George G Burton, M.D.* *From: Depts of Pulmonary Medicine and Respiratory Care Kettering Medical Center Dayton, OH 45429

Preventing Untimely Hospital Re-admission in Patients With Chronic

Obstructive Pulmonary Disease

George G Burton, M.D.*

*From: Depts of Pulmonary Medicine and Respiratory Care Kettering Medical Center Dayton, OH 45429

Goals of This Presentation

•Transformation of the traditional care environment•The PPAC Act of 2010 and value-based purchasing (VBP) •Reduction of hospital re-admissions as a goal•COPD in the spotlight•Literature (on and off) the subject•Remedies: Strategies and tactics•Role of Pulmonary Rehabilitation•Role of the Advanced Respiratory Care Practitioner•Where do we go from here?

Discuss/Review:

Evolving US Health Care Delivery System

•Increase access•Improve quality of health care outcomes•Improve patient safety•Eliminate duplication/waste•Enhance care coordination•Reduce rate of healthcare inflation to sustainable levels

Stated goals:

Patient Protection and Affordable Care Act of 2010•It’s the law of the land!

The Evolving Health Care EnvironmentKey Attributes

Traditional (Today) Tomorrow

•Acute treatment•Cost unaware•Professional Prerogative•In-patient•Individual professions•Traditional practice•Patient passivity•Fee-for-service•Volume-based

•Chronic disease mgmt•Cost-of-care the focus•Consumer responsive•Out-patient•Team•Evidence-based practice•Activated patients•Bundled/Episodic•Value-based

Transformation well-underway - - Federally-funded demonstrationProjects have shown significant improvement in chronic care

outcomes & health care utilization

Value-Based Purchasing Programaka Pay-For-Performance (P4P)

How will hospitals be evaluated?

Total Performance Score (TPS)

•Baseline performance data

•Achievement (current compared to ALL hospitals’ baseline)

•Improvement vs. achievement (my performance to my baseline)

•Achievement points

•Improvement points

www.hospitalcompare.hhs.gov

The RAC*Demonstration Project(2005-2008)

•> 500,000 overpayment determinations in study period…

•….valued at $693 million

•85% were related to inpatient hospital care

*CMS Evaluation of Appropriateness of Medicare Payments

Unplanned Rehospitalizations

Primary contribution factor – poorly coordinated transition of care

NEJM April 2009: Jencks, SF et al

October 1, 2003 through December 31, 2004

19.6% Medicare hospitalization due to the re-admission forsame condition within 30 days of discharge

•2.3 million of 11.8 million total

Diseases with highest recidivism rates:

•CHF (27%); Psychosis (25%); Vascular surgery (24%) COPD (23%); Pneumonia (20%)

Cost impact - $17.4 billion and largely preventable!

Change and Transition are Always Fraught with DANGER!

Examples: Childbirth Hand-off in Football Medical resident shift change hand-off Nursing shift change hand-off HOSPITAL DISCHARGE

75% of Re-admitted COPD Patients Had Not BeenGiven A Follow-Up AppointmentAt Time of Discharge!!

Hospital Value-based Purchasing Program (2013)

Carrot (Rewards): •Financial Rewards•Good Public Relations

•Signal Diseases (2013):AMICHFPneumonia

•Signal Diseases after 10/1/14:

COPD

Hospital Value-based Purchasing Program (2013)

Stick (Penalties):

•Big $$$$!•Poor Public Relations

Penalty Rate to Total Medicare Charges for the Index Year: 1.0% in FY 2013

2.0% in FY 2017

The general idea is: Reward $ = Penalty $*

*This concept is already “under review”

An Important Definition

Hospital Re-admission Rate=

# of Disease Specific Re-admissions /yr

# of Case-Mix Adjusted Disease-SpecificAdmissions /yr

How To Solve The Problem?(not really!)

Keep the denominator as high as possible!

CMS (2014): “Admissions for patients with an in-patient hospitaldeath are excluded because they are not eligible for re-admission.”

??? Government stupidity or shrewdness ???

COPD - - The Numbers

Prevalent yet treatable disease

•Affects 12-24 million Americans

126,000 deaths/yr

•3rd leading cause of death

Mortality now greater in women than men64,000 vs 60,000 deaths in 2007

Huge economic impact•$49.6 billion in 2010; $29.5 billion for direct care

4th leading cause of 30-day hospital re-admissions

Mortality after 2nd hospitalization in 1 year is approx. 60%

Inpatient COPD Care: The Evidence*

Efficacy Evidence Exists

Efficacy Evidence Lacking

Chest radiography/ABG’s

Sputum analysis

Oxygen therapy Acute spirometry

Bronchodilator therapy Mucolytic agents

Systemic steroids Chest physiotherapy

Antibiotics Methylxanthine bronchodilators

Ventilatory support (as required)

Leuktrine modifiers; Mast cell stabilizers

* Mc Crory DC, et al. Chest; April 2001

Under treatment of COPD: A Retrospective Analysis of US Managed Care and Medicare Patients*

“In 42,565 patients with commercial insurance and 8,507 MedicarePatients, COPD controller medications were NOT prescribed for 66.3% of commercial patients and 70.9% of Medicare patients…”

This study highlights a high degree of undertreatment of COPD With most patients receiving no maintenance pharmacotherapy.

