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COPD: Managing the Disease
Not The Symptoms
Patrick J. Dunne, MEd, RRT, FAARC
HealthCare Productions, Inc.
Fullerton, CA 92838
White Memorial Medical Center January 31, 2014 Los Angeles CA
Disclosure
Professional relationships with:
Monaghan Medical Corporation
Mylan Specialty, LP
Ohio Medical Corporation
Objectives
Review the provisions / timelines of Medicare’s Hospital Readmission Reduction Program;
List the clinical and economic impact of COPD and associated comorbidities;
List the evidence-based care guidelines for the inpatient treatment of a COPD exacerbation, and
Describe potential strategies to help reduce all-cause 30-day COPD readmissions.
Hospital Readmission Reduction ProgramSection 3025 Affordable Care Act
Effective FY 2013 (10/1/12 - 9/30/13)
2nd of 2 new payment policies
Financial penalties for excessive 30-day readmissions
3 Targeted conditions Acute MI (19.9%); CHF (24.5%); Pneumonia (18.2%)
Additional conditions to be added in FY 2015
Hospitals identified nationwide
FY 2013 - - 2,213 hospitals w/ $280 million in penalties (up to 1%)
FY 2014 - - 2,225 hospitals w/ $227 million in penalties (up to 2%)
FY 2015 - - penalty up to 3% of total Medicare payments
Page 113: “We believe the COPD
measure warrants inclusion in
the Hospital Readmission
Reduction Program for FY 2015”
Fiscal Year 2015
October 1, 2014 – September 30, 2015
Index Years:
July 1, 2010 – June 30, 2011
July 1, 2011 – June 30, 2012
July 1, 2012 – June 30, 2013
Penalty in FY 2015:
Up to 3% of Medicare payments
Now, About COPD . . . .
Definition: A progressive, inflammatory chronic disease characterized by
increasing airflow obstruction coupled with destruction of
pulmonary gas exchange areas. There are clinically relevant
extra-pulmonary effects secondary to systemic inflammation
Prevalence is increasing; 3rd Leading cause of death
Airflow obstruction/alveolar destruction largely irreversible
Primary cause: Long-term exposure to noxious inhalants
A largely preventable disease
Fourth leading cause of recidivism
Risk Factors for COPD
Socio-economic status
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Genes
Infections
Aging Populations
Cardiovascular Disease
Lung Cancer
Anxiety, Depression, Addiction
Peripheral Muscle Wasting & Dysfunction
Osteoporosis
Cachexia
Peptic UlcersGI Complications
Anemia
Pulmonary Hypertension
DiabetesMetabolic Syndrome
Adapted from Kao C, Hanania NA. Atlas of COPD. 2008.
COPD is a Multisystem Disease
COPD Comorbidities
COPDOpportunities for Improvement
Unplanned re-admissions are costly
30 day re-admits largely preventable
COPD evidence-based care guidelines exist
For both in-patient (exacerbation) and out-patient (Sx control)
Use of evidence-based care guidelines is low
Currently, care outcomes less than optimal
Growing concern over high recidivism rate
Under-treatment of COPD
Record review: 553 pts. discharged with Dx of COPD Darmella W, et al. Respir Care; October 2006
Only 31% had confirmatory spirometry
We must raise awareness of the need to confirm the diagnosis of COPD and it’s severity with spirometry
Record review: 169 pts. with 1,664 care events
Mularski RW, et al. Chest; December 2006
Subjects received 55% of recommended care; Only 30% with base-line hypoxemia received LTOT
The deficits and variability in processes of care for patients with obstructive lung disease presents ample opportunity
for improvement
Inpatient COPD Care: The EvidenceMcCrory DC, et al. Chest; 2001
EFFICACY EVIDENCE EXISTS EFFICACY EVIDENCE LACKING
Chest radiography/ABGs Sputum analysis
Oxygen therapy Acute spirometry
Bronchodilator therapy Mucolytic agents
Systemic steroids Chest physiotherapy
Antibiotics Methylxanthine bronchodilators
