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COPD: Managing The Disease, Not The Symptoms

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Presentation on theme: "COPD: Managing The Disease, Not The Symptoms"— Presentation transcript:

1 COPD: Managing The Disease, Not The Symptoms
2014 Annual Conference & Exhibits March 3-4, 2014  Birmingham  AL CMS Pulls The Trigger on COPD In Fiscal Year 2015 10/1/13: Updated for NYSSRC Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA 92838

2 Disclosure I have a professional relationship with
 Monaghan Medical Corporation  Mylan LP  Ohio Medical Corporation

3 Objectives Review 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, and Describe 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 policies Financial penalties for excessive 30-day readmissions 3 Targeted conditions Acute MI (19.9%); CHF (24.5%); Pneumonia (18.2%) Additional conditions to be added in FY 2015 Hospitals identified nationwide FY ,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 2015 October 1, 2014 – September 30, 2015 Index Years: July 1, 2010 – June 30, 2011 July 1, 2011 – June 30, 2012 July 1, 2012 – June 30, 2013 Penalty 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 inflammation Prevalence is increasing; 3rd Leading cause of death Airflow obstruction/alveolar destruction largely irreversible Primary cause: Long-term exposure to noxious inhalants A largely preventable disease Fourth leading cause of recidivism

7 © 2013 Global Initiative for Chronic Obstructive Lung Disease
Risk Factors for COPD Genes Infections Socio-economic status Aging Populations © 2013 Global Initiative for Chronic Obstructive Lung Disease

8 CMS Pulls The Trigger on COPD in FY2015
COPD is a Multisystem Disease Cardiovascular Disease Lung Cancer Anxiety, Depression, Addiction Peripheral Muscle Wasting & Dysfunction Osteoporosis Cachexia Peptic Ulcers GI Complications Anemia Pulmonary Hypertension Metabolic Risk Factors The 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. Hypertension High fasting blood sugar (or you're on medicine to treat high blood sugar). Mildly high blood sugar may be an early sign of diabetes. Diabetes Metabolic Syndrome Adapted from Kao C, Hanania NA. Atlas of COPD

9 COPD Comorbidities

10 COPD Opportunities for Improvement
Currently, care outcomes less than optimal Growing concern over high recidivism rate Unplanned re-admissions are costly 30 day re-admits largely preventable COPD evidence-based care guidelines exist For both in-patient (exacerbation) and out-patient (Sx control) Use of evidence-based care guidelines is low

11

12 Under-treatment of COPD
Record review: 553 pts. discharged with Dx of COPD Darmella W, et al. Respir Care; October 2006 Only 31% had confirmatory spirometry We must raise awareness of the need to confirm the diagnosis of COPD and it’s severity with spirometry Record review: 169 pts. with 1,664 care events Mularski RW, et al. Chest; December 2006 Subjects received 55% of recommended care; Only 30% with base-line hypoxemia received LTOT The 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 EXISTS EFFICACY EVIDENCE LACKING Chest radiography/ABGs Sputum analysis Oxygen therapy Acute spirometry Bronchodilator therapy Mucolytic agents Systemic steroids Chest physiotherapy Antibiotics Methylxanthine bronchodilators Ventilatory support (as required) Leukotrine modifiers; Mast cell stablizers Level 1-2 evidence of efficacy = Recommended care Insufficient efficacy evidence = Non-recommended care Non-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 2006 66% received all of recommended care; 45% received at least one non-recommended care; Only 30% received Ideal Care We 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 practice Claims data review: 42,565 commercial, 8,507 Medicare Make B, et al. Int J Chron Obstruct Pulmon Dis; January 2012 No pharmacotherapy – 60% commercial, 70% Medicare No smoking cessation – 82% commercial, 90% Medicare No influenza vaccination – 83% commercial, 76% Medicare This 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 condition Incidence is increasing Financial liability is escalating Diagnostic spirometry is woefully under-used Use of evidence-based treatment guidelines is low Failure to control symptoms a precursor to exacerbations COPD hospital re-admissions are largely preventable Chronic disease management strategies a necessity

