Exploring the Chronic Obstructive Pulmonary Disease (COPD) Clinical Pathway. Health Quality Ontario s integrated episode of care for COPD

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1 Exploring the Chronic Obstructive Pulmonary Disease (COPD) Clinical Pathway Health Quality Ontario s integrated episode of care for COPD Dr. Charlie Chan Health Quality Ontario Expert Panel Co-Chair May/June 2015

2 Faculty/Presenter Disclosure Faculty: Dr. Charlie Chan Relationships with commercial interests: Not applicable 1

3 Objectives 1. Briefly describe HQO s episode of care program and methodology for informing Quality-Based Procedures 2. Walk through the key recommendations in HQO s Integrated Clinical Handbook for Chronic Obstructive Pulmonary Disease a) Acute Episode of Care b) Post-Acute Episode of Care

4 Quality-Based Procedures in a nutshell The original idea: a new activity-based funding model for hospital-based services (funding = price x volume, adjusted for case mix) Each year, QBPs implemented for an expanding range of patient populations For each QBP, historical global budget funding carved out for estimated costs of current activity in QBP patient population Hospitals are then re-paid for activity using standard provincial prices The vision: In future, prices will be based on the cost of best practice QBP Expert Panels established through provincial agencies (HQO, CCO, CCN, UHN) to define patient populations to be funded and define best practice care pathways to be costed 3

5 HQO s Episode of Care lifecycle QBP topic selection and scoping Monitoring, evaluation and feedback Expert panel formation Population utilization analysis Develop implementation tools and supports Ministry QBP policy design & implementation Health sector adoption & implementation Define cohort, episode of care and case mix adjustors Recommend performance indicators Develop recommended practices 4 Evidence and guideline synthesis

6 HQO s COPD QBP journey (so far) Integration & update (completed Fall 2014) Post-acute episode (completed Summer 2014) Acute episode (completed Winter 2012) 5

7 Synthesizing and contextualizing different sources of evidence through the Expert Panel Recommended practice Supporting evidence Usual Medical Care (mild and moderate exacerbations) Administer mg prednisone for 7-14 day course of therapy for all patients unless contraindicated Theophylline is not recommended, unless patient is already receiving CTS: 1+ RCTs; good evidence GOLD: Expert consensus GOLD: RCTs, limited body of data NICE: Expert consensus Ventilation (severe exacerbations) Discharge planning (all patients) Use noninvasive ventilation as first line therapy for patients with acute respiratory failure and ph < 7.35 Refer all hospitalized patients to begin pulmonary rehabilitation within 1 month of discharge Develop an action plan with patients before discharge with instructions on how to manage future exacerbations Expert Panel Synthesis and Contextualizion OHTAC: Moderate quality evidence GOLD: RCTs, rich body of data OHTAC NICE: Systematic reviews Ontario administrative data OHTAC: Moderate quality evidence GOLD: RCTs, rich body of data CTS: 1+ RCTs; good evidence OHTAC GOLD: Expert consensus NICE: Expert consensus HQO RAPID EVIDENCE REVIEW

8 The episode of care model for a COPD acute exacerbation Legend Care module Mild Level of care Usual medical care (in ED / outpatient) N = 19,337 P = Recovers Discharge planning & full clinical assessment Assess recovery Go to usual medical care Treatment fails (inpatient) Home Patient presents with suspected exacerbation of COPD N = 43,215 P = 1.0 Assessment node Episode endpoint Moderate Level of care Assess level of care required Usual medical care (inpatient) N = 22,054 P = Recovers Assess recovery Treatment fails Discharge planning & full clinical assessment Go to ventilation (NPPV or IMV) Home N = 1,824 P =.042 Severe Level of care Decision on ventilation modality or palliative care NPPV N = 773 P =.018 IMV N = 1051 P =.024 Treatment fails 7 Recovers Usual medical care (inpatient) Assess recovery Treatment fails Recovers Wean from IMV Assess recovery Go to IMV End of life care Usual medical care (inpatient) Death Discharge planning & full clinical assessment Discharge planning & full clinical assessment Home Home

