4/26/2016. Strategies for Preventing COPD Exacerbations and Readmissions. Statistics. Objectives. Julie Morgan, RRT, ACCS

Transcription

1 Strategies for Preventing COPD Exacerbations and Readmissions Julie Morgan, RRT, ACCS Objectives Upon completion of the program, the learner will be able to: Identify the reasons patients experience hospital readmissions due to COPD. Identify methods to reduce hospital readmissions due to COPD. Statistics 3 rd leading cause of death in the United States 2010, COPD accounted for nearly $50 billion of cost in the United States Rate of hospitalizations due to COPD is increasing Hospitalizations for COPD exacerbations account for more than 50% of the cost of managing COPD 1

2 Exacerbations According to Chest, exacerbations that cause hospitalizations, contribute to death during hospitalization or shortly thereafter, expedite decline in pulmonary function, decrease quality of life, and consume financial resources. 2/3 are associated with respiratory tract infections or air pollution Why all the fuss about COPD, exacerbations, and hospital readmissions? Care quality and outcomes are less than optimal Gaps in service Underuse of diagnostic pulmonary function testing and overuse during an acute exacerbation Wide variation in treatment Underutilization of maintenance therapy Lack of patient education Lack of outpatient follow-up and chronic disease management Lack of patient resources/advocates Overall, hospital readmissions are largely preventable IT S THE RIGHT THING TO DO If that doesn t motivate us to do more for this patient population, maybe this will 2012 Affordable Care Act requires CMS to reduce payments for hospitals with excessive readmissions (Hospital Readmissions Reductions Program) First dx were AMI, CHF, and PNA Readmissions within 30 days of D/C to ANY hospital for all cause readmission (ANYTHING) 2015 CMS included COPD exacerbations Penalty up to 3% of all Medicare payments ($163,000 per hospital) $428 million in penalties across the nation 2

3 Where do we start? PREVENTION Types of Prevention American College of Chest Physicians and Canadian Thoracic Society: Guidelines for Preventing AE COPD Non-pharmacologic Inhaled therapies Oral therapies Non-Pharmacologic Vaccinations NIV (White et al., 2015) Appropriate treatment of psychological disorders (Singh et al., 2016) Smoking Cessation Pulmonary Rehab Patient Education Case Management Telemonitoring Transitional Care (Kangovi et al., 2014) 3

4 Smoking Cessation Only evidence-based intervention that improves COPD prognosis Effective strategies include behavioral, physiologic, and psychologic components Acknowledgment of current smoking Advise to quit Pharmacologic therapies (NRT, antidepressants, nicotine receptor modifier therapy) Counseling (in person or telephone) The sooner, the better Pulmonary Rehab Recommended: Patients w/ moderate, severe, or very severe COPD who have had a recent hospitalization (less than 4 weeks) Not Pulmonary rehab for prevention of readmission in patients who have been discharged for greater than 4 weeks Improves quality of life, exercise tolerance, and dyspnea Education, Case Management, & Telemonitoring Recommended: Education and Case Management with follow-up at least monthly Education with action plan and case management Not Education alone Case management alone Education with action plan but without case management Telemonitoring (compared to usual care does not prevent AE COPD) 4

5 Inhaled Medication Therapy Terminology Moderate Exacerbation = oral steroids, abx, or both Severe Exacerbation = requires hospitalization SABA = Short-acting ß 2 agonist LABA = Long-acting ß 2 agonist SAMA = Short-acting muscarinic antagonist LAMA = Long-acting muscarinic antagonist ICS = Inhaled Corticosteroid Inhaled Medication Therapy Recommended: LABA vs. Placebo LAMA vs. Placebo, LABA, or SAMA ICS/LABA combo vs. placebo, LABA alone, or ICS alone LABA/LAMA combo, or ICS/LABA combo, or LAMA alone SAMA/SABA vs. SABA alone SAMA/LABA vs. LABA alone SAMA vs. SABA LABA vs. SAMA LAMA/ICS/LABA vs. placebo Oral Medication Therapy Long-term macrolides (1 or more moderate/severe exacerbations in the year despite optimal maintenance inhaler tx; prolong QT) Systemic corticosteroids in first 30 days after subsequent exacerbation Phosphodiesterase 4 inhibitors for chronic bronchitis with at least one exacerbation in previous year (i.e. daliresp); weight loss and diarrhea Theophylline slow release BID; requires monitoring; need to know if patient stops smoking while taking theophylline NAC 2 or more exacerbation in previous year; antioxidant, anti-inflammatory, and mucolytic 5

6 Long-term systemic corticosteroid use (beyond 30 days) to prevent AE COPD Statins We need to work together to break this cycle. QUESTIONS? References Criner, Gerard J. et al. Executive Summary: Prevention of Acute Exacerbation of Copd: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest (2015): Silverchair. Web. 26 Aug Kangovi, S., & Grande, D. (2014). Transitional care management reimbursement to reduce COPD readmission. Chest, 145(1), doi: /chest Shah,Tina et al. Understanding Why Patients With COPD Get Readmitted : A Large National Study to Delineate the Medicare Population for the Readmissions Penalty Expansion: American College of Chest Physicians Chest.147 (2015) 5. Singh, G., Zhang, W., Kuo, Y., & Sharma, G. (2016). Association of Psychological Disorders With 30-Day Readmission Rates in Patients With COPD. Chest, 149(4), doi: /chest White, D. P., Criner, G. J., Dreher, M., Hart, N., Peyerl, F. W., Wolfe, L. F., & Chin, S. A. (2015). The role of noninvasive ventilation in the management and mitigation of exacerbations and hospital admissions/readmissions for the patient with moderate to severe COPD (multimedia activity). Chest, 147(6), doi: /chest