HQO s Episode of Care for Chronic Obstructive Pulmonary Disease Dr. Chaim Bell, MD PhD FRCPC Ontario Hospital Association Webcast October 23, 2013
Objectives 1. Describe the rationale and methodology for HQO s episode of care approach as it applies to identifying cohorts, grouping patients, considering complexity and defining the scope of the episode of care 2. Review the previous recommendations of the Congestive Heart Failure Acute Episode of Care panel in these areas 3. Discuss and seek feedback from this Panel on the approach to be applied for the Congestive Heart Failure Community-based Episode of Care
Recap: why do we need to stratify the post-acute heart failure population? A core deliverable requested by the Ministry for each QBP topic area is a recommended approach to stratifying the clinical population Purpose is to break down heterogenous populations into subgroups that are more clinically and resource homogenous, in order to: 1. Define best practices relevant to specific patient trajectories and sub-trajectories (pathway and triage tool) 2. Appropriately fund cases with different needs at different rates Often (but not always), clinically meaningful approaches to stratifying patients also result in meaningful groupings from a cost perspective HQO s Episode of Care method draws from clinical expert panel input to define patient characteristics to model for their association with variation in cost, length of stay and other key outcomes Output of this analysis: a set of patient groups (e.g. high and low risk) and patient complexity factors identified for risk adjustment within the groups (e.g. age, comorbidity) 2
The major components of our approach Case Mix Best Practice Define inclusion / exclusion criteria for the patient cohort to be studied Set the scope and parameters of the episode of care for analysis Recommend an approach to stratifying patients within the cohort Develop evidence-based care pathway(s) for the cohort and subgroups Develop indicators for measuring adherence to the care pathway and resulting outcomes
Defining the inclusion / exclusion criteria for the COPD cohort Inclusion / exclusion criteria: 1. Diagnoses: Most responsible diagnosis In the Range of J41-J44, excluding J43.1 J43.2 J43.0 2. Age: Age greater than or equal to 35 at time of admission 3. Intervention: Is not assigned to an intervention based HIG cell based on the current methodology. (i.e. MCC_partition variable is not I ) 4
Review: Defining the COPD patient grouping approach Three major patient groups: 1) Mild exacerbation Treated in ED or outpatient; not admitted ED, Urgent Care Centre or outpatient visit recorded without a subsequent hospital admission 2) Moderate exacerbation Admitted to inpatient care; not ventilated Inpatient acute discharge without a procedure code for noninvasive positive pressure ventilation or invasive mechanical ventilation, and without an ICU stay recorded 3) Severe exacerbation Admitted to inpatient, ventilated (NPPV or IMV) and/or admitted to ICU Inpatient acute discharge with procedure code for noninvasive positive pressure ventilation and/or invasive mechanical ventilation and/or with ICU stay recorded 5
Identifying markers for complexity in COPD patient population Factors that contribute to COPD patient complexity: COPD severity markers O 2 dependence Respiratory failure Recent (e.g. within 30 days) discharge from ED / hospital Frequency of acute exacerbations over previous 6 12 months Oral steroid use / dependence Lung function (FEV 1 / FVC) Failed response to outpatient therapy Functional ability / dyspnea (MRC grade) Housing / supports / frailty markers Homeless Lack of support (CCAC, isolation/transportation) Continuing care / nursing home resident Access to primary care Functional status (e.g. walking aids) Drug plan Access to pulmonary rehab Significant comorbidities Bronchiectasis Pneumonia Coinfections (pseudomonas, mycobacterium, urosepsis) Mental health (anxiety, depression, dementia, delirium) Congestive heart failure Arrhythmia (including atrial fibrillation) Diabetes Tobacco dependence Benzodiazepine dependence / chronic use Immunosuppressant disease Lung cancer Renal failure Osteoporosis BMI (overweight or underweight) Chronic pain Sleep apnea Myocardial infarction Neuromuscular disorder GERD Muscoskeletal disorders Asthma Interstitial lung disease 6
