effective discharge of the oxygen dependant copd patient

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Effective Discharge of the Oxygen Dependant COPD Patient Bob Messenger BS, RRT Manager, Respiratory Education Invacare Corporation

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Effective Discharge of the Oxygen Dependant COPD Patient. Bob Messenger BS, RRT Manager, Respiratory Education Invacare Corporation. Disclosures. Relevant Disclosures Employed by the Invacare Corp. A version of this lecture has been accepted for publication in Professional Case Management. - PowerPoint PPT Presentation

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Page 1: Effective Discharge of the Oxygen Dependant COPD Patient

Effective Discharge of the Oxygen Dependant COPD Patient

Bob Messenger BS, RRTManager, Respiratory Education

Invacare Corporation

Page 2: Effective Discharge of the Oxygen Dependant COPD Patient

Disclosures

• Relevant Disclosures– Employed by the Invacare Corp.

– A version of this lecture has been accepted for publication in Professional Case Management

Page 3: Effective Discharge of the Oxygen Dependant COPD Patient

30-Day Readmissions -Hospital Directed Reform

Provision of PPACA (Section 3025) Penalty for excessive 30-day Potentially Preventable Readmits

Bottom 25th percentile – Penalized on ALL Medicare receipts CMS payments (1% in 2012, 2% in 2013, 3% in 2014) Risk adjustment Moving target

Diagnosis specific Effective Oct. 1, 2012

CHF, AMI, Pneumonia Effective Oct. 1, 2015

COPD, Angioplasty, CABG & vascular diseases

Page 4: Effective Discharge of the Oxygen Dependant COPD Patient

30-Day Readmission Rates

Page 5: Effective Discharge of the Oxygen Dependant COPD Patient

Readmission Chains

• A sequence of readmissions that are all related to a single initial discharge– Essentially an episode of related hospitalizations– Provides a more precise description of the

readmission pattern associated with the care given during & after specific types of initial discharges

Page 6: Effective Discharge of the Oxygen Dependant COPD Patient

Example of a Readmission Chain

Initial Admission: CABG SurgeryReadmission: Post-op Wound InfectionReadmission: PTCA

• Without Readmission Chains: readmission sequence is a CABG discharge with one readmission followed by an unrelated PTCA admission

• With Readmission Chains: a CABG discharge and two related readmissions– Post-op infection and PTCA are related to initial CABG surgery

Page 7: Effective Discharge of the Oxygen Dependant COPD Patient

Test Your Understanding…

• A readmission for diabetes following an initial admission for diabetes

• Potentially Preventable Readmission?

• YES

Page 8: Effective Discharge of the Oxygen Dependant COPD Patient

Test Your Understanding…

• An admission for trauma following a discharge for AMI

• Potentially Preventable Readmission?

• NO (unrelated acute event)

Page 9: Effective Discharge of the Oxygen Dependant COPD Patient

Test Your Understanding…

• A readmission for diabetes in a patient whose initial admission was for an acute myocardial infarction

• Potentially Preventable Readmission?

• YES

Page 10: Effective Discharge of the Oxygen Dependant COPD Patient

Test Your Understanding…

• A readmission for a broken hip in a patient whose initial admission was for an exacerbation for COPD. (NOTE: patient went home on O2 and tripped on the oxygen tubing)

• Potentially Preventable Readmission?

• ???? Maybe

Page 11: Effective Discharge of the Oxygen Dependant COPD Patient

Defining “Readmissions”

• Potentially Preventable Readmission (PPR)

– Could have been prevented through:

• Improved quality of care in the initial hospitalization

• Better discharge planning

• Improved post-discharge follow-up

• Improved coordination inpatient/outpatient health care teams

Page 12: Effective Discharge of the Oxygen Dependant COPD Patient

What’s so special about

the COPD Patient?