16 CMS Pulls The Trigger on COPD in FY2015
GOLD Guidelines Pre-2013 IV: Very Severe III: Severe II: Moderate FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure I: Mild FEV1/FVC < 0.70 30% ≤ FEV1 < 50% predicted FEV1/FVC < 0.70 50% ≤ FEV1 < 80% predicted FEV1/FVC < 0.70 FEV1 ≥ 80% predicted Active reduction of risk factor(s); smoking cessation, flu vaccination Add short-acting bronchodilator (as needed) Add regular treatment with long-acting bronchodilators; Begin Pulmonary Rehabilitation The 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 regimen At 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 exacerbations Add LTOT for chronic hypoxemia. Consider surgical options

17 Combined Assessment of COPD GOLD Guidelines (2013)
CMS Pulls The Trigger on COPD in FY2015 Combined Assessment of COPD GOLD Guidelines (2013) 4 (C) (D) ≥ 2 3 Risk GOLD Classification of Airflow Limitation Risk Exacerbation history 2 (A) (B) 1 1 mMRC 0-1 (or) CAT < 10 mMRC > 2 (or) CAT > 10 Symptoms (mMRC or CAT score)

18 Left (or) Right - - - Up (or) Down
> 2 exacerbations 0-1 exacerbations Fewer More Symptoms Symptoms

19 Combined Assessment of COPD GOLD Guidelines (2013)
CMS Pulls The Trigger on COPD in FY2015 Combined Assessment of COPD GOLD Guidelines (2013) 4 (C) (D) ≥ 2 3 Risk GOLD Classification of Airflow Limitation Risk Exacerbation history 2 (A) (B) 1 1 mMRC 0-1 (or) CAT < 10 mMRC > 2 (or) CAT > 10 Symptoms (mMRC or CAT score)

20 CMS Pulls The Trigger on COPD in FY2015
Assessment of Symptoms GOLD Guidelines (2013) Modified British Medical Research Council (mMRC) Dyspnea Questionnaire: A 5-item measure of perceived dyspnea Self-report on grade 0 – 5 (or) COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD Self-report on scale 0 – 5 Both have been validated and relate well to other measures of health status and predict future mortality risk.

21 CMS Pulls The Trigger on COPD in FY2015
Modified MRC (mMRC) Questionnaire GOLD 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) ≥ 2 3 30-50% 4 <30% Risk Pre-2013 GOLD Classification of Airflow Limitation Risk Exacerbation history (A) (B) 1 1 ≥ 80% 2 50-80% mMRC 0-1 (or) CAT < 10 mMRC > 2 (or) CAT > 10 Symptoms (mMRC or CAT score)

25 Combined Assessment of COPD GOLD Guidelines (2013)
CMS Pulls The Trigger on COPD in FY2015 Combined Assessment of COPD GOLD Guidelines (2013) When assessing risk, choose the highest risk according to GOLD grade or exacerbation history Patient Characteristics Spirometric Classification Exacerbations per year mMRC CAT A Less Symptoms Low Risk GOLD 1-2 0-1 < 10 B More Symptoms ≥ 2 ≥ 10 C High Risk GOLD 3-4 D

26 COPD Maintenance Treatment by Airflow Limitation/Risk
GOLD Guidelines (2013) FEV1 % PREDICTED (AIRFLOW LIMITATION) EXACERBATION GRADE (RISK) TREATMENT CONSIDERATIONS ≥ 80% LOW Smoking cessation; Vaccinations; SABA prn 50 – 80% MEDIUM Add to above: Nebulized LABA-LAMA daily; Pulm Rehab; Exacerbation action plan 30 – 50% HIGH Add to above: ICS for exacerbation prone; Referral to pulmonologist ≤ 30% VERY HIGH Add to above: long-term oxygen therapy; Consider surgical options

