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CME Evaluation with Post-activity Survey

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1 CME Evaluation with Post-activity Survey
Prior to the start of the program, please check your syllabus to ensure you have the following printed program materials: Pre-activity Survey Located at the front of your syllabus CME Evaluation with Post-activity Survey Located at the back of your syllabus


3 Disclosures The relevant financial relationships reported by faculty that they or their spouse/partner have with commercial interests are located on page 5 of your syllabus The relevant financial relationships reported by the steering committee that they or their spouse/partner have with commercial interests are provided on page 5 of your syllabus The relevant financial relationships reported by the non-faculty content contributors and/or reviewers that they or their spouse/partner have with commercial interests are located on page 5 of your syllabus

4 Off-label Discussion Disclosure
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the Food and Drug Administration. PCME does not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings. The opinions expressed are those of the presenters and are not to be construed as those of the publisher or grantors. CAROL

5 Learning Objectives Identify lapses in COPD care that led to the Centers for Medicare and Medicaid Services (CMS) quality measures, and identify opportunities to improve the quality of that care across the healthcare continuum Apply current clinical evidence and guidelines to develop a comprehensive care plan that addresses common reasons for repeat exacerbations and hospital readmissions Apply quality-of-care models and develop programs to foster effective transitions of care and ongoing maintenance treatments for patients with COPD

6 Polling Question Pre-activity Survey
What percentage of your COPD patients who present for management of exacerbations do you refer for pulmonary rehabilitation? All of my COPD patients 51%-75% of my COPD patients 25%-50% of my COPD patients <25% of my COPD patients

7 Polling Question Pre-activity Survey
In what percentage of your patients presenting for management of COPD exacerbations do you evaluate and manage comorbidities? All of my COPD patients 51%-75% of my COPD patients 25%-50% of my COPD patients <25% of my COPD patients

8 Polling Question Pre-activity Survey
Please rate your level of familiarity with the CMS Core Measures for COPD: Not at all familiar Expert

9 Polling Question Pre-activity Survey
Please rate your level of confidence in your ability to implement strategies to ensure continuity of care for COPD patients based on the CMS Core Measures for COPD: Not at all confident Expert

10 Polling Question Pre-activity Survey
What is the most common cause of mortality in COPD patients? COPD Depression Cardiovascular disease Diabetes

11 Polling Question Pre-activity Survey
A 72-year-old woman is released after management of COPD exacerbation. She has type 2 diabetes, hypertension, hypothyroidism, and rheumatoid arthritis. She is not at the goal for hemoglobin A1C nor blood pressure. She also has mild depression, for which she is successfully managed with trazodone. What is her greatest risk for frequent exacerbations going forward? Her age Age at onset of COPD Her uncontrolled diabetes Her history of exacerbations

12 Polling Question Pre-activity Survey
Based on the GOLD 2014 recommendations, which of the following criteria should be present before hospital discharge following COPD exacerbation? Patient has been clinically stable for hours Patient is able to walk around the block (if previously ambulatory) Patient requires inhaled short-acting beta2-agonist therapy every 2-4 hours Patient had stable arterial blood gases for hours

13 Polling Question Pre-activity Survey
Which of the following non-pharmacologic interventions has been shown to decrease readmissions for COPD exacerbation? Vitamin D supplementation Decreased physical activity Yearly influenza vaccination None of the above

14 Polling Question Pre-activity Survey
So far, the only therapy documented to reduce COPD disease progression is: Physical activity Influenza vaccination Smoking cessation Good nutrition

15 Polling Question Pre-activity Survey
Which of the following outcomes may be seen when enrolling patients in an integrated disease management plan for COPD? Decreased frequency of viral infection Weight gain Decreased readmissions and lengths of stay Significantly increased health care costs

16 Polling Question Pre-activity Survey
When selecting a medication delivery system for your COPD patient, which is your most important criteria? Amount of medication deposited in the lungs Cost Disease severity Hand-breath coordination Presence of support system to help administer the medication

17 Opportunities to Improve COPD Care
Focus on the CMS Quality Measures

18 The Impact of COPD ~15 million people diagnosed (additional 12M are undiagnosed) 2nd leading leading cause of disability 3rd leading cause of 30-day readmissions 3rd leading cause of death (2nd to CV disease and cancer) Mortality rate predicted to increase by 30% over the next decade Exacerbations ~800,000 hospitalizations (+ 3.5 million COPD 2nd dx) 1.5 million ER visits/year Costs for COPD in the United States, 2010 = $50 billion and rising CDC. Accessed Dec. 2, The COPD Foundation. Accessed Nov. 10, 2014. National Heart, Lung and Blood Institute (NHLBI). COPD – Learn More, Breath Better. Accessed Nov. 10, 2014. Guarascio AJ et al. Clinicoecon Outcomes Res. 2013;5:

19 Most COPD Costs are Hospital-related
New Clinic Visit (1%) Emergency (7%) Exacerbation (70%) Speaker Notes This study evaluated the direct costs of treating exacerbations with a focus on the costs associated with initial treatment failure. A total of 2,414 patients with exacerbated chronic bronchitis and COPD were recruited from 268 general practices located throughout Spain. Patients were followed for 1 month. A total of 507 patients (21%) relapsed; of these, 161 (31.7%) required attention in emergency departments and 84 (16.5%) were admitted to the hospital. The total direct mean cost of all exacerbations was $159; and patients who were hospitalised generated 58% of the total cost. Cost per failure was $477 and failures were responsible for an added mean cost of $100 per exacerbation. Reference Miravitlles M, Murio C, Guerrero T, Gisbert R; DAFNE Study Group. Decisiones sobre Antibioticoterapia y Farmacoeconomía en la EPOC. Pharmacoeconomic evaluation of acute exacerbations of chronic bronchitis and COPD. Chest. 2002;121: Hospitalization (92%) 30-day readmission rates for COPD are ~25% Miravitlles M et al. Chest. 2002;121: Jencks SF et al. N Engl J Med. 2009; 360:

20 COPD Readmissions are Common and Costly
Condition Types of Hospital Admission # of Admits with Readmission* Readmission Rate Avg. Medicare Payment for Readmission Total Spending on Readmissions Heart Failure Medical 90,273 12.5% $6,531 $590,000,000 COPD 52,327 10.7% $6,587 $345,000,000 Pneumonia 74,419 9.5% $7,165 $533,000,000 Acute MI Surgical 20,866 13.4% $6,535 $136,000,000 CABG 18,554 13.5% $8,136 $151,000,000 PTCA 44,293 10.0% $8,109 $359,000,000 Other Vascular 18,029 11.7% $10,091 $182,000,000 Total for 7 Conditions 318,760 $2,296,000,000 Total DRGs (% of Total) 1,134,483 (28.1%) $7,980,000,000 (28.8%) CABG = coronary artery bypass graft; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty *Readmissions within 15 days of discharge of the initial inpatient stay MedPAC (Medicare Payment Advisory Commission), Report to Congress

21 Hospital Readmissions and the Affordable Care Act (ACA): CMS Performance Report
Hospital readmissions have been singled out for improvement by CMS National Strategy for Quality Improvement in Health Care The goal of the CMS strategy is a 20% reduction in hospital readmission rates, potentially preventing 1.6 million hospitalizations and saving an estimated $15 billion CMS will publicly report COPD measures on Hospital Compare beginning in as part of the Hospital Inpatient Quality Reporting (IQR) program Data reported in the 2013 Chartbook (1/2009 – 12/2011) summarize “dry run” results shared with hospitals COPD readmission measure will be included in the Fiscal Year Hospital Readmissions Reduction Program (HRRP) Centers for Medicaid and Medicare Services. Medicare Hospital Quality Chartbook. Performance Report on Outcome Measures (September 2014). Available at: HospitalQualityInits/Downloads/Medicare-Hospital-Quality-Chartbook-2014.pdf. Accessed Nov. 14, 2014.

22 Benefits of Guideline-based Treatment
Improved lung function1,2 Improved symptoms1,2 Improved exercise tolerance1,2 Improved QoL1,2 Prolonged life and better QoL with smoking cessation1,2 Delayed time to first exacerbation1,2 Fewer exacerbations1,2 Fewer hospitalizations1,2 Cost savings3 Restrepo RD et al. Int J COPD. 2008;3: Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 3/10/14. Asche CV et al. Int J Chron Obstruct Pulmon Dis. 2012;7:

23 Management of Acute Exacerbations

24 Patient Case Study (1 of 4)
JS is a 58-year-old white male who presents to his primary care physician with painful right inguinal hernia Past medical history Lack of routine health care x 20 years Considers himself to be active, works outside as a construction supervisor and teaches horseback-riding lessons Denies other significant medical conditions other than punctured lung in his early 30s due to a horseback-riding accident Smokes 1½ to 2 PPD x 39 years Successfully underwent 2 open hernia repairs 3 months apart Never screened for COPD on pre-operative evaluation and no chest x-ray performed Photo from image #

25 Patient Case Study (2 of 4)
JS underwent his 2nd open hernia repair Post-operative course after 2nd surgery was complicated by episode of bronchitis for which he presented to his PCP and was treated with azithromycin x 5 days PCP also prescribed: Albuterol nebulizer solution Ipratropium nebulizer solution Advair inhaler BID Albuterol inhaler prn Prednisone 5 mg po q day Roflumilast 500 mcg po q day No follow-up appointment or referral to pulmonologist

26 Impact of Exacerbations in COPD
Patients With Frequent Exacerbations Faster Decline in Lung Function Greater Airway Inflammation Poorer Quality of Life Higher Mortality COPD Foundation.