Page 13: Effective Discharge of the Oxygen Dependant COPD Patient

US COPD Data• In 2010 COPD costs the US est. $29.5 billion in direct

costs & $20.4 billion in indirect costs1

– 14.8 million Americans diagnosed with COPD2

– 150 million days of lost work annually1

– A person with COPD dies every 4-minutes in the US3

– 3rd leading of cause of death4

– 2nd leading cause of disability1

1. NHLBI: Morbidity and Mortality: 2007 Chartbook on Cardiovascular, Lung and Blood Diseases.

2. CDC Fast Facts: COPD. http://www.cdc.gov/nchs/fastats/copd.htm - accessed 3/17/11.

3. Extrapolated from CDC data: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm - accessed 3/24/11

4. National Vital Statistics Reports Volume 59, Number 2. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_02.pd//f

Page 14: Effective Discharge of the Oxygen Dependant COPD Patient

More US COPD Data• COPD ranks #3 in acute hospital admissions (DRG: 088)

– 672,000 COPD discharges in 20061

– Avg. annual hospitalized days 8.182

– Avg. LOS 5.1 days3 – Avg. per day cost $2,9594

– Avg. total cost/admission $15,0934

– Avg. payment/admission $19,6355

• There are an est. 1.5 million home oxygen users

1. CDC. National Hospital Discharge Survey, 1979-2006. 2006 Unpublished Data.2. Schneider KM, O’Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States’ Medicare

population. Health Qual Life Outcomes. 2009;7:82.3. http://www.health.ny.gov/nysdoh/hospital/drg/2009_siw.pdf4. Dalal AA, Christensen L, Liu F, Riedel AA. Direct costs of chronic obstructive pulmonary disease among

managed care patients. Int J COPD 2010;5:341-49.5. 2007 Medicare PPS Inpatient Hospital Discharge Data.

Page 15: Effective Discharge of the Oxygen Dependant COPD Patient

COPD Re-Admission Data• 22.6% of COPD patients are readmitted within 30-days1

• Key readmission predictors2

– Use of long-term oxygen therapy– Low health status– Lack of routine physical activity

• Key components to reducing readmissions3-8 – Comprehensive pre-discharge planning– Patient-centric education

• Medications and compliance (including LTOT)• AODL• Recognition and response to exacerbation

– Education reinforcement– Transportation, medication and nutritional support

1. Jencks SF. N Eng J Med 2009;360:1418-28.

2. Bahadori K. Int J COPD 2007;2(3):241-51.

3. Farrero E. Chest 2001;119(2):364-9.

4. Bourbeau J. Arch Intern Med 2003;163:585-91.

5. Ramani AA. J Care Mgmt 2010;11(4):249-53.

6. Carlin BW. Respir Care 2010; 55(11):1535.

7. Laher D. Respir Care 2003; 48(11):1116.

8. Stegmaier J. Respir Care 2006;51(11):1305.

Page 16: Effective Discharge of the Oxygen Dependant COPD Patient

COPD Hospitalization Rates

Holt JB, et al. Geographic disparities in COPD hospitalization among Medicare beneficiaries in the United States. CDC. Intern J of COPD 2011;6:321-328.

Page 17: Effective Discharge of the Oxygen Dependant COPD Patient

Roots of COPD

Page 18: Effective Discharge of the Oxygen Dependant COPD Patient

NOTT (Nocturnal Oxygen Therapy Trial)Ann Intern Med 1980;93(3):391-398

• 203 pts. randomized to continuous or nocturnal O2 for 5-years– Enrollment criteria– Continuous Group averaged 17.7 4.8 h/d– Nocturnal Group averaged 12.0 2.5 h/d

• After 3½ years the mortality for nocturnal O2 group was 1.94 times that for the continuous O2 group– Continuous O2 therapy reduces mortality – Basis for current LTOT standards

Page 19: Effective Discharge of the Oxygen Dependant COPD Patient

NOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211

Patients in study203

Pedometer data available

157

No match (computer modeling to +/- 1%)

77

Matched patients (age, sex, severity of

disease)80

Nocturnaloxygen therapy -

low walk22

Continuousoxygen therapy -

low walk18

Nocturnaloxygen therapy -

high walk22

Continuousoxygen therapy -

high walk18

Page 20: Effective Discharge of the Oxygen Dependant COPD Patient

NOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211

0 0.25 0.5 0.750000000000003

1 1.25 1.5 1.75 2 2.25 2.5 2.75 3 3.25 3.5 3.75 40%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Years in Study

Su

rviv

or

Fra

cti

on

High Walk COT

High Walk NOTLow Walk COT

Low Walk NOT

Page 21: Effective Discharge of the Oxygen Dependant COPD Patient

NOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211

7.2

5.5

4.7

2.2

0

1

2

3

4

5

6

7

8

Low Walk NOT Low Walk COT High Walk NOT High Walk COT

Day

s

Matched Data

Average Per Patient Annual Duration of Hospitalization

Page 22: Effective Discharge of the Oxygen Dependant COPD Patient

  Since long-term oxygen is so good for COPD patients, they must all be

very compliant… Right?