9 Populating the components of the model: Evidence-based recommendations and performance indicators Patient presents with suspected exacerbation of COPD ASSESSMENT NODE: Assess level of care required Mild Level of care Moderate Level of care Usual medical care (in ED / outpatient) N = 19,337 Pr = Usual medical care (inpatient) N = 22,054 Pr = Recovers Assess recovery Go to usual medical care Treatment fails (inpatient) Recovers Discharge planning & full clinical assessment CARE MODULE: NONINVASIVE VENTILATION Recommended Practice Discharge planning & full Evidence clinical assessment Reviewed Assess recovery Offer NPPV as OHTAC first line therapy Recommendation Go to GOLD, ventilation NICE Treatment fails (NPPV guidelines or IMV) Short-acting GOLD, NICE, ASSESS IN ED / DECISION TO ADMIT % receiving Severe Recovers bronchodilators Usual medical CTS guidelines bronchodilators Discharge planning Risk factor Treat Admit care (inpatient) in ED to ward Level of care & full clinical Home NPPV Assess recovery assessment SaO Antibiotics GOLD, CTS % receiving 2 < 90% No Yes N = 1,824 N = 773 Go to IMV Guidelines, antibiotics Treatment fails Changes on P = No.042 P =.018 Expert Opinion Discharge planning chest Present X-ray Recovers Wean Usual medical & full clinical Home Decision on from IMV care (inpatient) assessment Arterial ph level > ventilation < 7.35 IMV Assess recovery Arterial modality or 8 PaO 2 > 7 kpa < 7 kpa N = End of life care palliative care Treatment fails Death Pr =.024 Home Home Indicator % receiving NPPV vs IMV

10 COPD admissions/discharges from ED Province-wide, the % of COPD ED visits admitted/discharged has remained relatively constant over the past 3 years Registration Fiscal Year Visit Disposition Cases (SUM) Cases (SUM) Cases (SUM) 01 Discharged Home (no support services) 27, % 24, % 24, % 05 Left against medical advice (triaged, treatment initiated) % % % 06 Admitted into reporting facility as inpatient (CCU or OR) 1, % 1, % 1, % 07 Admitted into reporting facility as inpatient (to another unit) 16, % 15, % 15, % 08 Transferred to another acute care facility % % % 09 Transferred to another non-acute care facility % % % 10 Death after arrival (DAA) % % % 11 Death on arrival (DOA) % % % 15 Discharged to place of residence (with support services) 1, % 1, % 1, % 47,929 43,431 42,927 Diagnosis: COPD, CTAS Level: 1, 2, and 3, Age Group: (All) But there is significant variation in this percentage between individual hospitals: 9 William Osler HC Trillium Health Partners Hamilton HSC Kingston General Hospital London Health Sciences Peterborough Regional HC St. Joseph's HCS, Hamilton Ottawa Hospital St. Mary's General, Kitchener Royal Victoria Hospital Barrie Toronto East General Niagara HS Thunder Bay Regional Lakeridge Health Cornwall Community Hospital Grey Bruce HS Quinte Healthcare 0% 20% 40% 60% 80%

11 Diagnosis of COPD Consider clinical diagnosis of COPD in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease Spirometry is required to make clinical diagnosis: postbronchodilator FEV1/FVC <0.70 confirms COPD Spirometry need not be performed during the initial phase of an exacerbation when the patient is unstable, but should be performed once the patient has stabilized Spirometry should only be performed if the patient has no recent, reliable, objective documentation of COPD by spirometry 10

12 Decision to admit Decision to admit relies largely on clinical judgment and availability of local resources see NICE / GOLD criteria below NICE Decision Guidelines for Hospital Admission (2011) Factors to consider when deciding where to manage exacerbations (Take into account the person s preference) Treat at home? Treat in hospital? Able to cope at home Yes No Breathlessness Mild Severe General condition Good Poor/deteriorati ng Level of activity Good Poor/confined to bed Cyanosis No Yes Worsening peripheral oedema No Yes Level of consciousness Normal Impaired Already receivingltot No Yes Social circumstances Good Living alone/not coping Acute confusion No Yes Rapid rate of onset No Yes Significant comorbidity (particularly cardiac disease and insulindependent diabetes) No Yes SaO 2 < 90% No Yes Changes on chest X- ray No Present Arterial ph level 7.35 < 7.35 GOLD Indications for Hospital Assessment or Admission 11

