January 20-22, 2012 Des Moines Marrio, 700 Grand Avenue, Des Moines, IA Session 1: Clinical Transi ons and Preven on of Hospital Readmissions C: Chronic Obstruc ve Pulmonary Disease 11:15am - 12:15pm ACPE UAN 107-000-12-012-L01-P Ac vity Type: Applica on-based 0.1 CEU/1.0 Hr Program Objec ves for Pharmacists: Upon comple on of this CPE ac vity par cipants should be able to: 1. List preventable risk factors for hospital readmission for COPD 2. Describe mechanisms to prevent hospital readmissions for COPD related to medica on use 3. Recommend and defend pharmacotherapeu c interven ons to prevent high-risk pa ents from being rehospitalized for exacerba ons of COPD 4. Construct plans for monitoring effec ve medica on use in pa ents with COPD Speaker: Gary Milavetz, BS, PharmD, RPh, received his Bachelor of Science in Pharmacy and Doctor of Pharmacy degrees from the University of Minnesota. A er comple ng a Post-Doctoral clinical pharmacy fellowship in pediatric respiratory diseases, he was appointed to the faculty of the University of Iowa College of Pharmacy. Currently, he is an Associate Professor of Pharmacy and is also a clinical pharmacist in the Allergy and Pulmonary Division of the Department of Pediatrics at the University of Iowa Hospitals and Clinics. He sees pa ents, directs introductory and advanced prac ce student pharmacists and precepts pharmacy residents at the Pediatric Allergy and Pulmonary Clinics. He lectures in respiratory therapeu cs. His most recent research is in understanding driver impairment by therapeu c medica ons at the Na onal Advanced Driving Simulator on the University of Iowa campus. He is a Fellow of the American College of Clinical Pharmacy. Speaker Disclosure: Gary Milavetz does not report any actual or poten al conflicts of interest in rela on to this CPE ac vity. Off-label use of medica ons will not be discussed during this presenta on.
Clinical Transitions and Prevention of Hospital Readmissions: Chronic Obstructive Pulmonary Disease Faculty Disclosure Gary Milavetz reports no actual or potential conflicts of interest associated with this presentation. Gary Milavetz, BS, PharmD, FCCP Associate Professor The University of Iowa College of Pharmacy Gary Milavetz indicates that off label use of medications will be discussed during this presentation. Learning Objectives Upon completion of this activity participants will be able to: List risk factors for hospital readmission for COPD Describe medication interventions geared to prevent hospital re admissions for COPD. Recommend and support pharmacotherapeutic interventions to prevent high risk patients from being rehospitalized for exacerbations of COPD Construct plans for monitoring effective medication use in patients with COPD Pre Assessment Questions 1. What is the primary cause of COPD? A. Smoking B. Pollution C. Old age D. Chronic pulmonary infections 2. List primary pharmacotherapy for COPD A. Bronchodilators and corticosteroids B. Antibiotics and bronchodilators C. Antibiotics and corticosteroids D. Mucolytics and oxygen 3. Non pharmacologic therapy should include: A. Education B. Nutrition C. Physical activity Case vignette #1: Stubborn Stella CC: I got smothern spells again and don t bother telling me to stop smoking because I ain t gonna do it. Just let me catch my breath. HPI: 76 y.o. Caucasian female with a long history of COPD with exacerbations (4 6x/yr). She has SOB and coughs up several tablespoons of sputum several times a day. Respiratory symptoms have worsened over the past week. Coughing paroxysms result in her lips and nail beds getting dusky. History of smoking 1 ½ packs/day for about 60 years. Med Hx: Levalbuterol 1.25mg by nebulizer q4h. Combivent MDI prn (uses 4 6 x/day, last refill 3 weeks ago) Maxair Autohaler prn (uses 4 6x/day, last refill 3 weeks ago) Amoxicillin 250mg TID (filled 4 days ago) Why is COPD important? COPD is the 3 rd leading cause of death in the US In 2001, more than 12 million were diagnosed as having COPD * COPD costs US about $32.1B in 2002* Major cause of disability Patients are frequently hospitalized *http://www.copd international.com/library/statistics.htm Accessed 12/1/11 1