27 Patient Case Study (3 of 4)
JS had 2 episodes of bronchitis over the next 3 months characterized by shortness of breath limiting activity and copious sputum production The first episode he received a breathing treatment in the office, chronic medications were continued and he was given levofloxacin x 10 days The 2nd episode he self-treated with levaquin leftover from his previous episode and refill of prednisone 3 months later JS presents to the emergency department with acute bronchitis, shortness of breath, copious sputum production Treated with IV corticosteroids, nebulizers, supplemental oxygen, cefuroxime IV Spirometry performed on hospital day 3 confirmed a diagnosis of COPD , FEV1 65% predicted

28 Management of Severe (Not Life-Threatening) Exacerbations Requiring Hospitalization
Assess severity of symptoms, blood gases, chest radiograph Supplemental oxygen therapy Bronchodilators: Increase doses and/or frequency of short-acting bronchodilators Combine short-acting beta2-agonists and anticholinergics Use spacers or air-driven nebulizers Add oral or intravenous corticosteroids Consider antibiotics (oral or intravenous) when signs of bacterial infection Consider noninvasive mechanical ventilation Monitor fluid balance and nutrition Consider subcutaneous heparin or low molecular weight heparin Identify and treat associated conditions (e.g. heart failure, arrhythmias) Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 11/10/14.

29 Indications for ICU Admission
Severe dyspnea that responds inadequately to initial emergency therapy Changes in mental status (confusion, lethargy, coma) Persistent or worsening hypoxemia (PaO2 <5.3 kPa, 40 mmHg) and/or Severe/worsening respiratory acidosis (pH <7.25) despite supplemental Oxygen and noninvasive ventilation Need for invasive mechanical ventilation Hemodynamic instability – need for vasopressors Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 11/10/14.

30 Stage 1: Initial Management Pathway for Hospitalized Patients
Slide provided by Thomashow B. NewYork-Presbyterian Hospital Clinical Pathway.

31 A 5-day Course of Oral CS May Be Appropriate after COPD Exacerbations Re-exacerbations in the REDUCE Trial Proportion of patients without re-exacerbation ITT analysis HR, 0.95 (90% CI, ) P for noninferiority = 0.006 Proportion of patients without re-exacerbation Per-protocol analysis HR, 0.93 (90% CI, ) P for noninferiority = 0.005 ITT = intention to treat; REDUCE = Reduction in the Use of Corticosteroids in Exacerbated COPD Lueppi JD et al. JAMA. 2013;309:

32 Stage 2: Management Pathway
Slide provided by Thomashow B. NewYork-Presbyterian Hospital Clinical Pathway.

33 Strategies for Improving COPD Across the Continuum

34 High Index of Suspicion for COPD Screening and Diagnosis
Consider COPD in patients with any symptoms and history of exposure to risk factors SYMPTOMS RISK FACTORS SYMPTOMS Persistent shortness of breath Chronic cough Chronic sputum production Wheezing RISK FACTORS Tobacco smoke Indoor/outdoor air pollution Occupational pollutants Family history Age >40 years Spirometry is required to make diagnosis Post-bronchodilator FEV1/FVC <0.70 confirms presence of persistent airflow limitation* *Post-bronchodilator FEV1/FVC measured min after 2-4 puffs of a short-acting bronchodilator FEV1, forced expired volume in 1 second; FVC, forced vital capacity Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 11/10/14. 2013 Paradigm Medical Communications, LLC, except where noted

35 Facilitate Discharge Transitions of Care
Patient can be discharged when he/she: Is able to use long-acting bronchodilators, either beta2-agonists and/ or anticholinergics with or without inhaled corticosteroids Does not require inhaled short-acting beta2-agonist therapy more frequently than every 4 hours Is able to walk across room, if previously ambulatory Is able to eat and sleep without frequent awakening by dyspnea Has been clinically stable for hours Has stable arterial blood gases for hours Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 11/10/14.

36 Stage 3: Discharge Planning
Slide provided by Thomashow B. NewYork-Presbyterian Hospital Clinical Pathway.

37 COPD Exacerbations Preventative Measures
Spirometry to confirm diagnosis and determine severity of COPD Improve guideline-based non-pharmacologic treatment Improve guideline-based pharmacologic treatment Manage comorbidities Identify and address social issues Engage in continuous care

38 Prevention: The Ultimate Way to Prevent Readmissions for COPD
Smoking cessation Like home oxygen therapy, smoking cessation is the only intervention that has been shown to decrease mortality at all levels of COPD Effective at primary, secondary, and tertiary levels of care Pulmonary rehabilitation Physical activity Good nutrition Immunizations (influenza vaccine)

39 Smoking Cessation is The Most Important Thing to Slow Progression of COPD
Quitting is challenging but achievable Many options are available to help patients quit smoking Gums Patches Prescription medicine More information at: COPD Foundation. Quitting Smoking. Available at: Accessed Nov. 10, 2014.

40 Pulmonary Rehabilitation Decreases Readmissions
Physiology of acute COPD exacerbations1 Decline in quadriceps muscle strength of 5% between day 3 and 8 of hospital admission Quadriceps force continues to decline for up to 3 months after hospital discharge Hospitalized patients spend <10 minutes per day walking and remain inactive for up to 1 month after discharge vs those with stable COPD and similar disease severity High re-exacerbation and readmission risk in early recovery phase Cochrane Review of 9 in 432 patients Pulmonary rehabilitation significantly reduced Hospital admissions (pooled OR 0.22, 95% CI 0.08 to 0.58), NNT = 4 (95% CI 3 to 8) over 25 weeks Mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT = 6 (95% CI 5 to 30) over 107 weeks NNT = number needed to treat Suh ES et al. BMC Medicine. 2013;11:247. Puhan MA et al. Cochrane Database Syst Rev. 2011:5;CD doi: / CD pub3.

