiple modes of communication Reliable, standardized discharge documentation Consistent, concise, complete medication & treatment plans Rattray NA, et al. Jt Comm J Qual Patient Saf. 2017;43(3):127-137. 47
Importance of Follow-up After Hospitalization for an Exacerbation An outpatient visit within 1 month after admission resulted in fewer ED visits (14%) and 30-day readmissions (9%) 1 30-day readmission was 10 times more likely for patients not attending primary care follow-up within 4 weeks postdischarge 2 Not attending a follow-up visit within 30 days was associated with an increased risk of rehospitalization within 90 days of discharge (OR, 2.91; 95% CI, 1.06-8.01) 3 1. Sharma G, et al. Arch Intern Med. 2010;170(18):1664-1670; 2. Misky GJ, et al. J Hosp Med. 2010;5(7):392-397; 3. Gavish R, et al. Chest. 2015;148(2):375-381. 48
49 Case Study: 2-week Follow-up Visit Patient reports improved adherence to her therapeutic regimen Symptoms have significantly improved
Guiding Principles IV: Preventing 30-Day Readmissions 50 The goals during the transition of care are to ensure alignment between inpatient and outpatient healthcare providers, and the return of the patient to a safe home environment in which home care providers are equipped to successfully implement the plan of care, monitor health status, and prevent the need for hospital readmission.
Additional Resources SHM Project BOOST www.hospitalmedicine.org/boost Project RED (Re-Engineered Discharge) www.bu.edu/fammed/projectred/ COPD Foundation www.copdfoundation.org The Primary Care Resource Center: A New Model for Complex Patients (PRHI) https://www.youtube.com/watch?v=mldf3h5fcsi PRHI, Pittsburgh Regional Health Initiative; SHM, Society of Hospital Medicine. 51
52 Summary Exacerbations of COPD represent a significant health and economic burden in the hospital setting In-hospital care provides an important opportunity to improve long-term COPD management via confirmation of diagnosis and optimization of maintenance therapy during inpatient treatment and following discharge Individualized discharge and transitional care plans that address specific behavioral, physical, and environmental barriers to care can prevent hospital readmissions
Thank You! 53