patrick j. dunne, med, rrt, faarc fullerton, ca · the transition of copd patients 7/25/18 5 copd...

TheTransitionofCOPDPatients 7/25/18

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Patrick J. Dunne, MEd, RRT, FAARCFullerton, CA

[email protected]

KSRC West Central DistrictRespiratory Summit 2018

July 25, 2018 w Paducah w KY

The Transition of COPD Patients From Inpatient Acute Care to Community-Based

Chronic Care

Objectives

✦ Review the causes of recidivism in patients with chronic medical conditions;

✦ List the basic elements of a successful COPD care transition plan;

✦ Describe strategies where RTs can help reduce all-cause 30-day COPD readmissions by improving care transition, and

✦ State the benefits of tracking the health care utilization of chronically ill patient populations;


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Government Changes in Health CareNewly Emerging Environment of Care

TRADITIONALEMPHASIS NEWEREMPHASIS

Acutecare Chroniccare

In-patient Out-patient

Treatsymptoms Managedisease

Individualpatient At-riskpopulations

Billableprocedures Outcomesofcare

Fee-for-service Pay-for-performance

Fee-for-service = volume drivenPay-for-performance = value driven

Now, About COPD . . . .

✦ Prevalence increasingv 3rd Leading cause of death (120,000/year)

§ Since 2000, mortality greater in women

v 4th Leading cause of recidivism (EXPENSIVE $$$$)

v Cost of hospital stay greater than reimbursement

✦ Primary cause: Long-term exposure to noxious inhalantsv A largely preventable disease

✦ Definition:v A progressive, inflammatory chronic disease characterized by:

§ Increasing airflow obstruction, § Destruction of pulmonary gas exchange areas, and § Clinically relevant extra-pulmonary effects secondary to systemic

inflammation


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The Tobacco Nation

Per Capita Incidence of COPD


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Cardiovascular Disease

Lung Cancer

Mental/Behavioral Health Issues

Peripheral Muscle Wasting/Dysfunction

Osteoporosis

Cachexia

MalnutritionGI Complications

Anemia

Pulmonary Hypertension

DiabetesMetabolic Syndrome

Adapted from Kao C, Hanania NA. Atlas of COPD. 2008.

COPD is a Multisystem Disease

Hospital ReadmissionsPrimary Contributing Factors for COPD

✦ Poorly coordinated transition of carev Patients not prepared for continuing self-care responsibilities

§ Gaps in knowledge of disease & progression § Unaware of impact of non-adherence, repeat exacerbations§ Unaware of early warning signs/symptoms of relapse

v 3 of 4 re-admitted patients – no MD visit after discharge§ Ideally seen within 5-7 days of discharge

✦ Low use of evidence-based medical practice (GOLD Guidelines)v Sub-optimal prescribing of controller medications

§ Delivery device incongruence§ Continued access issues


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COPD Care Transition PlanEssential Elements (Coleman EA. www.caretransitions.org)

✦ Formalized Care Planv Patient centricv Comprehendiblev Shared

✦ Red Flag Warningsv Increased cough, dyspnea, mucusv Whom to call & when

✦ Medication Reconciliationv Maintenance medsv Appropriate delivery devicev Continued access

✦ Follow-up Appointmentsv Primary care, specialistv Pulmonary rehabv Spirometry, immunizationsv Tobacco counseling

✦ Daily Activity Planv Medication adherencev ADLs and ambulation as tolerated

§ 30 mins/day 5 days a week

✦ Ensuring Follow-throughv Directly or via surrogatev Ongoing monitoring

§ Telehealth; Patient registry

Medication ReconciliationEnsuring Post-Acute Care Symptom Control

✦ Caveats:v Not a straightforward processv Patient input can be incomplete

§ Comorbidities adds further complexity

v Traditionally 3 disciplines (MDs, RNs, PharmDs)

§ Roles/responsibilities vary§ Evidence supports RTs best at respiratory meds and devices!