Page 23: Effective Discharge of the Oxygen Dependant COPD Patient

Compliance with O2 Prescription• Pepin1 et al.

– 930 LTOT patients on O2 for at least 36-mos.

– Mean daily duration of O2 prescribed 16±3 hrs.

– Only 45% of pts used O2 for 15 hrs or > per day.

• Peckham2 et al.– RCT: 86 pts (45 treatment & 41 control)– Treatment group received additional clinician training– Daily O2 use for 15 hrs or more after 6-months:

• Treatment group 82%• Control group 44%1. Long-term oxygen therapy at home: compliance with medical prescription and effective use of

therapy. Chest 1996;109:1144-50.2. Improvement in patient compliance with long-term oxygen therapy following formal assessment and

training. Respir Med 1998;92(10):1203-6.

Page 24: Effective Discharge of the Oxygen Dependant COPD Patient

Why are patients sent home on sub-standard device?

Device Related Saturation Shortfalls Uncovered During Rehab Visits

Premier pulmonary rehab reviewed 65 patients post discharge:•Treadmill test to evaluate ability of home device to meet 90% saturation goal.•60% did not meet target: 20% needed setting adjusted upward; 40% could not be titrated at any setting (replaced device).

Gaps Between Titration Settings at Discharge vs. Titration on Home Device

Source: Changes in Supplemental Oxygen Prescription in Pulmonary Rehabilitation, Limberg et al, Resp Care Nov 06; Vol 51 (11), pg 1302.

Page 25: Effective Discharge of the Oxygen Dependant COPD Patient

Now let’s get to know our COPD

Patients

Page 26: Effective Discharge of the Oxygen Dependant COPD Patient

Characteristics of COPD Patients• 80-90% of COPD results from cigarette smoking1

• Prevalence of those who smoke– Education2

• < High school education 32%• High school education 29.3%• College graduates 13.3%

– Income2

• Below poverty level 36.5%• At or near poverty level 32.8%• Above poverty level 22.5%

• Average age when started on LTOT: 74±8 years3

1. American Lung Association: http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html (accessed 2/4/2011).

2. CDC – Morbidity & Mortality Weekly Report. January 14, 2011 / 60(01);109-113.3. Ekstrom MP, Wagner P, Strom KE. Trends in cause-specific mortality in oxygen-dependent COPD. AJRCCM articles in press.

Published 1/7/2011. doi:10.1164/rccm.201010-1704OC.

Page 27: Effective Discharge of the Oxygen Dependant COPD Patient

Patients started on oxygen in 2012

• Were born in 1930 – 1946• Turned 18 yrs old in 1948 – 1964

– 1948: 35% graduated HS, 7% college (4-years)– 1964: 49% graduated HS, 12% college (4-years)

Page 28: Effective Discharge of the Oxygen Dependant COPD Patient

Barriers to Teaching Older Adults• Vision Changes

– Pupil admits 50% less light for a person of 50 than for someone that is 20.

• Hearing Changes– Primarily caused by atrophy of inner ear

structures. – Higher frequencies go first. – Effect very prominent in cigarette smokers.

Page 29: Effective Discharge of the Oxygen Dependant COPD Patient

Neuropsychologic Impairment and Severity of COPD

• 4 groups matched for age & education– Control (n=99)– Mild COPD (n=86)– Moderate COPD (n=155)– Severe COPD (n=99)

• Memory and neuro-performance tests compared to controlGroup Mild Moderate Severe

Performance deficit 27% 61%

Grant I, et al. Arch Gen Psychiatry 1987;44(11):999-1006

Page 30: Effective Discharge of the Oxygen Dependant COPD Patient

Additional Confounding Factors• 17% of Alzheimer’s patients have COPD1.