Ventilatory support (as required) Leukotrine modifiers; Mast cell stablizers
Level 1-2 evidence of efficacy = Recommended care
Insufficient efficacy evidence = Non-recommended care
Non-recommended care = Unnecessary care
Under-treatment of COPD
Record review: 69,820 records from 360 hospitals Lindenauer PK, et al. Ann Intern Med; June 2006
66% received all of recommended care; 45% received at least one non-recommended care; Only 30% received Ideal Care
We identified widespread opportunities to improve quality of care and to reduce costs by addressing problems of underuse, overuse and
misuse of resources, and by reducing variation in practice
Claims data review: 42,565 commercial, 8,507 Medicare Make B, et al. Int J Chron Obstruct Pulmon Dis; January 2012
No pharmacotherapy – 60% commercial, 70% Medicare No smoking cessation – 82% commercial, 90% Medicare No influenza vaccination – 83% commercial, 76% Medicare
This study highlights a high degree of undertreatment of COPD, with most patients receiving no maintenance pharmacotherapy
or influenza vaccination
Under-treatment of COPD: Summary
COPD - an expensive, chronic condition
Incidence is increasing
Financial liability is escalating
Diagnostic spirometry is woefully under-used
Use of evidence-based treatment guidelines is low
Failure to control symptoms a precursor to exacerbations
COPD hospital re-admissions are largely preventable
Chronic disease management strategies a necessity
• 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 vaccination
Add short-acting bronchodilator (as needed)
GOLD GuidelinesPre-2013
Combined Assessment of COPDGOLD Guidelines (2013)
Risk
GOLD Classification of Airflow Limitation
Risk
Exacerbation history
≥ 2
1
0
(C) (D)
(A) (B)
mMRC 0-1 (or) CAT < 10
4
3
2
1
mMRC > 2 (or) CAT > 10
Symptoms(mMRC or CAT score)
Left (or) Right: Up (or) Down
Fewer MoreSymptoms Symptoms
> 2 exacerbations
0-1 exacerbations
Modified British Medical Research Council (mMRC) Dyspnea Questionnaire:
A 5-item measure of perceived dyspneaSelf-report on grade 0 – 5
(or)
COPD Assessment Test (CAT):
An 8-item measure of health status impairment in COPDSelf-report on scale 0 – 5
Assessment of SymptomsGOLD Guidelines (2013)
Both have been validated and relate well to other measures of
health status and predict future mortality risk.
Modified MRC (mMRC) QuestionnaireGOLD Guidelines (2013)
COPD Assessment Test (CAT)GOLD Guidelines (2013)
COPD Assessment Test (CAT)GOLD Guidelines (2013)
Combined Assessment of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD
Risk Pre-2013 GOLD Classification of
Airflow Limitation
Risk
Exacerbation history
≥ 2
1
0
(C) (D)
(A) (B)
mMRC 0-1 (or) CAT < 10
4<30%
3 30-50%
1≥ 80%
mMRC > 2 (or) CAT > 10
Symptoms(mMRC or CAT score)
2 50-80%
Patient Characteristics Spirometric Classification
Exacerbations per year
mMRC CAT
ALess Symptoms
Low RiskGOLD 1-2 0-1 0-1 < 10
BMore Symptoms
Low RiskGOLD 1-2 0-1 ≥ 2 ≥ 10
CLess Symptoms
High RiskGOLD 3-4 ≥ 2 0-1 < 10
DMore Symptoms
High RiskGOLD 3-4 ≥ 2 ≥ 2 ≥ 10
Combined Assessment of COPDGOLD Guidelines (2013)
When assessing risk, choose the highest risk according to GOLD grade or
exacerbation history
COPD Maintenance Treatment by Airflow Limitation/RiskGOLD Guidelines (2013)
Inpatient COPD Care: The EvidenceMcCrory DC, et al. Chest; 2001
EFFICACY EVIDENCE EXISTS EFFICACY EVIDENCE LACKING
Chest radiography/ABGs Sputum analysis
Oxygen therapy Acute spirometry
Bronchodilator therapy Mucolytic agents
Systemic steroids Chest physiotherapy
Antibiotics Methylxanthine bronchodilators
Ventilatory support (as required) Leukotrine modifiers; Mast cell stablizers
Acute Spirometry with COPD Exacerbation Isn’t spirometry needed to Confirm Dx and Grade Airflow Limitation?
