Presentation on theme: "COPD: Managing The Disease, Not The Symptoms"— Presentation transcript:
1 COPD: Managing The Disease, Not The Symptoms 2014 Annual Conference & ExhibitsMarch 3-4, 2014 Birmingham ALCMS Pulls The Trigger on COPDIn Fiscal Year 201510/1/13: Updated for NYSSRCPatrick J. Dunne, MEd, RRT, FAARCHealthCare Productions, Inc.Fullerton, CA 92838
2 Disclosure I have a professional relationship with Monaghan Medical Corporation Mylan LP Ohio Medical Corporation
3 ObjectivesReview the provisions / timelines of Medicare’s Hospital Readmission Reduction Program;List the clinical and economic impact of COPD and associated comorbidities;List the evidence-based care guidelines for the inpatient treatment of a COPD exacerbation, andDescribe potential strategies to help reduce all-cause 30-day COPD readmissions.
4 Hospital Readmission Reduction Program Section 3025 Affordable Care Act Effective FY 2013 (10/1/12 - 9/30/13)2nd of 2 new payment policiesFinancial penalties for excessive 30-day readmissions3 Targeted conditionsAcute MI (19.9%); CHF (24.5%); Pneumonia (18.2%)Additional conditions to be added in FY 2015Hospitals identified nationwideFY ,213 hospitals w/ $280 million in penalties (up to 1%)FY ,225 hospitals w/ $227 million in penalties (up to 2%)FY Penalty up to 3% of total Medicare payments
5 Up to 3% of Medicare payments Page 113: “We believe the COPD measure warrants inclusion in the Hospital Readmission Reduction Program for FY 2015”Fiscal Year 2015October 1, 2014 – September 30, 2015Index Years:July 1, 2010 – June 30, 2011July 1, 2011 – June 30, 2012July 1, 2012 – June 30, 2013Penalty in FY 2015:Up to 3% of Medicare payments
6 Now, About COPD . . . . Definition: A progressive, inflammatory chronic disease characterized by increasing airflow obstruction coupled with destruction of pulmonary gas exchange areas. There are clinically relevant extra-pulmonary effects secondary to systemic inflammationPrevalence is increasing; 3rd Leading cause of deathAirflow obstruction/alveolar destruction largely irreversiblePrimary cause: Long-term exposure to noxious inhalantsA largely preventable diseaseFourth leading cause of recidivism
8 CMS Pulls The Trigger on COPD in FY2015 COPD is a Multisystem DiseaseCardiovascular DiseaseLung CancerAnxiety, Depression, AddictionPeripheral Muscle Wasting & DysfunctionOsteoporosisCachexiaPeptic UlcersGI ComplicationsAnemiaPulmonary HypertensionMetabolic Risk FactorsThe five conditions described below are metabolic risk factors. You must have at least three metabolic risk factors to be diagnosed with metabolic syndrome.A large waistline. This also is called abdominal obesity or "having an apple shape." Excess fat in the stomach area is a greater risk factor for heart disease than excess fat in other parts of the body, such as on the hips.A high triglyceride level (or you're on medicine to treat high triglycerides). Triglycerides are a type of fat found in the blood.A low HDL cholesterol level (or you're on medicine to treat low HDL cholesterol). HDL sometimes is called "good" cholesterol. This is because it helps remove cholesterol from your arteries. A low HDL cholesterol level raises your risk for heart disease.HypertensionHigh fasting blood sugar (or you're on medicine to treat high blood sugar). Mildly high blood sugar may be an early sign of diabetes.DiabetesMetabolic SyndromeAdapted from Kao C, Hanania NA. Atlas of COPD
10 COPD Opportunities for Improvement Currently, care outcomes less than optimalGrowing concern over high recidivism rateUnplanned re-admissions are costly30 day re-admits largely preventableCOPD evidence-based care guidelines existFor both in-patient (exacerbation) and out-patient (Sx control)Use of evidence-based care guidelines is low
12 Under-treatment of COPD Record review: 553 pts. discharged with Dx of COPDDarmella W, et al. Respir Care; October 2006Only 31% had confirmatory spirometryWe must raise awareness of the need to confirm the diagnosis of COPD and it’s severity with spirometryRecord review: 169 pts. with 1,664 care eventsMularski RW, et al. Chest; December 2006Subjects received 55% of recommended care; Only 30% with base-line hypoxemia received LTOTThe deficits and variability in processes of care for patients with obstructive lung disease presents ample opportunity for improvement