41 Advances in Pulmonary Rehabilitation
Exercise training includes: endurance training, strength training, upper-limb training, and transcutaneous neuromuscular electrical stimulation Can be home-based Exercise training reduces anxiety and depression Exercise rehab started during acute or critical illness reduces the extent of functional decline and speeds recovery Pulmonary rehab started after a hospitalization for COPD exacerbation is effective, safe, and leads to a reduction in subsequent hospital admissions Symptomatic patients with lesser degrees of airflow limitation derive similar benefits as those with severe disease Spruit MA et al. Am J Respir Crit Care Med. 2013;188:e13–e64.

42 Increased Physical Activity Prevents Readmissions for COPD
Mean Minutes Per Day of Higher Level Physical Activity Without 30-day Readmission Mean n With 30-day Readmission P Value Week 1 114 ± 19 26 42 ± 14 12 0.02 Week 2 126 ± 20 25 46 ± 13 10 Week 3 139 ± 25 23 35 ± 09 9 0.20 Week 4+ 131 ± 27 17 1312 ± 10 2 0.16 Those with lower physical activity (<60 mins/day) over week 1 after discharge were more likely to have 30-day all-cause readmissions than those with higher activity: odds ratio = 6.7; P=0.02. Chawla H et al. Ann Am Thorac Soc. 2014;11:

43 Readmission Within 30-days (Probability)
Oral Nutritional Supplements Decrease LOS and Prevent Readmissions for COPD Effect of ONS use on length of stay (LOS) and 30-day Readmissions*1 Outcome Unit Length of Stay (Days) Episode Cost (US Dollars) Readmission Within 30-days (Probability) Effect of any ONS use (Standard error) -1.88** (0.71) -$1,570** (41.8) ** (0.0162) Predicted Outcome w/o ONS 8.75 12,523 0.335 Predicted Outcome With ONS 6.87 10,953 0.291 % Change due to ONS Use -21.5% -12.5% -13.1% # of Observations 14,326 11,712 *Medicare patients age 65+ out of 10,322 ONS hospitalizations and 368,097 non-ONS hospitalizations **Indicates significance at the 1% level A well-balanced diet is beneficial to all COPD patients for pulmonary benefits and benefits in metabolic and cardiovascular risk2 Thornton SJ et al. Chest. 2014; doi: /chest [Epub ahead of print]. Schols AM et al. Eur Respir J. 2014; in press | DOI: /

44 Recommended Vaccines for Patients with COPD
2014 GOLD Guidelines recommend:1 Pneumococcal vaccine May reduce mortality2-4 Newer conjugated vaccines may have greater efficacy Influenza vaccine2,5-8 May decrease risk for acute COPD exacerbations 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 11/10/14. 2. Osthoff M et al. Swiss Med Weekly. 2013;143: Schembri S et al. Thorax. 2009;64: 4. Pitsiur GG et al. Respir Med. 2011;105: Poole PJ et al. Cochrane Database Syst Rev. 2006;(1):CD 6. Michiels B et al. Vaccine. 2011;29: Walters JA et al. Cochrane Database Syst Rev. 2010;(11):CD 8. Vila-Corcoles A et al. Expert Rev Vaccines. 2012;11:

45 Outcomes of Noninvasive Ventilation (NIPPV) for Acute Exacerbations of COPD in US 1998-2008
>4-fold increase in NIPPV use 5% NIV required invasive mechanical support (IMV) Those transitioning from NIPPV to IMV had a 61% greater chance of death (30% in-hospital mortality) compared to those only treated with IMV alone (more than 20% mortality) Clearly defines need for Close observation and potentially earlier intubation in some Alternative to IMV Chandra D et al. Am J Respir Crit Care Med. 2012;185;2;

46 Long-term NPPV Targeted to Reduce Hypercapnea Improves Survival in Stable COPD
Randomized to NPPV (n=102) or control (n=93) Stable GOLD stage IV COPD Partial PaCO2 of ≥7 kPa (51.9 mm Hg) or pH >7.35 NPPV to  baseline PaCO2 by ≥20% or PaCO2 <6.5 kPa (48.1 mm Hg) Only ADE: rash in 14% - change type of mask 1-year mortality 12% NPPV vs 33% control HR 0.24 (95% CI ; P=0.0004) HR = hazard ratio; NPPV = non-invasive positive pressure ventilation; PaCO2 = carbon dioxide pressure Köhnlein T et al. Lancet Respir Med. 2014;2:

47 COPD Exacerbations Preventative Measures: Non-pharmacologic
Spirometry to confirm diagnosis and determine severity of COPD Improve guideline-based non-pharmacologic treatment Improve guideline-based pharmacologic treatment Manage comorbidities Identify and address social issues Engage in continuous care


49 GOLD 2014 Categories of COPD Severity and Suggested Therapies
LABA + LAMA Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 11/10/14.