The COPD Episode of Care Model Legend Care module Mild Level of care Usual medical care (in ED / outpatient) N = 19,337 Pr = 0.447 Recovers Assess recovery Treatment fails Discharge planning & full clinical assessment Go to usual medical care (inpatient) Home Assessment node Episode endpoint Patient presents with suspected exacerbation of COPD N = 43,215 Pr = 1.0 Assess level of care required Moderate Level of care Usual medical care (inpatient) N = 22,054 Pr = 0.511 Recovers Assess recovery Treatment fails Discharge planning & full clinical assessment Go to ventilation (NPPV or IMV) Home N = 1,824 P =.042 Severe Level of care Decision on ventilation modality or palliative care NPPV N = 773 P =.018 Recovers Recovers Assess recovery Treatment fails Wean from IMV Usual medical care (inpatient) Go to IMV IMV Assess recovery N = 1051 End of life care Treatment fails Pr =.024 Usual medical care (inpatient) Death Discharge planning & full clinical assessment Discharge planning & full clinical assessment Home Home
Diagnosis of COPD Consider clinical diagnosis of COPD in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease Spirometry is required to make clinical diagnosis: postbronchodilator FEV1/FVC <0.70 confirms COPD Spirometry need not be performed during the initial phase of an exacerbation when the patient is unstable, but should be performed once the patient has stabilized Spirometry should only be performed if the patient has no recent, reliable, objective documentation of COPD by spirometry 8
Patient presents to hospital with suspected COPD exacerbation Vital signs and physical exam Check patient history Document and reconcile medications currently used Chest X-ray Baseline bloodwork ECG Check arterial blood gases, where appropriate If suspected pneumonia or sepsis draw blood cultures Cardiac markers, if appropriate Patient wishes: goals of care and/or limitations of treatment Spirometry Other diagnostic interventions as appropriate to identify / rule out other suspected diagnoses or co-morbidities 9
Decision to admit Decision to admit relies largely on clinical judgment and availability of local resources see NICE / GOLD criteria below NICE Decision Guidelines for Hospital Admission (2011) Factors to consider when deciding where to manage exacerbations (Take into account the person s preference) Treat at home? Able to cope at home Yes No Treat in hospital? Breathlessness Mild Severe General condition Level of activity Good Good Cyanosis No Yes Worsening peripheral oedema Level of consciousness Already receiving LTOT Social circumstances No Normal No Good Poor/deteriorati ng Poor/confined to bed Yes Impaired Yes Acute confusion No Yes Rapid rate of onset No Yes Significant comorbidity (particularly cardiac disease and insulindependent diabetes) No Living alone/not coping Yes SaO 2 < 90% No Yes Changes on chest X- ray No Present Arterial ph level 7.35 < 7.35 Arterial PaO 2 7 kpa < 7 kpa GOLD Indications for Hospital Assessment or Admission 10
Usual medical care (1 of 2) Short-acting bronchodilators (Beta-2 agonists recommended) If patient is already on long-acting anticholinergics, continue to administer in combination with Beta-2 agonists Metered dose inhalers with spacers are the preferred delivery vehicle; nebulizers should be considered second line treatment due to infection risk Corticosteroids are effective except for only very mild exacerbations, or if contraindicated 30 50 mg / day Prednisone or equivalent 10-14 days Manage corticosteroid-induced side effects Theophylline is not recommended, unless already receiving If necessary, deliver oxygen to maintain 90% oxygen saturation Where appropriate, initiate bronchopulmonary (lung) hygiene physical therapy to clear mucus and secretion from the airway If patient is admitted, use early ambulation therapy Begin discharge planning, including referral to pulmonary rehab 11
Usual medical care (2 of 2) Use antibiotics for indications of infection (e.g. purulent or high volume sputum) Refer to institution-specific antimicrobial stewardship policies Oral antibiotics are preferred Intravenous antibiotics should be considered a 2nd line therapy used only when oral antibiotics are contraindicated (e.g. GI issues) See CTS guidelines below (2007) 12
Decision on ventilation If possible, seek patient preferences for ventilation therapy before proceeding to ventilation interventions If ventilation is not desired, proceed to palliative care NPPV should be considered as first line treatment for patients with acute respiratory failure and ph < 7.35 NPPV should be trialed before proceeding to invasive ventilation for all patients with indications for ventilation, including severe patients (ph < 7.20), unless contraindications are present Where patients have expressed preferences against intubation, NPPV can still be considered but ensure that therapy does not progress to IV in the case of failure to respond to NPPV 13
Noninvasive ventilation Ensure continuous monitoring of patients receiving NPPV Specialized respiratory teams and/or units are likely to be more effective in delivering NPPV Invasive ventilation Use NPPV to help wean patients from IV when they fail spontaneous breathing tests There may be a volume-outcome relationship at the hospital level associated with effectiveness of IV 14
