Presentation on theme: "CME Evaluation with Post-activity Survey"— Presentation transcript:
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 SurveyLocated at the front of your syllabusCME Evaluation with Post-activity SurveyLocated at the back of your syllabus
3 DisclosuresThe relevant financial relationships reported by faculty that they or their spouse/partner have with commercial interests are located on page 5 of your syllabusThe 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 syllabusThe 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 ObjectivesIdentify 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 continuumApply current clinical evidence and guidelines to develop a comprehensive care plan that addresses common reasons for repeat exacerbations and hospital readmissionsApply 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 patients51%-75% of my COPD patients25%-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 patients51%-75% of my COPD patients25%-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?COPDDepressionCardiovascular diseaseDiabetes
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 ageAge at onset of COPDHer uncontrolled diabetesHer 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 hoursPatient is able to walk around the block (if previously ambulatory)Patient requires inhaled short-acting beta2-agonist therapy every 2-4 hoursPatient 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 supplementationDecreased physical activityYearly influenza vaccinationNone of the above
14 Polling Question Pre-activity Survey So far, the only therapy documented to reduce COPD disease progression is:Physical activityInfluenza vaccinationSmoking cessationGood 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 infectionWeight gainDecreased readmissions and lengths of staySignificantly 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 lungsCostDisease severityHand-breath coordinationPresence 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 disability3rd leading cause of 30-day readmissions3rd leading cause of death (2nd to CV disease and cancer)Mortality rate predicted to increase by 30% over the next decadeExacerbations~800,000 hospitalizations (+ 3.5 million COPD 2nd dx)1.5 million ER visits/yearCosts for COPD in the United States, 2010 = $50 billion and risingCDC. Accessed Dec. 2, The COPD Foundation. Accessed Nov. 10, 2014.National Heart, Lung and Blood Institute (NHLBI). COPD – Learn More, Breath Better. https://www.nhlbi.nih.gov/health/educational/copd/index.htm. 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 NotesThis 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.ReferenceMiravitlles 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 ConditionTypes of Hospital Admission# of Admits with Readmission*Readmission RateAvg. Medicare Payment for ReadmissionTotal Spending on ReadmissionsHeart FailureMedical90,27312.5%$6,531$590,000,000COPD52,32710.7%$6,587$345,000,000Pneumonia74,4199.5%$7,165$533,000,000Acute MISurgical20,86613.4%$6,535$136,000,000CABG18,55413.5%$8,136$151,000,000PTCA44,29310.0%$8,109$359,000,000Other Vascular18,02911.7%$10,091$182,000,000Total for 7 Conditions318,760$2,296,000,000Total 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 stayMedPAC (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 CareThe goal of the CMS strategy is a 20% reduction in hospital readmission rates, potentially preventing 1.6 million hospitalizations and saving an estimated $15 billionCMS will publicly report COPD measures on Hospital Compare beginning in as part of the Hospital Inpatient Quality Reporting (IQR) programData reported in the 2013 Chartbook (1/2009 – 12/2011) summarize “dry run” results shared with hospitalsCOPD 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:http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ HospitalQualityInits/Downloads/Medicare-Hospital-Quality-Chartbook-2014.pdf. Accessed Nov. 14, 2014.