27 Inpatient COPD Care: The Evidence McCrory DC, et al. Chest; 2001
EFFICACY EVIDENCE EXISTS EFFICACY EVIDENCE LACKING Chest radiography/ABGs Sputum analysis Oxygen therapy Acute spirometry Bronchodilator therapy Mucolytic agents Systemic steroids Chest physiotherapy Antibiotics Methylxanthine bronchodilators Ventilatory support (as required) Leukotrine modifiers; Mast cell stablizers

28 Acute Spirometry with COPD Exacerbation Isn’t spirometry needed to Confirm Dx and Grade Airflow Limitation? Acute spirometry Hospitalized patients not ready for full PFT studies Unable to exert maximal effort; Repeat maneuvers Pre-post bronchodilator response of limited value Make appointment for 4-6 weeks post recovery What about peak inspiratory flow? Not a demanding test but insightful Ability to use a DPI Generate ≥ 40 L/min PIF

29 CMS Pulls The Trigger on COPD in FY2015
Secretion Retention with COPD Exacerbation Can Contribute to Airflow Obstruction;  WOB Chest physiotherapy An airway clearance technique (ACT) Secretion retention, ineffective cough problematic Trendelenburg position contraindicated in COPD Proven alternate ACT techniques in use for CF ACBT, AD, HFCWO, IPV, OPEP Which to consider for COPD? OPEP Rx a viable regimen Inexpensive, non-invasive Alone or in combo with SVN ACBT = active cycle breathing techniques; AD = autogenic drainage Vibration: 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 FY2015 Medication 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!

32 Dynamic Hyperinflation

33 Breath Actuated Nebulizer in COPD Haynes J. Respir Care; Sept 2012
Prospective, randomized controlled trial Objective: compare bronchodilator response w/ BAN to standard SVN Patients admitted w/ COPD exacerbation N = 40 of 46; Similar baseline characteristics Dyspnea secondary to dynamic hyperinflation Medication regimen 2.5 mg albuterol/0.5 mg ipratropium (3 mL) Q4H 2.5 albuterol Q2H prn Common adverse effects monitored during/after each Rx Data 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. SVN RR 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 FY2015 Role of Nebulized Therapy in COPD Dhand R, et al. COPD; Feb 2012 RECOMMENDATION: 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 technique Addresses inconvenience issue Effective and reliable drug delivery Use not limited by disease severity or mental acuity Device & medications covered under Medicare Part B

38 Managing Stable COPD Goals of Therapy
Relieve airflow obstruction Improve exercise tolerance Reduce symptoms Improve health status Prevent disease progression Prevent & treat exacerbations Reduce risk Reduce mortality Reduced symptoms + Reduced risk = Successful disease management

39 Improving COPD Care Outcomes Summary
A new COPD care pathway essential COPD patients will impact hospital’s revenue Patient volume will vary by institution (1-2/month to 6-8/month) Advocate evidence-base care Re-design current workload Allocate resources accordingly Start small; Expand as necessary Appoint, anoint, elect one departmental COPD Guru Let patient volume drive program development Determine risk grade per 2013 GOLD Guidelines Use CAT (or) mMRC Ensure proper controller medications prescribed Recommend follow-up MD appointment within 5-7 days

40 New CMS Payment Models Summary
Two distinct programs Value-based Purchasing Program (VBP) Bonus payment (or) penalty Based on Core Performance Measures reported for: AMI, CHF, Pneumonia Hospital Readmission Reduction Program (HRRP) Penalty only Based on historic readmission rates for: Additional conditions to be added in FY 2015 COPD for HRRP COPD Core Performance Measures coming for VBP?

41 Domain of Likely COPD Performance Measures Timely and Effective Care
Performance measures tied to bonus or penalty payments Already 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 value Help your hospital achieve bonus payments!!!!

42 AARC Resources

43 COPD: Managing The Disease, Not The Symptoms
2014 Annual Conference & Exhibits March  Birmingham  AL CMS Pulls The Trigger on COPD In Fiscal Year 2015 10/1/13: Updated for NYSSRC Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA 92838


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