50 COPD Foundation Guidelines Spirometry Grades
SG 0 Normal spirometry does not rule out emphysema, chronic bronchitis, asthma, or risk of developing either exacerbations or COPD SG 1 (Mild) FEV1/FVC ratio <0.7, FEV1 >60% predicted SG 2 (Moderate) FEV1/FVC ratio <0.7, 30%-60% predicted SG 3 (Severe) FEV1/FVC ratio <0.7, FEV1 <30% predicted SG U (Undefined) FEV1/FVC ratio >0.7, FEV1 <80% predicted Consistent with restriction, muscle weakness, and other pathologies COPD Foundation. COPD Treatment. Accessed 11/8/14.

51 COPD Foundation Guide for COPD Treatment
*Indicated if chronic bronchitis, high exacerbation risk, and spirometry grades 2/3 all present **Suggest regular exercise program for all with COPD; those with SG2/3 should be considered for pulmonary rehab +Recommended in select cases with upper lobe predominant emphysema ++Off label, consider potential cardiac risks and resistance concerns COPD Foundation. COPD Treatment. Accessed 2/8/14.

52 Consider Switching from LABA/ICS TO LABA Only if Low Risk
Moderate COPD and no exacerbations in previous year 26-week, randomized double-blind, double-dummy, parallel-group study 581 patients with moderate COPD who were receiving salmeterol/fluticasone (SFC) for ≥ months Randomized to indacaterol 150 μg once daily or SFC 50/500 μg twice daily Non-inferiority achieved based on trough FEV1 after 12 weeks No significant differences for Breathlessness (transition dyspnea index) Health status (Saint George's Respiratory Questionnaire) Rescue medication use or COPD exacerbation rates over 26 weeks ICS = inhaled corticosteroids; LABA = long-acting beta2 agonist Rossi A et al. Eur Respir J pii: erj [Epub ahead of print].

53 COPD* Exacerbations and Lung Function after Withdrawal of ICS on 2 Long-acting Bronchodilators**
*Patients with severe COPD; ** tiotropium + salmeterol; ICS, inhaled corticosteroids Magnussen H et al; WISDOM Investigators. N Engl J Med. 2014;371:

54 There are Many Inhaler Devices Available in the United States – Choice is Important
Aerolizer™ Twisthaler® Respimat® Soft Mist™ Neohaler™ Breo Ellipta® Neohaler™ Pressair® MDI Diskus® Handihaler® SMI Flexhaler® 2013 Paradigm Medical Communications, LLC, except where noted

55 Strategies for Individualizing Inhaler Choice
Good hand-breath coordination is required for meter-dose inhalers (MDIs) May not be suitable for elderly, confused, or those with hand conditions (e.g. arthritis) Dry-powder inhalers (DPIs) do not require coordination of actuation and inhalation and are easier to use than MDIs Breath actuation may be difficult in patients with poor inspiratory effort Avoid changing inhaler types for individual patients Vincken W et al. Prim Care Respir J. 2010;19:10-20. De Coster DA et al. Cur Respir Care Rep. 2014;;3:

56 Nebulizers May be Beneficial for Some Patients with COPD
Small-Volume Nebulizers Effective drug delivery requires less intensive patient training vs pMDIs and DPIs1 Newer portable and efficient models available1 Efficacy of long-term nebulizer therapy is similar or superior to pMDI/DPIs in moderate-to-severe COPD, including during exacerbations1 Consider maintenance nebulizers in1 Elderly patients Severe COPD Frequent exacerbations Physical and/or cognitive limitations Patient/caregiver satisfaction is high2 image # skd190012sdc Dhand R et al. COPD. 2012;9:58-72. Sharafkhaneh A et al. COPD. 2013;10: 2013 Paradigm Medical Communications, LLC, except where noted

57 Medications Available via Nebulizer
Medication (Class)1 Notes Albuterol (SABA) Formoterol (LABA) Significantly improved FEV(1) and dyspnea, decreased rescue medication use, and a lower incidence of AEs and COPD exacerbations when added to maintenance tiotropium in patients with moderate to severe COPD2 Arformoterol (LABA) ∼40% lower risk of respiratory death or COPD exacerbation-related hospitalization over 1 year versus placebo in patients with COPD and FEV1 ≤ 65% predicted3 Ipratropium bromide (Short-acting anticholinergic) Beclomethasone dipropionate, flunisolide, fluticasone propionate, budesonide Valid alternative to inhalers in acute exacerbations of COPD with similar efficacy as oral or ICS and good tolerability4 ICS = inhaled corticosteroid; SABA = short-acting beta2 agonist; LABA = long-acting beta2 agonist 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 3/10/ Tashkin DP et al. Adv Ther. 2009; 26: Donohue JF et al. Chest doi: /chest Melani AS. Respiratory Care. 2012;57:

58 Identify and Address Poor Adherence
Barriers to adherence Inadequate education about COPD and therapy1 Perceived burden of medication regimen1,2 Device is difficult to use3 Depressed mood3 Medication-related cost3 Adverse effects3 Red Flags for non-adherence Failure to refill prescriptions Excessive use of rescue medication Frequent exacerbations Rapid decline in FEV1 LaForest L et al. Prim Care Resp J. 2010;19: George J et al. Chest. 2005;128: Restrepo RD et al. Int J COPD. 2008;3:

59 Predictors of Exacerbations and Readmissions Opportunities for Improvement in the Inpatient Setting
Spirometry to confirm diagnosis and determine severity of COPD Improve guideline-based pharmacologic treatment Improve guideline-based non-pharmacologic treatment Manage comorbidities Identify and address social issues Engage in continuous care

60 Interplay of Comorbidities in COPD
Barnes PJ et al. Eur Respir J. 2009;33: Barnes PJ. PLoS Med 2010;7:e

61 Comorbidities Increase the Risk of Readmission
Only 30% of readmission secondary to index cause

62 First-choice Treatments for Comorbidities in COPD
Comorbidity 1st Choice Treatment Issues Hypertension ACEI or ARB Avoid beta blockers if hypertension the only comorbidity Heart failure Cardioselective beta1-blocker in addition to ACEI or ARB Diuretics (loop preferred) If asthmatic component avoid beta blocker Oral corticosteroids may worsen HF – use ICS Ischemic heart disease Cardioselective beta1-blocker in addition to ACEI (regardless of BP or LV function) ICS may have protective effect for CV events Avoid high dose beta 2 agonists in USA Atrial fibrillation Non-dihydropyridine CCB (verapamil or diltiazem) or a cardioselective beta-blocker (i.e. bisoprolol) Avoid beta 2 agonist, nonselective beta blockers, theophylline, oral corticosteroids Diabetes Metformin at a low dose and gradual titration Consider contraindications: (diarrhea/abdominal cramp- ing/ lactic acidosis risk/ vitamin B12 deficiency/acidosis/hypoxia/dehydration/unstable heart failure) Metabolic syndrome Metformin Statins ACE or ARB Consider drug interactions and contraindications for statins, niacin Osteoporosis Vitamin D 800 IU/day and calcium 1 gr/day Bisphosphonates if osteoporosis Oral bisphosphonates cause significant gastrointestinal effects and dosing requirements Depression and anxiety Psychological therapy, benzodiazepines and SSRIs Choice of antidepressant should be made with consideration of risks, age, previous treatment, interactions, preferences and costs Tsiligianni IG et al. Curr Drug Targets. 2013;14:

63 Considerations for Specific Medications for Comorbidities in COPD
Cardioselective beta blockers Reduce the risk of exacerbations and improve survival in patients with COPD in long term treatment Associated with reduced mortality in acute COPD exacerbation and in COPD with atherosclerosis No significantly change in FEV1 or respiratory symptoms, no affect on the FEV1 treatment response to beta2-agonists Conflicted results in FEV1 improvement in long term treatment studies [146, 147]. Suggestions: Despite benefits they are still underused in COPD Not a first choice for hypertension An individualized approach starting at low doses and gradually titrating up is recommended Caution with cardioselective agents as cardioselectivity decreases with increased doses Angiotensin converting enzyme inhibitors or Angiotensin receptor blockers Chronic lowering of ACE improves pulmonary inflammation, respiratory muscle function, peripheral use of oxygen for long term treatment in COPD Reduce hospitalization and mortality in patients with COPD May be used in hypertension, CVD, metabolic syndrome with hypertension component Tsiligianni IG et al. Curr Drug Targets. 2013;14:

64 Considerations for Specific Medications for Comorbidities in COPD (cont’d)
Statins Recent prospective, randomized, double-blind, placebo-controlled trial in moderate to severe COPD showed no difference in exacerbation rate or mortality Have anti-inflammatory and anti-oxidant properties in the lungs Increase exercise time and decrease the levels of high-sensitivity C-reactive protein Reduce the decline in lung function Provide protection against the development of lung cancer Reduce requirement for intubation in exacerbations Suggestions: May be useful in metabolic syndrome, dyslipidemias, cardiovascular disease Beta 2 agonists Beta-blockers may neutralize the b2-agonists’ efficacy and COPD patients may have high tolerance for beta-blockers Survival benefit for beta-blockers was not found among patients concurrently using beta-agonists or with severe COPD or asthma after myocardial infarction Best to avoid if possible in CVD and concomitant cardioselective beta-blocker use in COPD. Anticholinergic agents Reduction in cardiac adverse events was associated with tiotropium in the UPLIFT study Start treatment with a long-acting antimuscarinic agent rather than LABA when patients have COPD with heart failure or when they have other CVD requiring use beta-blockers Tsiligianni IG et al. Curr Drug Targets. 2013;14: Criner GJ et al; COPD Clinical Research Network; Canadian Institutes of Health Research. N Engl J Med. 2014;370:

65 Effect of Simvastatin on Time to First Acute Exacerbation of COPD
Figure 3 Effect of Simvastatin on the Time to the First Acute Exacerbation of Chronic Obstructive Pulmonary Disease. There were no significant between-group differences in the time to the first exacerbation. The median time to the first exacerbation was 223 days (95% CI, 195 to 275) in the simvastatin group and 231 days (95% CI, 193 to 303) in the placebo group. Criner GJ et al. N Engl J Med. 2014;370:

66 Considerations for Specific Medications for Comorbidities in COPD (cont’d)
Inhaled Corticosteroids Possible protective effect against ischemic cardiac events and acute myocardial infarction Suggestions: In cases of COPD and DM glucose monitoring and titration of antidiabetic treatment is required. Evaluate for increased risk of fractures and loss of bone mineral density In patients receiving high dose of ICS or low to medium dose ICS with frequent use of oral CS screening for osteopenia or osteoporosis should be performed Systemic Corticosteroids Meta-analysis that included 24 studies suggested high dose oral CS have potentially harmful adverse effects (e.g. diabetes, hypertension, osteoporosis) In the case of AECOPD if systemic glucocorticoid steroids used close monitoring of serum glucose is recommended • If used in COPD close monitoring for diabetes and osteoporosis is recommended. Specific recommendations for osteoporosis management should be followed if patients take GC>3 months GOLD guidelines suggest limited dosage (7-10 days) and avoidance of recurrent courses of systemic CS for COPD exacerbations Tsiligianni IG et al. Curr Drug Targets. 2013;14:

67 The Frequent Exacerbator Phenotype: Identify and Target (Non-pharmacologic and Pharmacologic)
Stable state Greater inflammation Increases susceptibility to viral infection Greater bacterial colonization Faster FEV1 and functional decline Worse health status More severe depression Worsened comorbidity Increase hospitalization and mortality INCREASED EXACERBATION SUSCEPTIBILITY Persistent inflammation/slower recovery Higher exacerbation susceptibility Exacerbation triggers -Bacteria -Viruses -Irritants EXACERBATION Anti-inflammatory agents can modify the frequent exacerbator phenotype so that patients become infrequent exacerbators Wedzicha JA et al. BMC Med. 2013;11:181.

68 COPD Exacerbations Preventative Measures
Spirometry to confirm diagnosis and determine severity of COPD Improve guideline-based non-pharmacologic treatment Improve guideline-based pharmacologic treatment Manage comorbidities Identify and address social issues Engage in continuous care

69 Impact of Social Issues
Among the countries in the Organization for Economic Development, the United States ranks first in health care spending, but 25th in spending on social services Studies have shown the powerful effects that “social determinants” like safe housing, healthful foods, and opportunities for education and employment have on health Experts estimate that medical care accounts for only 10% of overall health, with social, environmental, and behavioral factors accounting for the rest Bradley EH et al. BMJ Qual Saf. 2011;20:

70 Social Issues Have a Significant Impact on Readmissions

71 The “Post-Hospital Syndrome”
Sleep deprivation Nutritional issues Aspiration risks Deconditioning Inadequately addressed pain or discomfort Cognitive issues – sleep/stress/medications “Marginal clothing” Krumholz HM. N Engl J Med. 2013;368:

72 COPD Exacerbations Preventative Measures
Spirometry to confirm diagnosis and determine severity of COPD Improve guideline-based non-pharmacologic treatment Improve guideline-based pharmacologic treatment Manage comorbidities Identify and address social issues Engage in continuous care

73 Care Transition and Coordination
Models of Care and Strategies for Implementation

74 Provide a Spectrum of Support for Patients With COPD
Spruit MA et al. Am J Respir Crit Care Med. 2013;188:e13–e64.

75 30-day Readmission Patients 40-64 Years of Age Admitted for COPD
50% Sharif R et al. Ann Am Thorac Soc. 2014;11:

76 Transitional Care Management (TCM)
CMS 2013 – 2 new payment codes (99495/99456) to incentivize ambulatory care providers to participate in TCM CMS will pay provider submitting the claim during 30-day post discharge window To bill, must provide 3 key services: Must contact patient within 2 days of discharge Have face-to-face visit within 7-14 days of discharge Provide indicated care-coordinated services during 30 days post discharge, including review of discharge info, review of pending tests and treatments, education, and arrange referrals and needed community resources Kangovi S, Grande D. Chest. 2014;145:

77 Patient Case Study (4 of 4)
JS is discharged on hospital day 3 following admission for COPD exacerbation He returns for follow-up visit, pulmonary rehabilitation and patient education 1 week later He successfully stops smoking after realizing the seriousness of his condition He noted: “Nothing has slowed me down like this before… I did not know I had a lung condition, I just thought it was part of getting older and smoking for so long. I know now that it is serious and I have to deal with it.”

78 Integrated Disease Management (IDM) Programs Work
Aim of IDM: To establish a program of different components of care (i.e. self-management, exercise, nutrition) in which several health care providers collaborate to provide efficient and good quality of care Cochrane review of 26 RCTs 2997 patients with COPD (mean age 68 years) Mean FEV1 44% predicted Patients in IDM vs controls Significantly improved quality of life scores Clinically relevant improvement of 44 m on 6-min walking distance Fewer patients with ≥1 respiratory related hospital admission (decreased from 27 to 20 per 100 patients) Significantly decreased duration of hospitalization (by nearly 4 days) Kuis AL et al. Thorax doi: /thoraxjnl [Epub ahead of print].