– One in eight people aged 65 and older (13%) has Alzheimer’s disease.– Nearly half of people aged 85 and older (43%) have Alzheimer’s disease.– Smoking almost doubles the risk of Alzheimer’s disease2.

• The prevalence of depression in COPD is 26%3.

• Racial, ethnic & cultural influences.

1. Alzheimer’s Association website. Alzheimer’s disease and chronic health conditions: the real challenge for 21st century medicine. www.alz.org/national /documents/report_chroniccare.pdf. Accessed 2/4/2011.

2. Janine K. Cataldo, Judith J. Prochaska, Stanton A. Glantz. Cigarette Smoking is a Risk Factor for Alzheimer's Disease: An Analysis Controlling for Tobacco Industry Affiliation. Journal of Alzheimer's Disease, 2010;10:2010-40.

3. Hanania NA, Müllerova H, Locantore NW, et al. Determinants of depression in the ECLIPSE chronic obstructive pulmonary disease cohort. Am J Respir Crit Care Med 2011;183(3):604-611.

Page 31: Effective Discharge of the Oxygen Dependant COPD Patient

  Can we overcome these training obstacles and improve

outcomes?

• Absolutely

• No freaking way!

Page 32: Effective Discharge of the Oxygen Dependant COPD Patient

LTOT Outcome Studies• Ringbaek TJ, Viskum K, Lange P. “Does long-term oxygen

therapy reduce hospitalization in hypoxemic chronic obstructive pulmonary disease? Eur Respir J. 2002

– Cohort study; n=246 10-mos. Pre vs. 10-mos. Post LTOT– LTOT period compared with the pre-oxygen period

• Hospital admission rate 23.8%• hospital days 43.5% • "ever hospitalized" 31.2%

– Author’s conclusion: “This study shows that in hypoxemic chronic obstructive pulmonary disease patients, long-term oxygen therapy is associated with a reduction in hospitalization.”

Page 33: Effective Discharge of the Oxygen Dependant COPD Patient

Can Homecare Providers Influence the 30-Day Readmission Rates for COPD?

• Retrospective analysis• Regional (Western PA) 30-day COPD readmit rate 25%• 180 pts enrolled in program (10 months)

– Referrals from 23 area hospitals

• Program components– Pre-discharge assessment– Home RT visits (days 2, 7 and 30)– 12 Care Coordinator phone calls

• 30-day readmission rate reduced to 3%

BW Carlin, Wiles K, Easley D. Respir Care 2010;55(11):1535 (abstract)

Page 34: Effective Discharge of the Oxygen Dependant COPD Patient

Prevalence of HME Provider Programs• Role of the Management Pathway in the Care of Advanced COPD Patient

in Their Own Homes. Ramani AA, et al. Care Manag J. 2010;11(4):249-53.• Effect of a Homecare Respiratory Therapist Education Program on 30 Day

Hospital Readmissions of COPD Patients. Kaufman LM, Smith AP. Respir Care 2011;56(10):1691 (abstract)

• Healthspring Medicare Advantage Plan Comprehensive Case management Respiratory Program. Prince D, Davidson M, Watson F. Respir Care 2011;56(10):1690 (abstract)

• 2011 AARC Congress– 5 symposia & 6 abstracts

• HME News poll of 120 HME Providers (2011;17(7) (July))– 97 (81%) Have no program in place to address COPD readmissions!

• HME Providers – Opportunity• Acute Care Providers – Need to vet your providers

Page 35: Effective Discharge of the Oxygen Dependant COPD Patient

Vetting a Respiratory HME Provider• What is the location of the nearest office?

– Is the phone answered locally?– Can I visit the office?

• Do they routinely provide OGPE? If yes,– On which patients?– Is it only for travel?– Does it have to be specifically prescribed?

• Do they have RTs on staff? If yes,– How many work out of local office?– Do they provide clinical services or marketing?

• What is the process for patient education?

Page 36: Effective Discharge of the Oxygen Dependant COPD Patient

Questions

[email protected]