13 Inpatient COPD Care: The Evidence McCrory DC, et al. Chest; 2001 EFFICACY EVIDENCE EXISTSEFFICACY EVIDENCE LACKINGChest radiography/ABGsSputum analysisOxygen therapyAcute spirometryBronchodilator therapyMucolytic agentsSystemic steroidsChest physiotherapyAntibioticsMethylxanthine bronchodilatorsVentilatory support (as required)Leukotrine modifiers; Mast cell stablizersLevel 1-2 evidence of efficacy = Recommended careInsufficient efficacy evidence = Non-recommended careNon-recommended care = Unnecessary care
14 Under-treatment of COPD Record review: 69,820 records from 360 hospitals Lindenauer PK, et al. Ann Intern Med; June 200666% received all of recommended care; 45% received at least one non-recommended care; Only 30% received Ideal CareWe identified widespread opportunities to improve quality of care and to reduce costs by addressing problems of underuse, overuse and misuse of resources, and by reducing variation in practiceClaims data review: 42,565 commercial, 8,507 Medicare Make B, et al. Int J Chron Obstruct Pulmon Dis; January 2012No pharmacotherapy – 60% commercial, 70% MedicareNo smoking cessation – 82% commercial, 90% MedicareNo influenza vaccination – 83% commercial, 76% MedicareThis study highlights a high degree of undertreatment of COPD, with most patients receiving no maintenance pharmacotherapy or influenza vaccination
15 Under-treatment of COPD: Summary COPD - an expensive, chronic conditionIncidence is increasingFinancial liability is escalatingDiagnostic spirometry is woefully under-usedUse of evidence-based treatment guidelines is lowFailure to control symptoms a precursor to exacerbationsCOPD hospital re-admissions are largely preventableChronic disease management strategies a necessity
16 CMS Pulls The Trigger on COPD in FY2015 GOLD Guidelines Pre-2013IV: Very SevereIII: SevereII: ModerateFEV1/FVC < 0.70FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failureI: MildFEV1/FVC < 0.7030% ≤ FEV1 < 50% predictedFEV1/FVC < 0.7050% ≤ FEV1 < 80% predictedFEV1/FVC < 0.70FEV1 ≥ 80% predictedActive reduction of risk factor(s); smoking cessation, flu vaccinationAdd short-acting bronchodilator (as needed)Add regular treatment with long-acting bronchodilators; Begin Pulmonary RehabilitationThe NHLBI/WHO guidelines for the diagnosis, treatment and management of COPD, otherwise known as the GOLD guidelines, outline approaches that define severity of disease by pulmonary function, FEV1, and symptoms.These guidelines then outline appropriate medial therapy for patients at each level of severity, in a cumulative fashion.All patients, starting at Stage I, or mild COPD, should have efforts to reduce risk factors, the primary issue here being smoking, influenza vaccine, and short-acting bronchodilators to use when needed.At Stage II, or moderate COPD, and above, regular treatment with one or more bronchodilators and rehabilitation should be added to the care regimenAt Stage III, or severe COPD, and above, inhaled glucocorticosteriods should be added if patients have repeated exacerbations.At Stage IV, or very severe COPD, and above, long-term oxygen should be added if patients have chronic respiratory failure, and surgical options should be considered.BROVANA is an appropriate medicine to consider for patients with moderate and above COPD who are not adequately controlled with or who overuse SABAs.Add inhaled glucocorticosteroids if repeated acute exacerbationsAdd LTOT for chronic hypoxemia.Consider surgical options
17 Combined Assessment of COPD GOLD Guidelines (2013) CMS Pulls The Trigger on COPD in FY2015Combined Assessment of COPD GOLD Guidelines (2013)4(C)(D)≥ 23RiskGOLD Classification of Airflow LimitationRiskExacerbationhistory2(A)(B)11mMRC 0-1 (or) CAT < 10mMRC > 2 (or) CAT > 10Symptoms(mMRC or CAT score)
18 Left (or) Right - - - Up (or) Down > 2 exacerbations0-1 exacerbationsFewer MoreSymptoms Symptoms
19 Combined Assessment of COPD GOLD Guidelines (2013) CMS Pulls The Trigger on COPD in FY2015Combined Assessment of COPD GOLD Guidelines (2013)4(C)(D)≥ 23RiskGOLD Classification of Airflow LimitationRiskExacerbationhistory2(A)(B)11mMRC 0-1 (or) CAT < 10mMRC > 2 (or) CAT > 10Symptoms(mMRC or CAT score)
20 CMS Pulls The Trigger on COPD in FY2015 Assessment of SymptomsGOLD Guidelines (2013)Modified British Medical Research Council (mMRC) Dyspnea Questionnaire:A 5-item measure of perceived dyspneaSelf-report on grade 0 – 5(or)COPD Assessment Test (CAT):An 8-item measure of health status impairment in COPDSelf-report on scale 0 – 5Both have been validated and relate well to other measures ofhealth status and predict future mortality risk.
