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
Example of a Readmission Chain Initial Admission:CABG Surgery Readmission:Post-op Wound Infection Readmission: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
Test Your Understanding… A readmission for diabetes following an initial admission for diabetes Potentially Preventable Readmission? YES
Test Your Understanding… An admission for trauma following a discharge for AMI Potentially Preventable Readmission? NO (unrelated acute event)
Test Your Understanding… A readmission for diabetes in a patient whose initial admission was for an acute myocardial infarction Potentially Preventable Readmission? YES
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
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
US COPD Data In 2010 COPD costs the US est. $29.5 billion in direct costs & $20.4 billion in indirect costs 1 – 14.8 million Americans diagnosed with COPD 2 – 150 million days of lost work annually 1 – A person with COPD dies every 4-minutes in the US 3 – 3rd leading of cause of death 4 – 2 nd leading cause of disability 1 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.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 3/24/11http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm 4.National Vital Statistics Reports Volume 59, Number 2. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_02.pd//f
More US COPD Data COPD ranks #3 in acute hospital admissions (DRG: 088) – 672,000 COPD discharges in 2006 1 – Avg. annual hospitalized days 8.18 2 – Avg. LOS 5.1 days 3 – Avg. per day cost $2,959 4 – Avg. total cost/admission $15,093 4 – Avg. payment/admission $19,635 5 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.pdf 4.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.
COPD Re-Admission Data 22.6% of COPD patients are readmitted within 30-days 1 Key readmission predictors 2 – Use of long-term oxygen therapy – Low health status – Lack of routine physical activity Key components to reducing readmissions 3-8 – 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.
NOTT (Nocturnal Oxygen Therapy Trial) Ann Intern Med 1980;93(3):391-398 203 pts. randomized to continuous or nocturnal O 2 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 O 2 group was 1.94 times that for the continuous O 2 group – Continuous O 2 therapy reduces mortality – Basis for current LTOT standards
NOTT Study (Revisited) Petty TL, Bliss PL. Respir Care 2000;45(2):204-211 Patients in study 203 Pedometer data available 157 No match (computer modeling to +/- 1%) 77 Matched patients (age, sex, severity of disease) 80 Nocturnal oxygen therapy - low walk 22 Continuous oxygen therapy - low walk 18 Nocturnal oxygen therapy - high walk 22 Continuous oxygen therapy - high walk 18
NOTT Study (Revisited) Petty TL, Bliss PL. Respir Care 2000;45(2):204-211 High Walk COT High Walk NOT Low Walk COT Low Walk NOT
NOTT Study (Revisited) Petty TL, Bliss PL. Respir Care 2000;45(2):204-211 Average Per Patient Annual Duration of Hospitalization
Since long-term oxygen is so good for COPD patients, they must all be very compliant… Right?
Compliance with O 2 Prescription Pepin 1 et al. – 930 LTOT patients on O 2 for at least 36-mos. – Mean daily duration of O 2 prescribed 16±3 hrs. – Only 45% of pts used O 2 for 15 hrs or > per day. Peckham 2 et al. – RCT: 86 pts (45 treatment & 41 control) – Treatment group received additional clinician training – Daily O 2 use for 15 hrs or more after 6-months: Treatment group82% 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.
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.
Characteristics of COPD Patients 80-90% of COPD results from cigarette smoking 1 Prevalence of those who smoke – Education 2 < High school education32% High school education29.3% College graduates13.3% – Income 2 Below poverty level36.5% At or near poverty level32.8% Above poverty level22.5% Average age when started on LTOT: 74±8 years 3 1.American Lung Association: http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html (accessed 2/4/2011).http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html 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.
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)
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.
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 control GroupMildModerateSevere Performance deficit27%61% Grant I, et al. Arch Gen Psychiatry 1987;44(11):999-1006
Additional Confounding Factors 17% of Alzheimer’s patients have COPD 1. – 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 disease 2. 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 21 st century medicine. www.alz.org/national /documents/report_chroniccare.pdf. Accessed 2/4/2011.www.alz.org/national /documents/report_chroniccare.pdf 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.
Can we overcome these training obstacles and improve outcomes? Absolutely No freaking way!
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.”
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)
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
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?