Clinical assessment of stabilized patient Where a patient has no prior objective documentation of spirometry assessment, spirometry should be performed on the stabilized patient before discharge (as time and patient s condition allows) or arranged for following discharge In addition to classification of airflow limitation, patients should also be assessed for their severity of symptoms and other risk factors (e.g. co-morbidities), considering tools such as the MRC dyspnea scale, CAT / BODE / LACE indices 15
Discharge planning (1 of 2) Perform full clinical assessment once patient stabilizes Patients should leave hospital with an individualized discharge plan (Re-)establish patients on their COPD maintenance bronchodilator therapy before discharge, including handheld inhalers Review and reconcile medications before discharge Ensure that patients understand their medication therapy, including when to stop corticosteroids if prescribed Assess the patient s inhaler technique before discharge Consider developing an action plan with patients, including identified patient responsibilities for their ongoing care and instructions for seeking help for future acute exacerbations Patients without up-to-date influenza or pneumococcal vaccinations should either be vaccinated or referred for vaccination following discharge, unless there are contraindications present 16
Discharge planning (2 of 2) COPD patients with functional disabilities should begin a pulmonary rehabilitation program within 1 month of discharge Patients who smoke should receive smoking cessation counseling while in hospital, with goal of referral to longer-term, intensive smoking cessation counseling in the outpatient setting Ensure that patient is supported by CCAC with appropriate home care services in the community after discharge Where appropriate, arrange for an assessment of the patient s home or living situation by an occupational therapist following discharge Ensure patients have a follow-up appointment with a primary care provider, respirologist or internist within 2 weeks of discharge Patients that qualify should be discharged on home oxygen If the patient does not have a regular primary care provider, ensure they are connected with one before discharge. PCP and CCAC receive discharge summary w/in 48 hrs of discharge 17
Where did the evidence for these recommendations come from? 18
The OHTAC COPD mega-analysis: A great source of evidence, but did not cover some key areas of the episode of care Evidence-based practices for COPD Long-acting maintenance bronchodilators Community-based diagnosis and assessment OHTAC mega-analysis Long-term oxygen therapy Community-based multidisciplinary care Non-invasive Ventilation Pulmonary rehabilitation following acute exacerbation QBF episode of care Short-acting bronchodilators Corticosteroids Pulmonary rehabilitation for stable COPD patients Vaccinations In-hospital diagnostics Antibiotics 19
We synthesized a variety of different forms of evidence through an Expert Panel to inform practice recommendations Usual Medical Care (mild and moderate exacerbations) Ventilation (severe exacerbations) Discharge planning (all patients) Recommended practice Administer 30-50 mg prednisone for 7-14 day course of therapy for all patients unless contraindicated Theophylline is not recommended, unless patient is already receiving Use noninvasive ventilation as first line therapy for patients with acute respiratory failure and ph < 7.35 Refer all hospitalized patients to begin pulmonary rehabilitation within 1 month of discharge Develop an action plan with patients before discharge with instructions on how to manage future exacerbations Expert Panel Contextualizion for Ontario Supporting evidence CTS: 1+ RCTs; good evidence GOLD: Expert consensus GOLD: RCTs, limited body of data NICE: Expert consensus OHTAC: Moderate quality evidence GOLD: RCTs, rich body of data OHTAC NICE: Systematic reviews and/or meta-analyses of RCTs OHTAC: Moderate quality evidence GOLD: RCTs, rich body of data CTS: 1+ RCTs; good evidence GOLD: Expert consensus NICE: Expert consensus OHTAC HQO RAPID REVIEW PENDING 20
Filling the gaps in the evidence: HQO s Rapid Review methodology Research Question Literature Search Is there a SR? Did SR use GRADE? YES Rate SR with AMSTAR No No YES Scoping PICO Study Selection Criteria 5 years Medline, EMBASE, Cochrane, CRD SR, HTA, MA Review of primary studies (RCT, Obs.) adjusting selection criteria as necessary Did SR GRADE outcomes of interest for RR? No YES Summarize results Obtain primary studies from SR with outcomes of interest GRADE Outcome(s) Max 2 Report Results 21
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