Reducing Hospital Readmissions for Chronic Obstructive Pulmonary Disease (COPD) Jin S. Oh, PharmD Larkin Community Hospital January 10, 2016 Fact COPD is the third leading cause of death in the United States Objectives 1. Define and identify risk factors associated with COPD hospitalization or readmission 2. Describe pharmacologic and nonpharmacologic strategies to prevent readmissions for COPD exacerbation 3. Discuss the evidence-based guidelines for COPD exacerbations 4. Discuss the benefits and limitations to CMS model to reduce 30 day readmission rates for COPD 1
Background Approximately 700,000 hospitalizations with the principal diagnosis of COPD in the Unites States each year 1 in 5 readmitted within 30 days COPD affects an estimated 24 million individuals in the U.S Hospitalization for COPD exacerbation account for approximately half of the $50 billion dollar in annual health care expenditures in the United States Background Center for Medicaid and Medicare Services (CMS) 2012: PN, AMI, CHF 2014: COPD, THA,TKA Most of COPD readmissions have been caused by conditions other than re-exacerbation of COPD Financial penalties can be as high as 3% for hospital readmissions within 30 days of discharge for all-cause COPD exacerbations Chronic Obstructive Pulmonary Disease A common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed December 2015 2
COPD emedicine.medscape.com/article/297664-overview. Accessed December 2015 Diagnosis of COPD SYMPTOMS shortness of breath chronic cough sputum EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY: Required to establish diagnosis goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed December 2015. Classification of Severity of Airflow Limitations in COPD FEV 1 /FVC < 0.70 GOLD 1 Mild FEV 1 > 80% predicted GOLD 2 Moderate 50% < FEV 1 < 80% predicted GOLD 3 Severe 30% < FEV 1 < 50% predicted GOLD 4 Very Severe FEV 1 < 30% predicted * Based on Post-Bronchodilator FEV 1 goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed December 2015 3
Combined Assessment of COPD Risk (GOLD Classification of Airflow Limitation)) 4 3 2 1 (C) (A) (D) (B) CAT < 10 CAT >10 Symptoms mmrc 0 1 mmrc > 2 Breathlessness 2 or >1 leading to hospital admission 1 (not leading to hospital admission) goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed December 2015. 0 Risk (Exacerbation history) Combined assessment of COPD Patient Characteristic Spirometric Classification A B C D Low Risk Less Symptoms Low Risk More Symptoms High Risk Less Symptoms High Risk More Symptoms Exacerbations per year CAT mmr C GOLD 1-2 1 < 10 0-1 GOLD 1-2 1 > 10 > 2 GOLD 3-4 > 2 < 10 0-1 GOLD 3-4 > 2 > 10 > 2 goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed December 2015. Pharmacologic Therapy GOLD 4 GOLD 3 GOLD 2 GOLD 1 C A ICS + LABA or LAMA SAMA prn or SABA prn ICS + LABA and/or LAMA LABA or LAMA D B 2 or more or >1 leading to hospital admission 1 (not leading to hospital admission) 0 Exacerbations per year CAT < 10 mmrc 0-1 CAT > 10 mmrc > 2 2015 Global Initiative for Chronic Obstructive Lung Disease 4
Risk factors for COPD readmissions Pharmacologic Non-adherence of drug regimens Complex Side effects Misuse of inhaler Non-adherence to supplemental O 2 Non-pharmacologic Lack of pulmonary rehabilitations Smoking Not receiving the influenza vaccine Not receiving the pneumococcal vaccine Risk factors for COPD readmissions Clinical Factors Diseases severity Comorbitities Post-hospital syndrome Access to hospital care Risk factors for COPD readmissions Socioeconomic Homelessness Food insecurity Substance abuse Lack of transportation Lack of caregiver support Behavioral health issues 5
Key Strategy Transition of Care Primary Care, Pulmonologist Pulmonary Rehabilitation, Smoking Cessation Patient Acute Care Providers Family, Caregivers onyxvantage.com/documents/10329-001- 01%20COPD%20Readmission%20Reduction%20Program%20White%20Paper.pdf. Accessed December 2015. Crucial elements of transitional care 1. COPD guideline-directed treatment protocols 2. Patient/caregiver education 3. Patient assessment of oxygen needs, comorbidities, goals of care, spirometry testing Crucial elements of transitional care 4. Follow-up plan post-discharge phone call pulmonary rehabilitation appropriate use of home care services 6
Transition of Care COPD Coordinator function Coordinator 1 Educating and training (PRRT) Coordinator 2 Extender of pulmonologist Communication between care providers Seamless discharge onyxvantage.com/documents/10329-001- 01%20COPD%20Readmission%20Reduction%20Program%20White%20Paper.pdf. Accessed December 2015. Transition of Care Home visit Proper equipment Medication reconciliation Smoking Cessation Cognition, family, and financial onyxvantage.com/documents/10329-001- 01%20COPD%20Readmission%20Reduction%20Program%20White%20Paper.pdf. Accessed December 2015. Patient Centered Care Self-monitoring and self-managing of exacerbations Early recognition Early response onyxvantage.com/documents/10329-001-01%20copd%20readmission%20reduction%20program%20white %20Paper.pdf. Accessed December 2015. 7
