patient care transitions in copd: improving...
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Provided by Integrity Continuing Education, Inc.
Supported by an educational grant from Sunovion Pharmaceuticals, Inc.
.
Held in conjunction with Hospital Medicine 2017, SHM’s Annual Meeting.
Patient Care Transitions in COPD:
Improving Collaboration Between
Inpatient and Outpatient Providers to
Reduce Readmissions
Faculty Panel
2
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
Faculty Disclosures
3
• 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.
Learning Objectives
• Describe long-term management strategies that may reduce COPD-related 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
4
The Current Landscape
COPD Readmissions
5
*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.
In-hospital Burden of COPD
• 1.1 million COPD-related ED visits1
• 660,000 hospital discharges2
• $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
6
The Hospital Readmissions Reduction
Program (HRRP)
7
Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-
program.html.
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.
The Impact of HRRP
• 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
8 Available at: http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/.
64 66
78 78 79
0
20
40
60
80
100
FY2013 FY2014 FY2015 FY2016 FY2017
Ho
sp
ita
ls P
en
ali
ze
d (
%) • 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
ACA, Affordable Care Act; FY, Fiscal Year.
Readmission Rates of Four High-volume
Conditions (2009–2013)
9 Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb196-Readmissions-Trends-High-Volume-Conditions.jsp.
Ra
te o
f R
ea
dm
iss
ion
(p
er
10
0 in
de
x s
tays
)
2009 2010 2011 2012 2013
Year
26
24
22
20
18
16
14
12
10
25.1
23.5
21.2
20.0
16.9
15.5 15.3
14.7
14.0 13.9
Congestive heart failure
COPD
Acute myocardial infarction
Pneumonia
Total index admissions for any cause
Stabilization of the Patient with an
Exacerbation
Index Hospitalization
10
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
11
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
12
• 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 beta2-agonist.
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
13
• Physical exam:
– Wheezing and decreased
breath sounds
– Temperature: 100.2
– HR: 70, regular rate,
no murmurs
– RR: 24
– BP: 130/72
– SpO2: 86%
BP, blood pressure; HR, heart rate; RR, respiration rate; SpO2, oxygen saturation as measured by pulse oximetry.
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
• O2 therapy
• Adjunctive therapies
• Noninvasive or invasive mechanical therapies
14
Global Strategy for the Diagnosis, Management and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2017. Available at: http://goldcopd.org.
5-day Course of Corticosteroids Preferred for
COPD Exacerbations
• GOLD Stage 3-4
• FEV1 ~31% predicted
• Randomized to 5 days or
14 days of prednisone (40 mg)
• 5-day regimen noninferior to
14-day regimen
• Average hospital stays 1 day
shorter with 5-day regimen
15
FEV1, forced expiratory volume in 1 second. Leuppi JD, et al. JAMA. 2013;309(21):2223-2231.
Pa
tie
nts
Wit
ho
ut
Ex
ac
erb
ati
on
(%
)
0 50 100 150 200
Time From Inclusion (days)
100
75
50
25
0
Short-term group (5 days)
Conventional group (14 days)
Discussion
16
Case Study: Hospital Admission
• The patient is admitted to the hospital based upon the
following factors:
– Exacerbation history
– Age
– Concerns about home care environment
17
Guiding Principles I: Stabilization of the Patient
with an Exacerbation
Management should be targeted at minimizing the
negative impact of the current exacerbation and
preventing the occurrence of future exacerbations and
disease progression.
18
Inpatient Management
19
Comorbidities Associated with Increased Risk of
Disease Progression and Future Exacerbations
20
DEPRESSION
ANXIETY
LUNG CANCER OSTEOPOROSIS
CHF
SKELETAL MUSCLE
WEAKNESS
COPD
PROGRESSION AND
FUTURE
EXACERBATION
CHF, congestive heart failure.
Early COPD-related Rehospitalization
Favors No COPD-related Favors COPD-related Rehospitalization Rehospitalization
Yes (n=174)
No (n=3438)
Odds Ratio (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
Impact of Comorbidities on Risk for 30-day
COPD-related Readmission
21 Roberts MH, et al. BMC Pulm Med. 2016;16(1):68.
0.5 1 2 3 4 Odds Ratio (95% CI) CI, confidence interval.
GOLD 2017: The Redefined ABCD
Assessment Tool
22
CAT, COPD Assessment Test; FVC, forced vital capacity; mMRC, modified Medical
Research Council Dyspnea Scale. GOLD 2017 Update. Available at: http://goldcopd.org.