*Make B, et al. Int J Chron Obstruct Pulmon Dis; January 2012

The Quality of Obstructive Lung Disease Care for Adults in theUS as Measured by Adherence for Recommended Processes*

“Americans with obstructive lung disease receive only 55% ofrecommended care… Only 30% of patients discharged with

chronic hypoxemia receive supplemental oxygen.”

*Mularski RW, et al. Chest; December 2006

Quality of Care for Patients Hospitalized for Acute Exacerbationof Chronic Obstructive Pulmonary Disease*

“In this study of nearly 70,000 patients hospitalized with acuteexacerbation of COPD, we identified widespread opportunities toimprove quality of care and to reduce costs by addressingproblems of underuse, overuse and misuse of resources, and byreducing variation in practice.”

*Lindenauer PK, et al. Ann Intern Med; June 2006

COPD Care or Lack of It!*

* Darharla W, et al. : Resp Care 2006

•Simple diagnostic tests were underutilized:

CHF: 78% had 2-D Echocardiogram

COPD: 31% ever had spirometry

Strategies Vs. Tactics

• Strategy: The science or art of military commandas applied to overall planning and conduct of large scale operations.

Depends on RESOURCES.

•Tactic: An expedient for achieving a goal Depends on PEOPLE.

“Tactics are used to win an engagement; strategies to win a war.” Bull of Atomic Scientists

The Re-admission Issue

Strategy #1: Question: “Are we in Trouble?”Or

“Are we in Trouble Yet?”

Answer: Hard to find out!

•? Ignorance ? Fear ? IT weakness

•Lack of consensus on (how close is close)?

Absolute vs. Trended Data

•Guesstimate of length of remediation time

Data From our Hospitals“Are we in Trouble Yet?”

Re-admissions

KH

Re-admissions SH

CHF

2012 25.0 (n=38) 21.8 (n=12)

2013 21.8 (n=42) 24.4 (n=12)

Pneumonia

2012 22.2 (n=18) 16.7 (n=18)

2013 16.7 (n=11) 13.5 (n=11)

COPD

2012 14.6 (n=13) 15.2 (n=5)

2013 21.3 (n=16) 13.3 (n=5)

Solution #1: Remediation Strategies and Tactics

WHAT HAS BEEN TRIED TO REMEDIATE THE COPD RE-ADMISSION PROBLEM?

What has worked?What has not?

The literature paints a grim picture!

Part 1 Literature Review: Interventions to Reduce HospitalizationsFollowing Exacerbations of COPD – 1966-2013*

•5 Studied (out of 913) meet evidence-based criteria (1393 participants) All were RCT’s

•Primary outcome: Rehospitalization at 6 or 12 months

•No study examined 30-day all-caused rehospitalization rate

•All tested a different set of interventions


•Two studies (one in Canada, one in Spain/Belgium showed a decrease in rehospitalization rate (45% /yr vs. 67% /yr

•Two US studies showed no signification change between groups

•One US study (VAH) found a 22% higher risk of mortality in theintervention group and no significant change in rehospitalization rate.

•Unclear which interventions were effective or harmful

•“CMS penalties are unjustified.”


Timing:

Pre-Discharge 2 of 5

Transition (bridging) 2 of 5

Post-Discharge 5 of 5

All Three 2 of 5


Which?:

Common to all:•Patient Education•Exacerbation Response Planning (Action Plan)•Telephone Hotline

Common to 4 of 5: •Above Plus…

•General Health Counseling•Coordination with PCP


*Pritao-Centurion, V et al.: Ann. Am. Thorac. Society Jan. 14, 2014 Epub. ahead of print

Which?:

Common to 3 of 5:

•Above plus smoking cessation assistance•Social services referral

1 of 5:•USE OF PULMONARY REHABILITATION•USE OF RCPs ON “TEAM”

IN NONE:•PROVISION OF 10 DAYS WORTH OF MEDICATION•WRITTEN CONTRACT WITH DME PROVIDER•SCHEDULED FOLLOW-UP PHYSICIAN APPOINTMENT


Note: Only 40% of the patients assigned to the pulmonary rehabilitationarm of the study completed the required 75% of a priori definition of compliance.

