20170319165801-20170315085955-20170221133318...
Transcript of 20170319165801-20170315085955-20170221133318...
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Beyond the Norm: Reviewing Complex Cases
of COPDEmily Pherson, PharmD., BCPS
Clinical Pharmacy Specialist – Internal MedicineThe Johns Hopkins Hospital
Baltimore, MD
Michael J. Cawley, PharmD., RRT, CPFT, FCCMProfessor of Clinical Pharmacy
Philadelphia College of PharmacyUniversity of the Sciences
Philadelphia, PA
DisclosuresMichael J. Cawley and Emily C. Pherson declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts,
stock holdings, and honoraria.
The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
• Target Audience: Pharmacists
• ACPE#: 0202-0000-17-100-L04-P
• Activity Type: Knowledge-based
Learning Objectives1. Develop an appropriate plan for the initiation,
titration, monitoring and altering of pharmacotherapy for COPD management
2. Discuss appropriate COPD management strategies in patients during transition of care
3. Describe examples of pharmacists’ activities that have been found to reduce hospital readmission rates for patients with COPD
1. When determining appropriate drug therapy for COPD which elements must be included in the assessment?
A. Exacerbation history B. Spirometry C. Symptoms and exacerbation history D. Symptoms, spirometry and exacerbation history
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2. What is the recommend first line treatment for a patient who is categorized as GOLD Group C?
A. Long-acting muscarinic antagonist (LAMA)B. Long-acting beta agonist (LABA) C. LAMA + LABAD. LABA + inhaled corticosteroid (ICS)
3. Which of the following is the MOST important pharmacist management strategy to reduce readmissions for COPD?
A. Making sure patients know the role of each medication
B. Assess the patients ability to understand the signs and symptoms of worsening of disease
C. Evaluate ability of patient to maintain medication adherence
D. All equally important
4. Which of the following metric(s) demonstrate the impact of outpatient pharmacist care in COPD?
A. Reduction of hospital admissionB. Decrease medication use C. Improve patient compliance with insurance copaysD. Recommend use of antibiotics in all patients
Assessment of COPD
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 10
• Current level of patient symptoms• Modified Medical Research Council Questionnaire (mMRC)
• Measure of breathlessness
Grade Patient’s description of breathlessness Grade 0 I only get breathless with strenuous exercise Grade 1 I get short of breath when hurrying on the level or walking
up a slight hillGrade 2 I walk slower than people of the same age on the level
because of breathlessness or have to stop for breath when walking at my own pace on the level
Grade 3 I stop for breath after walking about 100 yards or after a few minutes on the level
Grade 4 I am too breathless to leave the house or I am breathless when dressing
Assessment of COPD• COPD Assessment Test (CAT)
• 8 item measure of health status impairment in COPD• Frequency of cough• Presence of mucus in chest • Chest tightness • Breathlessness when walking on an incline• Limitation in activities at home• Confidence in leaving home • Sleep satisfaction • Energy level
• COPD Control Questionnaire (CCQ)• 10 item self-administered questionnaire
112017 Global Initiative for Chronic Obstructive Lung Disease, Inc.
Assessment of COPD
• Severity of the spirometric abnormality • FEV1/FVC < 0.70: diagnostic of COPD
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Gold 1: Mild FEV1 > 80% predicted
Gold 2: Moderate 50% < FEV1 < 80% predicted
Gold 3: Severe 30% < FEV1 < 50% predicted
Gold 4: Very severe FEV1 < 30% predicted
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc.
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Assessment of COPD
• Exacerbation risk• Best predictor of having frequent exacerbations (2 or more per
year) is a history of previous treated events
132017 Global Initiative for Chronic Obstructive Lung Disease, Inc.
Refined assessment tool
2016 Global Initiative for Chronic Obstructive Lung Disease, Inc. 2017 Global Initiative for Chronic Obstructive Lung Disease, Inc.
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2011 – 2016 2017Classification of airflow limitation
Present Removed
mMRC/CAT Present PresentExacerbation history Higher risk: > 2
Lower risk: 0 or 1 Higher risk: > 2 or > 1 leading to hospitalization
Lower risk: 0 or 1 not leading to hospitalization
Patient Case #1
VF is a 55 y/o male with a PMH significant for CAD (s/p PCI w/ placement of 2 DES in October 2014), hypothyroidism and COPD (FEV1 50% May 2016). He presents to the emergency room with malaise, shortness of breath, and cough. He is admitted for treatment of a COPD exacerbation.