22 Benefits of Guideline-based Treatment Improved lung function1,2Improved symptoms1,2Improved exercise tolerance1,2Improved QoL1,2Prolonged life and better QoL with smoking cessation1,2Delayed time to first exacerbation1,2Fewer exacerbations1,2Fewer hospitalizations1,2Cost savings3Restrepo 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:
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 herniaPast medical historyLack of routine health care x 20 yearsConsiders himself to be active, works outside as a construction supervisor and teaches horseback-riding lessonsDenies other significant medical conditions other than punctured lung in his early 30s due to a horseback-riding accidentSmokes 1½ to 2 PPD x 39 yearsSuccessfully underwent 2 open hernia repairs 3 months apartNever screened for COPD on pre-operative evaluation and no chest x-ray performedPhoto from image #
25 Patient Case Study (2 of 4) JS underwent his 2nd open hernia repairPost-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 daysPCP also prescribed:Albuterol nebulizer solutionIpratropium nebulizer solutionAdvair inhaler BIDAlbuterol inhaler prnPrednisone 5 mg po q dayRoflumilast 500 mcg po q dayNo follow-up appointment or referral to pulmonologist
26 Impact of Exacerbations in COPD Patients With Frequent ExacerbationsFaster Decline in Lung FunctionGreater Airway InflammationPoorer Quality of LifeHigher MortalityCOPD 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 productionThe first episode he received a breathing treatment in the office, chronic medications were continued and he was given levofloxacin x 10 daysThe 2nd episode he self-treated with levaquin leftover from his previous episode and refill of prednisone3 months later JS presents to the emergency department with acute bronchitis, shortness of breath, copious sputum productionTreated with IV corticosteroids, nebulizers, supplemental oxygen, cefuroxime IVSpirometry 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 radiographSupplemental oxygen therapyBronchodilators:Increase doses and/or frequency of short-acting bronchodilatorsCombine short-acting beta2-agonists and anticholinergicsUse spacers or air-driven nebulizersAdd oral or intravenous corticosteroidsConsider antibiotics (oral or intravenous) when signs of bacterial infectionConsider noninvasive mechanical ventilationMonitor fluid balance and nutritionConsider subcutaneous heparin or low molecular weight heparinIdentify 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 therapyChanges in mental status (confusion, lethargy, coma)Persistent or worsening hypoxemia (PaO2 <5.3 kPa, 40 mmHg) and/orSevere/worsening respiratory acidosis (pH <7.25) despite supplementalOxygen and noninvasive ventilationNeed for invasive mechanical ventilationHemodynamic instability – need for vasopressorsGlobal 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 TrialProportion of patients without re-exacerbationITT analysisHR, 0.95 (90% CI, )P for noninferiority = 0.006Proportion of patients without re-exacerbationPer-protocol analysisHR, 0.93 (90% CI, )P for noninferiority = 0.005ITT = intention to treat; REDUCE = Reduction in the Use of Corticosteroids in Exacerbated COPDLueppi 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 factorsSYMPTOMSRISK FACTORSSYMPTOMSPersistent shortness of breathChronic coughChronic sputum productionWheezingRISK FACTORSTobacco smokeIndoor/outdoor air pollutionOccupational pollutantsFamily historyAge >40 yearsSpirometry is required to make diagnosisPost-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 bronchodilatorFEV1, forced expired volume in 1 second; FVC, forced vital capacityGlobal 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 corticosteroidsDoes not require inhaled short-acting beta2-agonist therapy more frequently than every 4 hoursIs able to walk across room, if previously ambulatoryIs able to eat and sleep without frequent awakening by dyspneaHas been clinically stable for hoursHas stable arterial blood gases for hoursGlobal 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 COPDImprove guideline-based non-pharmacologic treatmentImprove guideline-based pharmacologic treatmentManage comorbiditiesIdentify and address social issuesEngage in continuous care
38 Prevention: The Ultimate Way to Prevent Readmissions for COPD Smoking cessationLike home oxygen therapy, smoking cessation is the only intervention that has been shown to decrease mortality at all levels of COPDEffective at primary, secondary, and tertiary levels of carePulmonary rehabilitationPhysical activityGood nutritionImmunizations (influenza vaccine)
39 Smoking Cessation is The Most Important Thing to Slow Progression of COPD Quitting is challenging but achievableMany options are available to help patients quit smokingGumsPatchesPrescription medicineMore information at:COPD Foundation. Quitting Smoking. Available at: Accessed Nov. 10, 2014.