Assessment of
airflow limitation
Spirometrically
confirmed COPD
Post-bronchodilator
FEV1/FVC <0.7 GOLD FEV1
(% predicted)
1 ≥80
2 50–79
3 30–49
4 <30
Assessment of symptoms/
risk of exacerbations
C
B
D
A
Exacerbation
History
≥2 or ≥1
leading to
hospital
admission
0 or 1 (not
leading to
hospital
admission)
mMRC 0–1
CAT <10
mMRC ≥2
CAT ≥10
Symptoms
Treatment Recommendations by GOLD Grade
23
*If FEV1 is <50% predicted and patient has chronic bronchitis; †In former smokers.
GOLD 2017 Update. Available at: http://goldcopd.org.
GROUP C
LAMA + LABA LABA + ICS
LAMA
Further exacerbation(s)
GROUP A Continue, stop, or try alternative
bronchodilator class
A bronchodilator
Evaluate effect
GROUP B LAMA + LABA
Persistent symptoms
LABA or LAMA
GROUP D Consider
macrolide† Further
exacerbation(s)
Consider
roflumilast*
LAMA LAMA + LABA LABA + ICS
Further exacerbation(s)
Persistent
symptoms/further
exacerbation(s)
LAMA + LABA + ICS
Bronchodilators Anti-Inflammatory
Short-Acting Long-Acting Inhaled
Anticholinergic (SAMA)
Ipratropium
β2-Agonists (SABA)
Albuterol
Levalbuterol
Metaproterenol
Pirbuterol
SAMA + SABA
Ipratropium + albuterol
Bronchodilators Anti-Inflammatory
Short-Acting Long-Acting Inhaled
Anticholinergic (SAMA)
Ipratropium
β2-Agonists (SABA)
Albuterol
Levalbuterol
Metaproterenol
Pirbuterol
SAMA + SABA
Ipratropium + albuterol
Anticholinergic (LAMA)
Tiotropium
Aclidinium
Umeclidinium
β2-Agonists (LABA)
Salmeterol, or Formoterol, or Arformoterol,
or Indacaterol (ultra), or Olodaterol
LAMA + LABA
Tiotropium + olodaterol
Umeclidinium + vilanterol
Xanthine Derivative: Theophylline
Pharmacologic Options
Bronchodilators Anti-Inflammatory
Short-Acting Long-Acting Inhaled
Anticholinergic (SAMA)
Ipratropium
β2-Agonists (SABA)
Albuterol
Levalbuterol
Metaproterenol
Pirbuterol
SAMA + SABA
Ipratropium + albuterol
Anticholinergic (LAMA)
Tiotropium
Aclidinium
Umeclidinium
β2-Agonists (LABA)
Salmeterol, or Formoterol, or Arformoterol,
or Indacaterol, or Olodaterol
LAMA + LABA
Tiotropium + olodaterol
Umeclidinium + vilanterol
Glycopyrrolate + indacaterol
Xanthine Derivative: Theophylline
ICS + LABA
Fluticasone + salmeterol
Budesonide + formoterol
Fluticasone + vilanterol
Therapies on the Horizon
25
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*
27
*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.
1.47
1.62
1.50 1.54
1.00
1.20
1.40
1.60
1.80
HospitalAdmissions
ED Visits AntimicrobialCourses
CorticosteroidCourses
Od
ds R
ati
o
Common Inhaler Devices
28
DPI MDI
SMI Nebulizer
Physical
• Validated teach-back methods
for specific devices
• Check for inspiratory flow
(eg, In-Check DIAL)
Assessments to Aid in Device Selection
29 Available at: http://www.alliancetechmedical.com/products/check-dial-training-device/.
Cognitive
• Any test for higher-level
cognitive function
− Failure indicates MDI or
DPI may be inappropriate
Overcoming Cognitive and Physical Limitations
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.
Limitation Potential Strategy
Cognitive
• Unable to coordinate breathing with device
requirements Spacer, SMI, nebulizer
• Unable to remember instructions for device
actuation Device with fewer steps, nebulizer
• Unable to keep track of doses Device with a dose counter
Physical
• Unable to generate adequate PIFR SMI, nebulizer
• Impaired manual dexterity Nebulizer
• Pain or weakness from neuromuscular disease Nebulizer
30
PIFR, peak inspiratory flow rate.
Case Study: In-hospital Care
• Patient is doing well with corticosteroid and antibiotic
treatment
• Corticosteroids and antibiotics are continued
• Maintenance bronchodilator therapy is initiated
31
*
0
2
4
6
8
10
12
14
January February March Jan-MarCombined
Hospital Stays for Exacerbations
of COPD Following Initiation of LAMA
32
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.
Drescher GS, et al. Respir Care. 2008;53(12):1678-1684.