13 Usual medical care (1 of 2) Short-acting bronchodilators (Beta-2 agonists recommended) If patient is already on long-acting anticholinergics, continue to administer in combination with Beta-2 agonists Metered dose inhalers with spacers are the preferred delivery vehicle; nebulizers should be considered second line treatment due to infection risk Corticosteroids are effective except for only very mild exacerbations, or if contraindicated mg / day Prednisone or equivalent days Manage corticosteroid-induced side effects Theophylline is not recommended, unless already receiving If necessary, deliver oxygen to maintain 90% oxygen saturation Where appropriate, initiate bronchopulmonary (lung) hygiene physical therapy to clear mucus and secretion from the airway If patient is admitted, use early ambulation therapy Begin discharge planning, including referral to pulmonary rehab 12

14 Usual medical care (2 of 2) Use antibiotics for indications of infection (e.g. purulent or high volume sputum) Refer to institution-specific antimicrobial stewardship policies Oral antibiotics are preferred Intravenous antibiotics should be considered a 2nd line therapy used only when oral antibiotics are contraindicated (e.g. GI issues) See CTS guidelines below (2007) 13

15 Decision on ventilation If possible, seek patient preferences for ventilation therapy before proceeding to ventilation interventions If ventilation is not desired, proceed to palliative care NPPV should be considered as first line treatment for patients with acute respiratory failure and ph < 7.35 NPPV should be trialed before proceeding to invasive ventilation for all patients with indications for ventilation, including severe patients (ph < 7.20), unless contraindications are present Where patients have expressed preferences against intubation, NPPV can still be considered but ensure that therapy does not progress to IV in the case of failure to respond to NPPV 14

16 Bringing it all together: A combined acute / post-acute model for COPD 15

17 Post- Acute: Functional Support Patients should leave the hospital with an individualized care plan, and a copy faxed to the patient s pharmacy of choice. Follow-up appointment with a prescriber or specialized respiratory professional within maximum 1 week of discharge, or when steroid dose a) tapers to <20mg/day or b) day of last dose (if discharged on <20mg/day); and complex patients receive a phone call within 48 hours. Ensure the patient, patient s PCP, associated specialist, and home care providers receive a care plan from the hospital, including full clinical assessment of the patient, at discharge 16

18 Post- Acute: Pulmonary rehabilitation OHTAC reaffirms the recommendations it made in 2012, namely: ongoing access to existing pulmonary rehabilitation for the management of moderate to severe chronic obstructive pulmonary disease (COPD) in stable patients, and the use of pulmonary rehabilitation in patients following an acute exacerbation (within 1 month of hospital discharge). Further, based on a field evaluation study, OHTAC recommends increased availability of resources for pulmonary rehabilitation following discharge for patients who have had an acute exacerbation of COPD. 17

19 End-of-Life Care OHTAC recommends that cardiopulmonary resuscitation (CPR) not be the default intervention for adults designated as palliative and for whom death is anticipated. Symptom management with opioids, benzodiazepines, antidepressants, major tranquilizers, other non-opioid therapies and oxygen when appropriate for breathlessness is recommended when unresponsive to other therapies. If ventilation is not desired, proceed to palliative care management of the patient, consistent with OHTAC s recommendation. (the fluctuating physical, psychosocial, spiritual, and information needs should be considered, without necessarily forgoing acute care or hope of improvement during and following severe exacerbations) 18

20 COPD Episode of Care Expert Panel: Specific COPD indicator recommendations Admission rate? % received recommended in-hospital pharmacotherapy? % had diagnosis confirmed with spirometry Use of NPPV LEGEND Indicators that are in current use Indicators that are potentially feasible with currently available data? Indicators that are not feasible with currently available data Length of stay In-hospital mortality 30-day readmissions In-hospital mortality Post-discharge physician follow-up? % referred to pulmonary rehab

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