79 A Multicomponent Disease Management Program Can Be Cost Effective
Intervention Single 1.5-h group education session conducted by case manager Individualized written action plan that included: (1) a description of the signs and symptoms of an exacerbation that should prompt initiation of self-treatment, (2) refillable prescriptions for prednisone and an oral antibiotic, (3) contact information for a case manager, and (4) the telephone number of the 24-hour VA nursing helpline Began action-plan medications for symptoms that were substantially worse than usual Case manager made monthly phone calls to each patient Patients encouraged to call the case manager during regular working hours if they took action-plan medications or if they had questions relating to their medical care No regularly scheduled clinic visits for the remainder of the 1-year follow-up period Intervention cost: $241,620 or $650 per patient The total mean±SD per patient in the DM group was $4491±4678 compared to $5084±5060 representing a $593 per patient cost savings Dewan NA et al. COPD. 2011;8:

80 Patient and Caregiver Engagement is Important
Educate, engage patient and family Develop individualized self-treatment plan for exacerbations Follow-up call monthly by a case manager Lower hospitalization rate and ED visits Rice KL et al. Am J Respir Crit Care Med. 2010;182:

81 Key Points No simple answer to reducing hospital readmissions:
Move away from “disease-centered” to “patient-centered” care Optimize medical therapy and address comorbidities Prevent “post-hospital syndrome” Address social issues Coordinate follow-up care (in-hospital care and with PCP) – communicate with treating physicians Engage patient (education, phone call reminders, etc.)

82 Free iphone App IS Now Available!
The COPD Foundation’s new mobile application includes: 7 Severity Domains Spirometry Grades Chart COPD Assessment Test (CAT) Breathlessness Scale (mMRC) Therapy Chart COPD Medications Spirometry Results And much more! The Guide was designed to be short and extremely practical. However, dissemination and implementation of any new physician tool such as the Guide requires careful planning. The COPD Foundation Guide to COPD Diagnosis and Management has the potential to allow the end user to feel more confident and competent in the up-to-date management of COPD and may also allow the physician to be more efficient in managing patients. Development of a smartphone version will facilitate the use of the Guide by all interested health professionals. In addition, an electronic format is greatly preferred by many physicians. For these reasons, the COPD Foundation has developed a smart-phone application. It will include all of the information that is in the print version of the COPD Pocket Consultant Guide with additional information for using the diagnostic categories and for implementing the therapeutic recommendations together with expanded descriptions of the severity domains. Hyperlinks will be provided to external resources. Expanded topics will include: smoking cessation, oxygen therapy, management of co-morbid conditions, pulmonary rehabilitation, and management of exacerbations. It will also allow physicians to record patients’ COPD Assessment Test (CAT) or mMRC results in real-time along with spirometry values and exacerbation history to assist in determining appropriate therapy based on the Therapy Chart. The software will also be able to flag patients for whom assessment of oxygenation or CT scan would be appropriate. The full medications list will contain brief details of medications, including a hyperlink to the FDA website for additional drug information. Hyperlinks will be provided to consensus guidelines for management of COPD associated co-morbidities. Scan the QR code on the phone above, or go to:

83 Register your Guide at:
A Wealth of Resources are Available for You and Your Patients Go to: A Wealth of Resources for you and your patients Register your Guide at: PocketGuideRegistration.aspx You may register your PCG card to receive notification of the new release. The Institutional Pack is designed to order bulk PCG cards, posters and mobile app flyers. You will also get access to the Grand Rounds PowerPoint Presentation that you saw today along with a dissemination plan for best strategies on distributing the PCG materials to your institution. The online catalogue is open to health care professionals to order COPD Foundation educational materials. The only fee is for shipping to your location. You are welcome to check out our online video that describes all the COPD Foundation educational materials at:

84 Downloads and Translations Most of the COPD Foundation printed materials are available online in a free pdf electronic downloadable file. This is the least expensive means of distribution and we highly encourage you to share this resource with your colleagues and patients. In addition to the English materials, the COPD Foundation has translated it’s 3 key educational materials into 9 languages in addition to English. This translation project includes the Big Fat Reference Guide (BFRG), the Slim Skinny Reference Guides (SSRGs) and the 1s, 2s and 3s of COPD. Downloads can be accessed here:

85 Learn, Connect, and Engage at COPD9USA
KEY OPPORTUNITIES Plenary sessions on hot topics and 3 dedicated tracks for clinical, research and care delivery topics Best practices in readmission reduction, team based care, asthma and COPD overlap, and more Young investigator and physician in training development and mentorship programs COPD9USA EXECUTIVE BOARD Byron Thomashow, MD Stephen Rennard, MD David Mannino, MD Ravi Kalhan, MD John Walsh

86 Thank you for joining us today!
Participant CME Evaluation Please take out the Participant CME Post-survey and Evaluation Form from the back of your packet and complete to receive credit. If you are not seeking credit, we ask that you fill out the information pertaining to your degree and specialty, as well as the few post-activity survey questions measuring the knowledge and competence you have garnered from this program. The post-survey begins on page 1 of the evaluation form. Your participation will help shape future CME activities. Thank you for joining us today!

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