*P<.05 H
osp
ital
Sta
y (
± S
D, d
ays
)
2004 2006 2004 2006 2004 2006 2004 2006
SD, standard deviation.
Odds of Readmission 31% Lower When
Nebulized LABA Initiated in Hospital
5.8
8.9
12.6
17.5
7.3
9.3 8.1
9.9
0
5
10
15
20
Minor Moderate Major Extreme
Neb-SABA
Arformoterol
33 Bollu V, et al. Int J Chron Obstruct Pulmon Dis. 2013;8:631-639.
Read
mis
sio
n R
ate
(%
)
Severity of Illness
P=.696 P=.867
P=.031
P=.028
Overall, significantly lower (8.7% vs 11.9%)
30-day readmissions with arformoterol
DPI Handling Errors Are More Frequent with
Greater COPD Severity
Lareau SC, et al. J Am Acad Nurse Pract. 2012;24(2):113-120.
Wieshammer S, et al. Respiration. 2008;75(1):18-25.
24 25 34
62
0
20
40
60
80
100
No COPD Mild Moderate Severe
Err
or
Rate
(%
)
Severity of COPD
34
Inpatient Portable Spirometry Can Be Used to
Identify Patients with COPD
35
Inpatient portable spirometry during AECOPD can predict airflow
obstruction that persists after recovery.
Obstructed on outpatient
spirometry Unobstructed on outpatient
spirometry Total
Obstructed on inpatient
spirometry 45 (75%) 15 (25%) 60
Unobstructed on inpatient
spirometry 4 (28.6%) 10 (71.4%) 14
Total 49 25 74
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.
Guiding Principles II: Considerations for
Management of the Stable Inpatient
• 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
36
Opportunities to Reduce Readmissions
Transitions of Care
37
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
38
Discussion
39
Upon
admission
• Initiate processes to reduce readmission risk factors
• Educate patients and caregivers in a patient-centered manner
• Address key patients and caregiver concerns
• Provide discharge instructions without medical jargon using “teach back”
• Communicate with outpatient HCPs about hospital stay and ongoing care
• Provide a complete discharge summary to outpatient HCPs
• Complete medication reconciliation
• Coordinate outpatient follow-up visits
At
discharge
• 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
Post-
discharge
Preparing Patients With COPD for Safe
Transitions of Care
40 Available at: http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/COPD/Best_Practices/transitions_pall.aspx.
Upon
admission
• Initiate processes to reduce readmission risk factors
• Educate patients and caregivers in a patient-centered manner
• Address key patients and caregiver concerns
Upon
admission
• Initiate processes to reduce readmission risk factors
• Educate patients and caregivers in a patient-centered manner
• Address key patient and caregiver concerns
• Provide discharge instructions without medical jargon using “teach back”
• Communicate with outpatient HCPs about hospital stay and ongoing care
• Provide a complete discharge summary to outpatient HCPs
• Complete medication reconciliation
• Coordinate outpatient follow-up visits
At
discharge
Pulmonary Rehabilitation Programs in the US
41 Available at: https://www.copdfoundation.org/Learn-More/Pulmonary-Rehabilitation/Find-a-PR-Center-Near-You.aspx.
The Pittsburgh Regional Health Initiative:
A Case Study in Reducing Hospital Readmissions
42 The Primary Care Resource Center: A New Model for Complex Patients. Available at: https://www.youtube.com/watch?v=mldF3h5fcsI.
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 “Perfect Discharge Bundle”
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
43 PCP, primary care provider.
A. 10%
B. 30%
C. 50%
44
A. B. C.
0%0%0%
8
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?
Audience Response Question
Communication Between Inpatient and
Outpatient Healthcare Providers
45
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
68
56 49
32 32 32 31
20 18
6
69
48
37 38 31 29 29 27
18
8 0
20
40
60
80 Notified of ED visit Notified of hospital discharge
NET NZ UK NOR US CAN SWIZ GER AUS SWE
% o
f C
ases
Discussion
46
Improving Communication Between Inpatient
and Outpatient HCPs
47
Consistent, concise,
complete medication &
treatment plans
Reliable,
standardized
discharge
documentation
Employment
of multiple
modes of
communication
Rattray NA, et al. Jt Comm J Qual Patient Saf. 2017;43(3):127-137.
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 postdischarge2
• 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
48
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.
Case Study: 2-week Follow-up Visit
• Patient reports improved adherence to her
therapeutic regimen
• Symptoms have significantly improved
49
Guiding Principles IV: Preventing 30-Day
Readmissions
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.
50
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
51 PRHI, Pittsburgh Regional Health Initiative; SHM, Society of Hospital Medicine.
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
52
Thank You!
53
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