✦ Inhalational drug delivery challengesv Therapeutic effect directly dependent on drug deliveryv Each aerosol delivery device has unique attributes

§ Drug-delivery device congruence per patient essential


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COPD Care Transition PlanMedication Reconciliation

✦ Post-hospital pharmacotherapy

v Proper maintenance meds § Rescue inhaler (with VHC)

§ Long-acting bronchodilators

§ Inhaled corticosteroids

§ Long-term oxygen therapy; Non-invasive ventilation

v Essential medical-grade equipment§ Home compressor-nebulizer

§ Ambulatory and portable oxygen systems

§ Respiratory assist devices


✦ Achieving sustained adherencev Patient/caregiver buy-in

v Able to use prescribed delivery device(s)

v Periodic reinforcement / re-training

v Continued access to maintenance meds

v Aware of consequences

Making it easy for our patients to be

Successful


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= =

Device Selection & Outcomes of Aerosol TherapyDolovich M, et al. Chest 2005

RESULTS: Each of the delivery devices provided similar outcomes in patients using the correct technique for inhalation.

CONCLUSIONS: Devices used for the delivery of bronchodilators and steroids can be equally efficacious

“We found that HCPs and patients prioritize medications over device when selecting treatments, showing limited concerns

about proper device use . . . Only 37% of HCPs considered type of device to be highly important . . .

. . . 64% of COPD patients were also relatively unconcerned with proper device technique”.

Hanania NA, Braman S, et.al. Journal of the COPD Foundation; Vol 5; No 2; 2018

Medication ReconciliationEnsuring Post-Acute Care Symptom Control


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• FEV1/FVC < 0.70• FEV1 ≥ 80% predicted

• FEV1/FVC < 0.70• 50% ≤ FEV1 < 80%

predicted

• FEV1/FVC < 0.70• 30% ≤ FEV1 < 50%

predicted

• FEV1/FVC < 0.70• FEV1 < 30% predicted

or FEV1 < 50% predicted plus chronic respiratory failure

Add regular treatment with long-acting bronchodilators; Begin Pulmonary Rehabilitation

Add inhaled glucocorticosteroids if repeated acute exacerbations

Add LTOT for chronic hypoxemia.Consider surgical options

III: Severe

I: MildII: Moderate

IV: Very Severe

Active reduction of risk factor(s); smoking cessation, flu vaccinationAdd short-acting bronchodilator (as needed)

GOLD Guidelines (Pre-2012)

Combined Assessment of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD

RiskPre-2013 GOLD Classification of

Airflow Limitation

RiskExacerbation

history

≥ 2

1

0

(C) (D)

(A) (B)

mMRC 0-1 (or) CAT < 10

4< 30%

330-50%

1≥ 80%

mMRC > 2 (or) CAT > 10

Symptoms(mMRC or CAT score)

250-80%


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Left (or) Right - - Up (or) Down

Fewer MoreSymptoms Symptoms

> 2 exacerbations

0-1 exacerbations

Combined Assessment of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD

RiskPre-2013 GOLD Classification of

Airflow Limitation

RiskExacerbation

history

≥ 2

1

0

(C) (D)

(A) (B)

mMRC 0-1 (or) CAT < 10

4< 30%

330-50%

1≥ 80%

mMRC > 2 (or) CAT > 10

Symptoms(mMRC or CAT score)

250-80%


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Treatment/Maintenance of Stable COPD

© 2017 Global Initiative for Chronic Obstructive Lung Disease

COPD Exacerbation – Inpatient Care

✦ The goal for treatment of COPD exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events.

✦ Short-acting inhaled beta2-agonists (SABAs), with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation.

✦ Maintenance therapy with long-acting bronchodilators (LABAs) should be initiated as soon as possible before hospital discharge.

2017 Global Initiative for Chronic Obstructive Lung Disease (www.goldcopd.org)


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Bronchodilator Assessment Score

BronchodilatorTherapyAssessmentScore SCORE

Breathsounds

0Normal/Clear

1EndExpiratory

Wheeze

2PronouncedExpiratoryWheeze

3Inspiratory&ExpiratoryWheeze

4Absentor

NearAbsent

Dyspnea(SOB) 0None

1Slight

2Mild

3Moderate

4Severe

TOTALSCORE:

TotalScore 0 1-2 3-4 5-6 7-8

Frequency

SABAQ4hoursPRNfor

increasedshortnessof

breath;continuelong-acting

bronchodilators

SABAQ4hoursPRNforincreasedshortnessof

breath;startlong-actingbronchodilators

SABAandAnticholinergicevery4hours;

considerstartinglong-acting

bronchodilators

Every 2hours;ifoncontinuous,thenweanSABAby5

mg/hr astolerateddown

to5mg/hr

Every1hourupto3treatments,thenstart continuous

SABAandAnticholinergic

When SABA use ≤ Q4H, convert to LABA, with SABA to Q4H/prn


✦ Medicare Drug Coverage – Post acute care

v Part B - - Physician services; DME Benefit ($134.00/month)

§ Annual deductible: $183.00§ Medicare pays 80%; Co-insurance 20%§ Home compressor/nebulizer, respiratory solutions (J-Code)

§ Home care pharmacy supplies maintenance medsü Minimal out-of-pocket expenses

v Part D - - Prescription Drug Plan ($35.00 – $60.00/month)

§ Annual deductible: Varies by plan§ Patient (25%) & plan (75%) pay until Total drug costs = $3,750

ü Patient enters “coverage gap”

§ Private pay (discounted) until Total “out-of-pocket” costs = $5,000ü Donut hole = No prescription refills = Non-adherence

§ All inhalers covered under Part D


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Inhaler Misuse in COPD PatientsImportant Considerations

✦ Age-related physical/mental “tail-off”v Visual, hearing, tactile, memory

✦ Add disease-related limitations v Inability to alter breathing patternv Actuation/inhalation coordination issuesv Diminished PIFR capability due to low FEV1

Physical Ability to Use a DPIPoor Use = Non-delivery of Medication

✦ Value of assessing peak inspiratory flow rate

v Not demanding but insightful maneuverv Ability to generate PIFR ≥ 35-40 L/minv PIFR ≤ 30L/min candidate for nebulizer


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Role of Nebulized Therapy in COPDDhand R, et al. COPD; Feb 2012

Recommendation:

“Many patients, especially elderly patients with COPD, are unable to use their pMDIs and DPIs in an optimal manner. For such patients, nebulizers should be employed on a domiciliary basis. . .

“Nebulizers are more forgiving to poor inhalation technique, especially

– Poor coordination with pMDIs, and

– The requirement to generate adequate peak inspiratory flows with DPIs.”

✦ Inconvenience, IC issues addressed

✦ Ease of use; simple technique

✦ Effective, reliable drug delivery

✦ Use not limited by disease severity or mental acuity

✦ Device and unit dose meds covered under Medicare Part B

Nebulized Therapy at HomeEnabling Sustained Medication Adherence


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Secretion Retention with COPD ExacerbationContributes to Airflow Obstruction; WOB

✦ Non-pharmacologic airway clearance therapy (ACT)v Secretion retention, ineffective cough problematic

v CPT uncomfortable for COPD patients

v Proven alternate ACT techniques for CF

§ ACBT, AD, HFCWO, IPV, OPEP

✦ Which to consider for COPD?v OPEP Rx a viable regimen

§ Inexpensive, non-invasive§ Alone or in combo with SVN

Home Cleaning/Sterilizing OptionsAeroEclipse Reusable; Aerobika

✦ Infection Control Optionsv Dishwasher safev Immersible in boiling waterv Microwave sterilizer


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Expanded Role for RTs in COPD CareAt The Very Least

v Disease management activities§ Nature of COPD § Importance of symptom control§ Consequences of repeat exacerbations§ Smoking cessation; Daily activity level

✦ Begin to plan for discharge at admission

v Medication reconciliation§ Proper use of SABAs, LABAs, LAMAs, LTOT & NIV

o SABAs prn only

§ Selection/training in delivery deviceso Compressor-nebulizer versus inhalers

§ Consequences of non-adherence

Expanded Role for RTs in COPD CareAt The Very Least

✦ Schedule post-discharge follow-up visitsv Primary care physician/clinic (within 7 days!)

v Additional appointments as needed§ Pulmonary Rehab, Tobacco Cessation, PFT, PSG

✦ Provide “action plan” for the unexpectedv Seek immediate care with:

§ Increasing cough§ Increasing dyspnea (especially if refractory to SABAs)

§ Changes in sputum volume, consistency, color

✦ Become active/visible in hospital-wide readmission reduction and transition care programs

patrick j. dunne, med, rrt, faarc fullerton, ca · the transition of copd patients 7/25/18 5 copd...

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