21 CMS Pulls The Trigger on COPD in FY2015 Modified MRC (mMRC) QuestionnaireGOLD Guidelines (2013)
22 COPD Assessment Test (CAT) GOLD Guidelines (2013)
23 COPD Assessment Test (CAT) GOLD Guidelines (2013)
24 CMS Pulls The Trigger on COPD in FY2015 Combined Assessment of COPD Global Strategy for Diagnosis, Management and Prevention of COPD(C)(D)≥ 2330-50%4<30%RiskPre-2013 GOLD Classification of Airflow LimitationRiskExacerbationhistory(A)(B)11≥ 80%250-80%mMRC 0-1 (or) CAT < 10mMRC > 2 (or) CAT > 10Symptoms(mMRC or CAT score)
25 Combined Assessment of COPD GOLD Guidelines (2013) CMS Pulls The Trigger on COPD in FY2015Combined Assessment of COPD GOLD Guidelines (2013)When assessing risk, choose the highest risk according to GOLD grade or exacerbation historyPatientCharacteristicsSpirometric ClassificationExacerbations per yearmMRCCATALess SymptomsLow RiskGOLD 1-20-1< 10BMore Symptoms≥ 2≥ 10CHigh RiskGOLD 3-4D
26 COPD Maintenance Treatment by Airflow Limitation/Risk GOLD Guidelines (2013)FEV1% PREDICTED(AIRFLOW LIMITATION)EXACERBATIONGRADE(RISK)TREATMENTCONSIDERATIONS≥ 80%LOWSmoking cessation; Vaccinations; SABA prn50 – 80%MEDIUMAdd to above: Nebulized LABA-LAMA daily; Pulm Rehab; Exacerbation action plan30 – 50%HIGHAdd to above: ICS for exacerbation prone; Referral to pulmonologist≤ 30%VERY HIGHAdd to above: long-term oxygen therapy; Consider surgical options
28 Acute Spirometry with COPD Exacerbation Isn’t spirometry needed to Confirm Dx and Grade Airflow Limitation?Acute spirometryHospitalized patients not ready for full PFT studiesUnable to exert maximal effort; Repeat maneuversPre-post bronchodilator response of limited valueMake appointment for 4-6 weeks post recoveryWhat about peak inspiratory flow?Not a demanding test but insightfulAbility to use a DPIGenerate ≥ 40 L/min PIF
29 CMS Pulls The Trigger on COPD in FY2015 Secretion Retention with COPD Exacerbation Can Contribute to Airflow Obstruction; WOBChest physiotherapyAn airway clearance technique (ACT)Secretion retention, ineffective cough problematicTrendelenburg position contraindicated in COPDProven alternate ACT techniques in use for CFACBT, AD, HFCWO, IPV, OPEPWhich to consider for COPD?OPEP Rx a viable regimenInexpensive, non-invasiveAlone or in combo with SVNACBT = active cycle breathing techniques; AD = autogenic drainageVibration: It is the repetitive motion of a body which may or may not be periodic. A vibrating body may not have a definite time period. Also the amplitude of vibration is generally small and changes with time. Example: The vibrating string of a guitar.Oscillation: It is the periodic motion of a body about a mean position. It has a definite time period of oscillation and the amplitude remains constant. Example: A freely oscillating pendulum.
30 Airway Clearance Therapy: The Evidence RESPIRATORY CARE: December 2013 ACT is not recommended for routine use in COPD.ACT may be considered in COPD patients with symptomatic secretion retention.
31 Medication Nebulizers Not all jet-nebulizers are created equal! CMS Pulls The Trigger on COPD in FY2015Medication Nebulizers Not all jet-nebulizers are created equal!Respirable Dose 30%Respirable Dose 10%Respirable Dose 15%Higher respirable dose = Quicker onset of action!Higher respirable dose = Shorter treatment times!Quicker onset/less time = Better RT deployment!