Active Lifestyle Inactivity is destructive Supports overall physical and mental health onyxvantage.com/documents/10329-001-01%20copd%20readmission%20reduction%20program%20white %20Paper.pdf. Accessed December 2015. Patient Training Teach-back method Proper administration Mobility and exercise Home Oxygen equipment Purse-lips breathing Airway clearance Avoid smoking Avoid toxins onyxvantage.com/documents/10329-001- 01%20COPD%20Readmission%20Reduction%20Program%20White%20Paper.pdf. Accessed December 2015. Teach-back method What to say How to say it When to Use Teach-Back DeWalt D.A., Callahan L.F., Hawk V.H., et al. Health Literacy Universal Precautions Toolkit. Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014. AHRQ Publication No. 10-0046-EF. Rockville, MD. Agency for Healthcare Research and Quality. April 2010. 8
Proper Equipment Metered dose inhalers (MDI) Oxygen equipment Pulse oximeter Airway clearance devices onyxvantage.com/documents/10329-001- 01%20COPD%20Readmission%20Reduction%20Program%20White%20Paper.pdf. Accessed December 2015. Recognize signs Rapid Action Plan Checklist-procedure Begin medications onyxvantage.com/documents/10329-001- 01%20COPD%20Readmission%20Reduction%20Program%20White%20Paper.pdf. Accessed December 2015. Pulmonary Rehabilitation Exercise training Assessment of functional status Assessment of severity of dyspnea Assessment of motivation Smoking cessation Disease management education Nutrition counseling 9
Purse Lip Breathing my.clevelandclinic.org/health/diseases_conditions/hic_understanding_copd/hic_pulmonary_rehabilitation_is_it_for_ You/hic_Pursed_Lip_Breathing Hospital Strategies to Prevent Readmissions 1. Early discharge planning 2. Transition of care coordination 3. Discharge information Early, timely, and easily accessible 4. Medication safety 5. Proactive patient education to promote self management Feemster LC and Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014 Mar 15;189(6):634-9. Hospital Strategies to Prevent Readmissions 6. Engaging community support 7. Advance care planning 8. Care coordination between inpatient and outpatient providers 9. Symptom treatment and assessment after discharge 10. Outpatient follow-up Feemster LC and Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014 Mar 15;189(6):634-9. 10
Pittsburgh Regional Health Initiative Pittsburgh Regional Health Initiative. prhi.org. Accessed December 2015. Pittsburgh Regional Health Initiative Best practices (evidence based) developed Primary care resource centers (PCRC) Community hospitals (n=6) Management team (RN, RT, pharmacist) Identify and follow when admitted Standardized staff educational program Transition to home (in home visits) Pittsburgh Regional Health Initiative. prhi.org. Accessed December 2015. Benefits of 30-day readmissions penalty Financial and public health importance Convenience Theoretically comparable across healthcare settings Feemster LC and Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014 Mar 15;189(6):634-9. 11
Limitations of 30-day readmissions penalty No adjustment for socioeconomic factors Lack of validated algorithm with high sensitivity and specificity using ICD- 10 codes to identify hospitalization for COPD exacerbations Feemster LC and Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014 Mar 15;189(6):634-9. Limitations of 30-day readmissions penalty Lack of evidence that decreasing readmissions improves outcomes Uncertainty regarding the preventability of readmissions Susceptible to gaming Feemster LC and Au DH. Penalizing hospitals for chronic obstructive pulmonary disease readmissions. Am J Respir Crit Care Med. 2014 Mar 15;189(6):634-9. Summary Promoting adherence to evidencebased clinical practice guidelines Medication reconciliation Promoting patient self-management skills Facilitating hand-offs during the transition from hospital to ambulatory care 12
PRAXIS Prevent and Reduce COPD Admissions through expertise and Innovation Sharing copdfoundation.org/praxis/about-praxis/what-is-praxis.aspx.accessed December 2015. Assessment Questions 1. True or False: In the U.S., hospital readmissions for all COPD patients within 30 days of discharge occur in approximately 22% of cases. 2. True or False: Patients who engaged in any level of moderate to vigorous physical activity prior to hospitalization had a 34% lower risk of being readmitted within 30-days of admission when compared to inactive patients. 3. True or False: The CMS model for establishing the hospital-specific expected 30-day readmission rate adjusts for socioeconomic status are included in the modeling. Assessment Questions 1. True or False: In the U.S., hospital readmissions for all COPD patients within 30 days of discharge occur in approximately 22% of cases. (T) 2. True or False: Patients who engaged in any level of moderate to vigorous physical activity prior to hospitalization had a 34% lower risk of being readmitted within 30-days of admission when compared to inactive patients. (T) 3. True or False: The CMS model for establishing the hospital-specific expected 30-day readmission rate adjusts for socioeconomic status are included in the modeling. (F) 13
Remember Questions 14