Chronic Obstructive Pulmonary Disease Two primary forms: Chronic bronchitis (inflamed airways) Emphysema (damaged alveoli) Most patients will have some combination of both Common symptoms Coughing with or without sputum production Wheezing Shortness of Breath (SOB) Dyspnea on Exertion (DOE) Frequent respiratory infections Develops over years to decades Causes of COPD Inhaled irritant exposure Primary cigarette smoke (#1 cause) Secondhand smoke Fire smoke without proper ventilation Chemicals, dust, other airborne particulates and pollution Treatment goals Slow or halt disease progression Reduce exposure to inhaled irritants Effectively treat acute symptoms Prevent exacerbations Allow normal lifestyle Treatment review Smoking cessation Education Pharmacotherapy Bronchodilators Glucocorticoids Inhaled Oral Others: Oxygen, antibiotics, mucolytics Physical activity Nutrition 2010 Global Initiative (GOLD) Update: http://www.goldcopd.org/uploads/users/files/goldreport_april112011.pdf accessed 12/1/11 Smoking cessation Pharmacotherapy Nicotine replacement Varenicline Bupropion Behavioral Slow reduction Cold turkey Substitution Alternative approaches Acupuncture Suggestion therapy Bronchodilators Methylxanthines Theophylline/aminophylline Others B 2 selective sympathomimetic agonists Short acting (for reversible component) Albuterol/levalbuterol Pirbuterol Long acting Salmeterol Formoterol/arformoterol Anticholinergics Ipratropium Tiotropium 2
Corticosteroids Inhaled (maintenance of asthmatic component) Beclomethasone Budesonide Ciclesonide Fluticasone Mometasone Oral (intervention) Prednisone/methylprednisone Hydrocortisone Dexamthasone Combination therapy ICS + LABA Advair (fluticasone + salmeterol) Symbicort (budesonide + formoterol) Dulera (mometasone + formoterol) Anticholinergic + SABA Combivent (albuterol + ipratropium) Pharmacotherapy: Other Antibiotics for evidence of a bacterial infection Depends on culture and sensitivity/local patterns Lack of evidence for use: BMC Medicine 2008, 6:28 Bacteria: H. influenzae, S. Pneumonia, M. catarrhalis Aminopenicillin (with or without clavulanic acid) Macrolide Tetracycline Mucolytics Dornase alfa (rhdnase) N acetylcysteine Oxygen Short term Long term Proper technique for inhaled medications Metered dose inhalers Valved holding chambers for MDIs Dry powder inhalers Nebulizers Non pharmacologic therapy Education Disease Treatment plan Nutrition Physical activity (Pulmonary rehabilitation) Individualized and gradual to reduce impairment Vaccinations Psychosocial support as needed Surgery? Case vignette #2: Chesterfield Chester Chester is a 66 yo retired machinist who has a 20 pack year history of smoking. He was admitted with an acute exacerbation of COPD and discharged after a 4 day tune up with the following prescriptions: Verenicline: 0.5mg qd x 3 days, then 0.5mg BID x 3 days then 1mg BID Tiotropium HandiHaler 1 capsule every day Azithromycin 500mg first day, now on day #3/5 of 250mg What other recommendations do you have? 3
What s the issue? COPD readmission rates (from AHRQ s H CUP database 1 ): Across 15 states in 2008 190,700 admissions with COPD as primary diagnosis 30 day readmission rate with COPD as primary diagnosis was 7.1% 30 day readmission rate with COPD for any diagnosis was 17.3% Costs were higher for readmissions Diabetes 30 day readmission range: 7.8 12.8% 2 What are the risk factors for readmissions? Previous hospital admission Dyspnea Oral corticosteroid use Long term O2 Low health status Poor health QoL No routine physical activity 1. http://www.hcup us.ahrq.gov/reports/statbriefs/sb121.jsp accessed 12/1/2011 2. Am J Public Health 2005;95:1561 7 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1449398/ Accessed 12/1/11 Bahadori and FitzGerald Int J of COPD 2007;2:241 51 Causes of COPD acute exacerbations Modifiable risk factors Smoking The most important activity to reduce progression of disease Physical inactivity Poor nutrition Fixed risk factors Underlying disease severity Can readmissions be prevented? Yes, with an integrated care approach Comprehensive assessment Education