Acute spirometry
Hospitalized patients not ready for full PFT studies
Unable to exert maximal effort; Repeat maneuvers Pre-post bronchodilator response of limited value
Make appointment for 4-6 weeks post recovery
What about peak inspiratory flow?
Not a demanding test but insightful Ability to use a DPI
Generate ≥ 40 L/min PIF
Secretion Retention with COPD ExacerbationCan Contribute to Airflow Obstruction; WOB
Chest physiotherapy
An airway clearance technique (ACT)
Secretion retention, ineffective cough problematic
Trendelenburg position contraindicated in COPD
Proven alternate ACT techniques in use for CF
ACBT, AD, HFCWO, IPV, OPEP
Which to consider for COPD? OPEP Rx a viable regimen
Inexpensive, non-invasive Alone or in combo with SVN
Medication NebulizersNot all jet-nebulizers are created equal!
Higher respirable dose = Quicker onset of action!
Higher respirable dose = Shorter treatment times!
Quicker onset/less time = Better RT deployment!
Respirable Dose 10% Respirable Dose 30%Respirable Dose 15%
Dynamichyperinflation
Dynamic Hyperinflation
Breath Actuated Nebulizer in COPDHaynes J. Respir Care; Sept 2012
Prospective, randomized controlled trial
Objective: compare bronchodilator response w/ BAN to standard SVN
Patients admitted w/ COPD exacerbation N = 40 of 46; Similar baseline characteristics
Dyspnea secondary to dynamic hyperinflation
Medication regimen 2.5 mg albuterol/0.5 mg ipratropium (3 mL) Q4H
2.5 albuterol Q2H prn
Common adverse effects monitored during/after each Rx
Data collected 2 hrs post 6th scheduled Rx (collector blinded) Inspiratory capacity; dyspnea; RR
Breath Actuated Nebulizer in COPDHaynes J. Respir Care; Sept 2012
Findings: Both groups received same # Rxs (6.25; 6.20)
IC higher in BAN v. SVN (1.83 L v. 1.42 L; P .03) Change in IC greater BAN v. SVN
RR lower in BAN v. SVN (19/min v. 22/min; P = .03)
No difference in BORG or LOS
Breath Actuated Nebulizer in COPDHaynes J. Respir Care; Sept 2012
Conclusions:
In this cohort of patients with ECOPD, the AeroEclipse II BAN was
more effective in reducing lung hyperinflation and respiratory rate
than traditional SVN.
It may be that the BAN group simply received more medication
because of the breath activated mode…Aerosols with MMAD of
3.0 μm produce the highest physiological response in terms of
FEV1 and airway conductance.
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.
Ease of use; simple technique
Addresses inconvenience issue
Effective and reliable drug delivery
Use not limited by disease severity or mental acuity
Device & medications covered under Medicare Part B
Nebulized Therapy at Home
Managing Stable COPD Goals of Therapy
Relieve airflow obstruction
Improve exercise tolerance Reduce symptoms
Improve health status
Relieve airflow obstruction
Improve exercise tolerance Reduce risk
Improve health status
Reduced symptoms + Reduced risk = Successful disease management
Improving COPD Care OutcomesSummary
A new COPD care pathway essential COPD pts. will impact hospital’s revenue Pt. volume will vary by institution
1-2/month up to 6-8/month Allocate resources accordingly
Re-design current workload Advocate evidence-base care
Start small; Expand accordingly Appoint, anoint, elect one departmental COPD Guru Let pt. volume drive program development
Determine risk grade per 2013 GOLD Guidelines Use CAT (or) mMRC Ensure proper controller medications prescribed Appointment for follow-up MD appointment 5-7 days
AARC Resources
Domain of Likely COPD Performance MeasuresTimely and Effective Care
Documented evidence in medical record of:
Smoking cessation (discussed at every visit)
Spirometry (within past 2-3 yrs.)
Bronchodilator therapy (esp. controller medications)
Immunizations (pneumococcal, influenza)
Performance measures tied to readmission penalties
Already required under Physician Quality Reporting System
(PQRS)
COPD: Managing the Disease
Not The Symptoms
Patrick J. Dunne, MEd, RRT, FAARC
HealthCare Productions, Inc.
Fullerton, CA 92838
White Memorial Medical Center January 31, 2014 Los Angeles CA