WINNING STRATEGY #1

• Involve/Re-Energize use of pulmonary rehabilitation - Inpatient, transition, and outpatient

• Think of inpatient stay as a “Teachable Moment”

• Evidence DOES support this…

WINNING STRATEGY #2

Improve the Situation at a National Level

• Support AARC/CoARC’s development of Advanced Practice RCPs (APRCs)

• Encourage Congress to pass HR 2619 (Medicare Respiratory

Therapist Act of 2013)* • Support local state legislation empowering RCPs

* Editorials (Point/Counterpoint): Chest 145(2): 211-218 (2014)

WINNING STRATEGY #3

Improve the Situation at Home

• Take personal ownership of the re-admission problem

• Encourage use of Evidence-Based Medical Practice Guidelines • Insist in the use of TDPs in your hospital

• Participate in discussions regarding “Transitional Care”

• Advocate use of supplying patients with 7-10 days of medications at time of discharge

• Consider use of a “Wallet Biopsy” regarding affordability of discharge medications

WINNING STRATEGY #4

Improve the Situation at Home

With respect to respiratory care EQUIPMENT-LINKED* hospital discharges

• Has DME Contract been accomplished?

• Will the equipment be at the patient’s home when he/she arrives?

• Will the patient (or a caregiver) know how to operate it?

• Is the patient at high risk for EQUIPMENT-LINKED problems?

*O2, aerosol generators, MDIs, ventilators, positive airway pressure devices, percussions

PART 1 Evidence-based Literature Review: Pulmonary RehabilitationFollowing Exacerbations of COPD*

• (ALL RCTs which included at least physical conditioning)

• Improved health-related quality of life

• Improved exercise capacity

• Nine (9) trials: 432 patients

• Significantly reduced hospital re-admissions over 25 weeks (range= 3-18 months)

* The Cochrane Collaboration: Puhan MA et all John Wiley and Sons, LTD, 2011, Issue 10, Article NO. CD005305

Evidence-based Literature Review: Pulmonary RehabilitationFollowing Exacerbations of COPD

In Pulmonary Rehabilitation (PR):

STRATEGY DRIVES TACTICS

Tactical Suggestions (part 1):

• Mandate involvement of PR by TDP in all hospitalized COPD patients• In sicker patients (Gold III-IV) mandate inpatient PR consultation• Task PR with responsibility for DME liaison when appropriate• Staff Transition Clinic with P-competent RCPs and APRCs• Develop-implement PR Protocols if not already available


Tactical Suggestions (Part 2):

• Involve RCPs at all levels of the process

Literature supports use of RCPs in

• Shortening the duration of invasive and Non-invasive ventilation• Via TDPs insuring proper cost affective utilization of respiratory care services• Educating patients in COPD self-management


Tactical Suggestions (Part 3):

• Involve RCPs at all levels of the process

“All levels of the process” includes:

• Planning• In hospital respiratory care and discharge planning• At time of transition• Post hospitalization

ALL AT THE FACE TO FACE LEVEL:

Tactical Suggestions (Part 4)

• Consider development of Transitional Care Unit (TCU)

Pulmonary or Cardiopulmonary Transitional Care Units (TCUs)

The TCU is a facility that provides patient-centered services noted for:

• Coordination and structuring • Continuous availability • Comprehensive care• Compassion• Cultural effectiveness• Competent employees

Services are available in the first several months after discharge in conjunction with the patient’s PCP*.

* Chest 145(1): 149-155, 2014

Tactics For Physicians

• Evaluate ED and “24-Hour Holding Units” Care of COPD patients. can the # of admissions be reduced at the source?

• Encourage the use of Evidence-Based practice guidelines and TDPs throughout the hospital particularly in the care of COPD patients

• Encourage the use of specialized consultation in COPD patients, especially GOLD III-IV and those with co-morbilities

• Develop institution-specific, culturally appropriate COPD patient education materials

• Develop/implement a co-morbility screening instrument to be used for all COPD patients in your practice and in every hospitalized COPD patient

In Closing… The Re-admission Penalty Problem WILL NOT GO AWAY!

So: JOIN THE BATTLE!

- Thank You! -

…With Thanks To:

Trina M. Limberg, BS, RRTJudith A. Tietsort, RN, RRTPatrick J. Dunne, MED, RRTDennis A. Cortese, MDRichard Hamrick, MDRoger Rickel, RRT, MHA

Documents

George G Burton, M.D.* *From: Depts of Pulmonary Medicine and Respiratory Care Kettering Medical Center Dayton, OH 45429