Individualized care plan Access to specialized nurse at hospital Primary care team consisted of physician, nurse and social worker Garcia Aymerich et al Resp Med 2007;101:1462 9 Integrated care to prevent readmissions Includes: Patient education Coordination of care amongst caregivers Improves: Patient compliance Exercise capacity Health related QoL Reduces: Hospital readmissions But not mortality Pharmacists role in preventing COPD readmissions Assure patients are on appropriate treatments Assess adherence at refills Assure patients can use devices Educate on medication use and treatment plans Encourage exercise Encourage good nutrition Conduct discharge counseling and follow up post hospitalizations Provide MD with all info regarding Rx use at hospitalization Facilitate smoking cessation Evaluate vaccination status and provide where needed Spirometry? 4
Coughing Karl 69 year old male is admitted for an acute exacerbation of COPD. Quit smoking cigarettes 4 years ago. Primary symptom on admission was coughing and unable to catch his breath. In the hospital he was treated with continuous albuterol nebulization until his peak flows returned to his prior best. He is discharged after 4 days in the hospital on the following medications: Albuterol inhalant solution one vial by nebulizer prn Salmeterol diskus one inhalation BID Combivent MDI 2 puffs QID Ipatropium 2 puffs q6h and up to twice more prn Return to Pulmonary clinic in 3 months What are the drug therapy problems? What else does Karl need? Post Assessment Questions An integrated care approach to COPD includes which of the following? [Please insert post assessment questions here & discuss answers with participants to allow them to self assess their learning of the information. These questions will also be included as the online exam which is required (with passing grade of 70%>) to receive CPE credit] Continuing Pharmacy Education Go to www.gotocei.org click on My Portfolio Scroll down to Take Exam Enter Access Code: (case sensitive) Pharmacists Technicians 5
2012 Educational Expo Chronic Obstructive Pulmonary Disease Gary Milavetz, BS, PharmD, RPh Post Assessment Questions 1. Which of the following best describes COPD disease progression? A. Complete reversibility of airway obstruction B. Gradual and progressive destruction of pulmonary tissue C. Thickening of alveolar capillary membranes reducing gas exchange D. Respiratory muscle fatigue resulting in reduced breathing effort 2. Which of the following is a COPD treatment goal A. Slow or halt disease progression B. Treat acute symptoms C. Prevent exacerbations D. All of the above 3. Treatment of COPD includes which of the following? A. Smoking cessation B. Pharmacotherapy C. Physical activity regimen D. All of the above 4. Metered dose inhaler technique differs from dry powder inhaler technique by which of the following actions? A. MDIs require a slow deep breath while DPIs require a rapid deep breath B. MDIs require a longer time to hold breath C. DPIs allow an open mouth inhalation D. DPIs must be shaken before dose is administered 5. Valved holding chambers have which of the following advantages? A. Hold aerosolized dose in chamber for up to five minutes B. Separate MDI actuation from inspiration C. May be used with nebulizers D. Reduces drug delivery time
Clinical Transitions and Prevention of Hospital Readmissions COPD Coughing Karl 69 year old male is admitted for an acute exacerbation of COPD. Quit smoking cigarettes 4 years ago. Primary symptom on admission was coughing and unable to catch his breath. In the hospital he was treated with continuous albuterol nebulization until his peak flows returned to his prior best. He was discharged after 4 days in the hospital on the following medications with treatment plan: Albuterol inhalant solution by nebulizer prn What went wrong? (Assessment) Patient problems: System problems: Salmeterol diskus one inhalation BID Combivent MDI 2 puffs QID Ipatropium 2 puffs q6h and up to twice more prn Return to Pulmonary clinic in 3 months Intervention: (Plan) What drug therapy problems can you identify? What else does Karl need?