40 Pulmonary Rehabilitation Decreases Readmissions Physiology of acute COPD exacerbations1Decline in quadriceps muscle strength of 5% between day 3 and 8 of hospital admissionQuadriceps force continues to decline for up to 3 months after hospital dischargeHospitalized 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 severityHigh re-exacerbation and readmission risk in early recovery phaseCochrane Review of 9 in 432 patientsPulmonary rehabilitation significantly reducedHospital admissions (pooled OR 0.22, 95% CI 0.08 to 0.58), NNT = 4 (95% CI 3 to 8) over 25 weeksMortality (OR 0.28; 95% CI 0.10 to 0.84), NNT = 6 (95% CI 5 to 30) over 107 weeksNNT = number needed to treatSuh 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 stimulationCan be home-basedExercise training reduces anxiety and depressionExercise rehab started during acute or critical illness reduces the extent of functional decline and speeds recoveryPulmonary rehab started after a hospitalization for COPD exacerbation is effective, safe, and leads to a reduction in subsequent hospital admissionsSymptomatic patients with lesser degrees of airflow limitation derive similar benefits as those with severe diseaseSpruit 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 ActivityWithout 30-day ReadmissionMean nWith 30-day ReadmissionP ValueWeek 1114 ± 192642 ± 14120.02Week 2126 ± 202546 ± 1310Week 3139 ± 252335 ± 0990.20Week 4+131 ± 27171312 ± 1020.16Those 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 COPDEffect of ONS use on length of stay (LOS) and 30-day Readmissions*1Outcome UnitLength 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 ONS8.7512,5230.335Predicted Outcome With ONS6.8710,9530.291% Change due to ONS Use-21.5%-12.5%-13.1%# of Observations14,32611,712*Medicare patients age 65+ out of 10,322 ONS hospitalizations and 368,097 non-ONS hospitalizations **Indicates significance at the 1% levelA well-balanced diet is beneficial to all COPD patients for pulmonary benefits and benefits in metabolic and cardiovascular risk2Thornton 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:1Pneumococcal vaccineMay reduce mortality2-4Newer conjugated vaccines may have greater efficacyInfluenza vaccine2,5-8May decrease risk for acute COPD exacerbations1. 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):CD6. Michiels B et al. Vaccine. 2011;29: Walters JA et al. Cochrane Database Syst Rev. 2010;(11):CD8. 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 use5% 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 forClose observation and potentially earlier intubation in someAlternative to IMVChandra 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 COPDPartial PaCO2 of ≥7 kPa (51.9 mm Hg) or pH >7.35NPPV to baseline PaCO2 by ≥20% or PaCO2 <6.5 kPa (48.1 mm Hg)Only ADE: rash in 14% - change type of mask1-year mortality12% NPPV vs 33% controlHR 0.24 (95% CI ; P=0.0004)HR = hazard ratio; NPPV = non-invasive positive pressure ventilation; PaCO2 = carbon dioxide pressureKöhnlein T et al. Lancet Respir Med. 2014;2:
47 COPD Exacerbations Preventative Measures: Non-pharmacologic Spirometry to confirm diagnosis and determine severity of COPDImprove guideline-based non-pharmacologic treatmentImprove guideline-based pharmacologic treatmentManage comorbiditiesIdentify and address social issuesEngage in continuous care
49 GOLD 2014 Categories of COPD Severity and Suggested Therapies LABA + LAMAGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed 11/10/14.
50 COPD Foundation Guidelines Spirometry Grades SG 0Normal spirometry does not rule out emphysema, chronic bronchitis, asthma, or risk of developing either exacerbations or COPDSG 1 (Mild)FEV1/FVC ratio <0.7, FEV1 >60% predictedSG 2 (Moderate)FEV1/FVC ratio <0.7, 30%-60% predictedSG 3 (Severe)FEV1/FVC ratio <0.7, FEV1 <30% predictedSG U (Undefined)FEV1/FVC ratio >0.7, FEV1 <80% predictedConsistent with restriction, muscle weakness, and other pathologiesCOPD 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 concernsCOPD 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 year26-week, randomized double-blind, double-dummy, parallel-group study581 patients with moderate COPD who were receiving salmeterol/fluticasone (SFC) for ≥ monthsRandomized to indacaterol 150 μg once daily or SFC 50/500 μg twice dailyNon-inferiority achieved based on trough FEV1 after 12 weeksNo significant differences forBreathlessness (transition dyspnea index)Health status (Saint George's Respiratory Questionnaire)Rescue medication use or COPD exacerbation rates over 26 weeksICS = inhaled corticosteroids; LABA = long-acting beta2 agonistRossi 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 corticosteroidsMagnussen 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®MDIDiskus®Handihaler®SMIFlexhaler®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 MDIsBreath actuation may be difficult in patients with poor inspiratory effortAvoid changing inhaler types for individual patientsVincken 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 NebulizersEffective drug delivery requires less intensive patient training vs pMDIs and DPIs1Newer portable and efficient models available1Efficacy of long-term nebulizer therapy is similar or superior to pMDI/DPIs in moderate-to-severe COPD, including during exacerbations1Consider maintenance nebulizers in1Elderly patientsSevere COPDFrequent exacerbationsPhysical and/or cognitive limitationsPatient/caregiver satisfaction is high2image # skd190012sdcDhand 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)1NotesAlbuterol (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 COPD2Arformoterol (LABA)∼40% lower risk of respiratory death or COPD exacerbation-related hospitalization over 1 year versus placebo in patients with COPD and FEV1 ≤ 65% predicted3Ipratropium bromide (Short-acting anticholinergic)Beclomethasone dipropionate, flunisolide, fluticasone propionate, budesonideValid alternative to inhalers in acute exacerbations of COPD with similar efficacy as oral or ICS and good tolerability4ICS = inhaled corticosteroid; SABA = short-acting beta2 agonist; LABA = long-acting beta2 agonist1. 