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