33 Breath Actuated Nebulizer in COPD Haynes J. Respir Care; Sept 2012 Prospective, randomized controlled trialObjective: compare bronchodilator response w/ BAN to standard SVNPatients admitted w/ COPD exacerbationN = 40 of 46; Similar baseline characteristicsDyspnea secondary to dynamic hyperinflationMedication regimen2.5 mg albuterol/0.5 mg ipratropium (3 mL) Q4H2.5 albuterol Q2H prnCommon adverse effects monitored during/after each RxData collected 2 hrs post 6th scheduled Rx (collector blinded)Inspiratory capacity; dyspnea; RR
34 Breath Actuated Nebulizer in COPD Haynes J. Respir Care; Sept 2012 Findings:Both groups received same # Rxs (6.25; 6.20)IC higher in BAN v. SVN (1.83 L v L; P .03)Change in IC greater BAN v. SVNRR lower in BAN v. SVN (19/min v. 22/min; P = .03)No difference in BORG or LOS
35 Breath Actuated Nebulizer in COPD Haynes J. Respir Care; Sept 2012 Conclusions:In this cohort of patients with ECOPD, the AeroEclipse II BAN was more effective in reducing lung hyperinflation and respiratory rate than traditional SVN.It may be that the BAN group simply received more medication because of the breath activated mode…Aerosols with MMAD of 3.0 μm produce the highest physiological response in terms of FEV1 and airway conductance.
36 Role of Nebulized Therapy in COPD Dhand R, et al. COPD; Feb 2012 CMS Pulls The Trigger on COPD in FY2015Role of Nebulized Therapy in COPD Dhand R, et al. COPD; Feb 2012RECOMMENDATION: Many patients, especially elderly patients with COPD, are unable to use their pMDIs and DPIs in an optimal manner. For such patients, nebulizers should be employed on a domiciliary basis. . .Nebulizers are more forgiving to poor inhalation technique, especially poor coordination with pMDIs and the requirement to generate adequate peak inspiratory flows with DPIs.2/26/12: MonMed Sales Mtg: Incorporate newest data from Make et al in 2011 on lack of maintenance therapy prescribed for COPD patients . . Mirrors Mularski; Do pts a favor - - become an advocate for EBM in COPD care, both inpatient & outpatient; Get them started during recovery phase on maintenance meds.
37 Nebulized Therapy at Home Ease of use; simple techniqueAddresses inconvenience issueEffective and reliable drug deliveryUse not limited by disease severity or mental acuityDevice & medications covered under Medicare Part B
39 Improving COPD Care Outcomes Summary A new COPD care pathway essentialCOPD patients will impact hospital’s revenuePatient volume will vary by institution (1-2/month to 6-8/month)Advocate evidence-base careRe-design current workloadAllocate resources accordinglyStart small; Expand as necessaryAppoint, anoint, elect one departmental COPD GuruLet patient volume drive program developmentDetermine risk grade per 2013 GOLD GuidelinesUse CAT (or) mMRCEnsure proper controller medications prescribedRecommend follow-up MD appointment within 5-7 days
40 New CMS Payment Models Summary Two distinct programsValue-based Purchasing Program (VBP)Bonus payment (or) penaltyBased on Core Performance Measures reported for:AMI, CHF, PneumoniaHospital Readmission Reduction Program (HRRP)Penalty onlyBased on historic readmission rates for:Additional conditions to be added in FY 2015COPD for HRRPCOPD Core Performance Measures coming for VBP?
41 Domain of Likely COPD Performance Measures Timely and Effective Care Performance measures tied to bonus or penalty paymentsAlready required under Physician Quality Reporting System (PQRS)Documented evidence in medical record of:Smoking cessation (discussed at every visit)Spirometry (within past 2-3 yrs.)Bronchodilator therapy (LABA vs. SABA-only)Immunizations (pneumococcal, influenza)Demonstrate your valueHelp your hospital achieve bonus payments!!!!
43 COPD: Managing The Disease, Not The Symptoms 2014 Annual Conference & ExhibitsMarch Birmingham ALCMS Pulls The Trigger on COPDIn Fiscal Year 201510/1/13: Updated for NYSSRCPatrick J. Dunne, MEd, RRT, FAARCHealthCare Productions, Inc.Fullerton, CA 92838