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 adherenceInadequate education about COPD and therapy1Perceived burden of medication regimen1,2Device is difficult to use3Depressed mood3Medication-related cost3Adverse effects3Red Flags for non-adherenceFailure to refill prescriptionsExcessive use of rescue medicationFrequent exacerbationsRapid decline in FEV1LaForest 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 COPDImprove guideline-based pharmacologic treatmentImprove guideline-based non-pharmacologic treatmentManage comorbiditiesIdentify and address social issuesEngage 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 Comorbidity1st Choice TreatmentIssuesHypertensionACEI or ARBAvoid beta blockers if hypertension the only comorbidityHeart failureCardioselective beta1-blocker in addition to ACEI or ARBDiuretics (loop preferred)If asthmatic component avoid beta blockerOral corticosteroids may worsen HF – use ICSIschemic heart diseaseCardioselective beta1-blocker in addition to ACEI (regardless of BP or LV function)ICS may have protective effect for CV eventsAvoid high dose beta 2 agonists in USAAtrial fibrillationNon-dihydropyridine CCB (verapamil or diltiazem) or a cardioselective beta-blocker (i.e. bisoprolol)Avoid beta 2 agonist, nonselective beta blockers, theophylline, oral corticosteroidsDiabetesMetformin at a low dose and gradual titrationConsider contraindications: (diarrhea/abdominal cramp- ing/ lactic acidosis risk/ vitamin B12 deficiency/acidosis/hypoxia/dehydration/unstable heart failure)Metabolic syndromeMetforminStatinsACE or ARBConsider drug interactions and contraindications for statins, niacinOsteoporosisVitamin D 800 IU/day and calcium 1 gr/dayBisphosphonates if osteoporosisOral bisphosphonates cause significant gastrointestinal effects and dosing requirementsDepression and anxietyPsychological therapy, benzodiazepines and SSRIsChoice of antidepressant should be made with consideration of risks, age, previous treatment, interactions, preferences and costsTsiligianni IG et al. Curr Drug Targets. 2013;14:
63 Considerations for Specific Medications for Comorbidities in COPD Cardioselective beta blockersReduce the risk of exacerbations and improve survival in patients with COPD in long term treatmentAssociated with reduced mortality in acute COPD exacerbation and in COPD with atherosclerosisNo significantly change in FEV1 or respiratory symptoms, no affect on the FEV1 treatment response to beta2-agonistsConflicted results in FEV1 improvement in long term treatment studies [146, 147].Suggestions:Despite benefits they are still underused in COPDNot a first choice for hypertensionAn individualized approach starting at low doses and gradually titrating up is recommendedCaution with cardioselective agents as cardioselectivity decreases with increased dosesAngiotensin converting enzyme inhibitors or Angiotensin receptor blockersChronic lowering of ACE improves pulmonary inflammation, respiratory muscle function, peripheral use of oxygen for long term treatment in COPDReduce hospitalization and mortality in patients with COPDMay be used in hypertension, CVD, metabolic syndrome with hypertension componentTsiligianni IG et al. Curr Drug Targets. 2013;14:
64 Considerations for Specific Medications for Comorbidities in COPD (cont’d) StatinsRecent prospective, randomized, double-blind, placebo-controlled trial in moderate to severe COPD showed no difference in exacerbation rate or mortalityHave anti-inflammatory and anti-oxidant properties in the lungsIncrease exercise time and decrease the levels of high-sensitivity C-reactive proteinReduce the decline in lung functionProvide protection against the development of lung cancerReduce requirement for intubation in exacerbationsSuggestions:May be useful in metabolic syndrome, dyslipidemias, cardiovascular diseaseBeta 2 agonistsBeta-blockers may neutralize the b2-agonists’ efficacy and COPD patients may have high tolerance for beta-blockersSurvival benefit for beta-blockers was not found among patients concurrently using beta-agonists or with severe COPD or asthma after myocardial infarctionBest to avoid if possible in CVD and concomitant cardioselective beta-blocker use in COPD.Anticholinergic agentsReduction in cardiac adverse events was associated with tiotropium in the UPLIFT studyStart 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-blockersTsiligianni 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 CorticosteroidsPossible protective effect against ischemic cardiac events and acute myocardial infarctionSuggestions: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 densityIn 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 performedSystemic CorticosteroidsMeta-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 monthsGOLD guidelines suggest limited dosage (7-10 days) and avoidance of recurrentcourses of systemic CS for COPD exacerbationsTsiligianni IG et al. Curr Drug Targets. 2013;14:
67 The Frequent Exacerbator Phenotype: Identify and Target (Non-pharmacologic and Pharmacologic) Stable stateGreater inflammationIncreases susceptibility to viral infectionGreater bacterial colonizationFaster FEV1 and functional declineWorse health statusMore severe depressionWorsened comorbidityIncrease hospitalization and mortalityINCREASED EXACERBATION SUSCEPTIBILITYPersistent inflammation/slower recoveryHigher exacerbation susceptibilityExacerbation triggers-Bacteria-Viruses-IrritantsEXACERBATIONAnti-inflammatory agents can modify the frequent exacerbator phenotype so that patients become infrequent exacerbatorsWedzicha JA et al. BMC Med. 2013;11:181.
68 COPD Exacerbations Preventative Measures Spirometry to confirm diagnosis and determine severity of COPDImprove guideline-based non-pharmacologic treatmentImprove guideline-based pharmacologic treatmentManage comorbiditiesIdentify and address social issuesEngage 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 servicesStudies have shown the powerful effects that “social determinants” like safe housing, healthful foods, and opportunities for education and employment have on healthExperts estimate that medical care accounts for only 10% of overall health, with social, environmental, and behavioral factors accounting for the restBradley EH et al. BMJ Qual Saf. 2011;20:
70 Social Issues Have a Significant Impact on Readmissions
71 The “Post-Hospital Syndrome” Sleep deprivationNutritional issuesAspiration risksDeconditioningInadequately addressed pain or discomfortCognitive 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 COPDImprove guideline-based non-pharmacologic treatmentImprove guideline-based pharmacologic treatmentManage comorbiditiesIdentify and address social issuesEngage 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 TCMCMS will pay provider submitting the claim during 30-day post discharge windowTo bill, must provide 3 key services:Must contact patient within 2 days of dischargeHave face-to-face visit within 7-14 days of dischargeProvide 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 resourcesKangovi S, Grande D. Chest. 2014;145:
77 Patient Case Study (4 of 4) JS is discharged on hospital day 3 following admission for COPD exacerbationHe returns for follow-up visit, pulmonary rehabilitation and patient education 1 week laterHe successfully stops smoking after realizing the seriousness of his conditionHe 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 careCochrane review of 26 RCTs2997 patients with COPD (mean age 68 years)Mean FEV1 44% predictedPatients in IDM vs controlsSignificantly improved quality of life scoresClinically relevant improvement of 44 m on 6-min walking distanceFewer 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 InterventionSingle 1.5-h group education session conducted by case managerIndividualized 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 helplineBegan action-plan medications for symptoms that were substantially worse than usualCase manager made monthly phone calls to each patientPatients 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 careNo regularly scheduled clinic visits for the remainder of the 1-year follow-up periodIntervention cost: $241,620 or $650 per patientThe total mean±SD per patient in the DM group was $4491±4678 compared to $5084±5060 representing a $593 per patient cost savingsDewan NA et al. COPD. 2011;8:
80 Patient and Caregiver Engagement is Important Educate, engage patient and familyDevelop individualized self-treatment plan for exacerbationsFollow-up call monthly by a case managerLower hospitalization rate and ED visitsRice 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” careOptimize medical therapy and address comorbiditiesPrevent “post-hospital syndrome”Address social issuesCoordinate follow-up care (in-hospital care and with PCP) – communicate with treating physiciansEngage patient (education, phone call reminders, etc.)
82 Free iphone App IS Now Available! The COPD Foundation’s new mobile application includes:7 Severity DomainsSpirometry Grades ChartCOPD Assessment Test (CAT)Breathlessness Scale (mMRC)Therapy ChartCOPD MedicationsSpirometry ResultsAnd 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 requirescareful planning. The COPD Foundation Guide to COPD Diagnosis and Management has the potential to allow the end user to feel more confident and competentin 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 willfacilitate 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 PocketConsultant Guide with additional information for using the diagnostic categories and for implementing the therapeutic recommendations together with expandeddescriptions 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 historyto 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 CTscan 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 patientsRegister your Guide at:copdfoundation.org/PocketGuideRegistration.aspxYou 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 copdfoundation.org/Learn-More/Educational-Materials/Brochures.aspxMost 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 OPPORTUNITIESPlenary sessions on hot topics and 3 dedicated tracks for clinical, research and care delivery topicsBest practices in readmission reduction, team based care, asthma and COPD overlap, and moreYoung investigator and physician in training development and mentorship programsCOPD9USA EXECUTIVE BOARDByron Thomashow, MDStephen Rennard, MDDavid Mannino, MDRavi Kalhan, MDJohn Walsh
86 Thank you for joining us today! Participant CME EvaluationPlease 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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