• Prior to admission medications: clopidogrel 75 mg PO daily, ASA 81 mg PO daily, levothyroxine 50 mcg PO every morning, tiotropium 1 capsule inhaled once daily, albuterol MDI 2 puffs q4‐6h PRN, azithromycin 250 mg PO daily (initiated June 2016)
• Social history: has been smoke‐free since October 2014, drinks alcohol socially, works in the warehouse at the amazon distribution center
Pharmacist’s Patient Care Process
• Collect
• Assess
• Plan
• Implement
• Follow-up: Monitor and Evaluate
https://www.pharmacist.com/sites/default/files/files/PatientCareProcess.pdf
Patient Case #1
• Question 1: • What workup needs to be done to properly assess VF’s COPD?
• Question 2: • What group (number) and grade (letter) score would you give VF?
Question 1
• What workup needs to be done to properly assess VF’s COPD?
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Question 1
• PFTs• FEV1 50% May 2016
• mMRC/CAT• CAT = 12
• History of exacerbations • Hospitalized once in June 2016, no clinic visits with exacerbations
Question 2
• What group (number) and grade (letter) score would you give VF?
Question 2
Grade = 2 Group = D
1 Mild FEV1 > 80% predicted
2 Moderate 50% < FEV1 < 80% predicted
3 Severe 30% < FEV1 < 50% predicted
4 Very severe FEV1 < 30% predicted
> 2 or > 1 leading to hospital admission
C D
0 or 1 (not leading to hospital admission)
A B
mMRC 0 – 1 CAT < 10
mMRC > 2CAT > 19
Symptoms
Exac
erba
tion
Hist
ory
Prevention of Exacerbations
Characteristic AzithromycinN = 558
PlaceboN = 559
Gold stage – %IIIIIIV
264034
264033
Medications for COPD - %Inhaled ICS + LABAsInhaled ICS + LABAs + LAMAs
1949
2246
Entry Criteria - %Exacerbation in past 12 months* Systemic steroids in past 12 monthsLong-term oxygen
508460
518559
N Engl J Med 2011;365:689-98. 22
*requiring ED visit or hospitalization
Prevention of Exacerbations
N Engl J Med 2011;365:689-98. 23
57% vs. 68%
Prevention of Exacerbation
N Engl J Med 2011;365:689-98. 24
Characteristic AzithromycinN = 558
PlaceboN = 559
P value
Audiogram-confirmed hearing decrement - %
25 20 0.04
Nasopharyngealcolonization - %
12 31 <0.001
Resistance to macrolides pre-study - %
52 57 0.64
Resistance to macrolidespost-study - %
81 41 <0.001
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Management of Stable COPD
Group A
A bronchodilator
Continue, stop or try alternative class of bronchodilator
Group B
LABA orLAMA
LAMA +LABA
LAMA orLABA
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 25Indicates preferred therapy
Management of Stable COPD
Group C
LAMA + LABA
LABA + ICS
LAMA
Group D
Considerroflumilast
Consider macrolide
LAMA + LABA + ICS
LAMA + LABA
LABA + ICS
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 26Indicates preferred therapy
Medications
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Timeline: Long-acting Beta2 Agonist
1994 SereventDiskus®
2001 Foradil
Aerolizer®
2006 Brovana®
2011 Arcapta
Neohaler®
2014 Striverdi
Respimat®
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Beta2-agonists Stimulation of
beta2 adrenergic receptors
Increase in cyclic AMP
Smooth muscle
relaxation
• Side effects:• Sinus tachycardia• Arrhythmias • Tremor
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 29
Products Generic Brand DosingLong-actingSalmeterol Serevent Diskus 1 inhalation
twice dailyFormoterol Foradil Aerolizer 1 capsule inhaled
twice dailyArformoterol Brovana 1 nebulization
twice dailyIndacaterol Arcapta Neohaler 1 capsule inhaled
once dailyOlodaterol Striverdi Respimat 2 inhalations
once daily
Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016. 30
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Differences • Efficacy:
• All: • No effect on mortality or rate of decline of lung
function• Improve FEV1, quality of life, exacerbation rate
• Salmeterol: reduces rate of hospitalization• Adverse events:
• Indacaterol: significant cough (24% of patients) • Frequency of dosing:
• Indacaterol/olodaterol: once daily • Cost:
• Formoterol/olodaterol: least expensive
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2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
Timeline:Long-acting muscarinic antagonists (LAMA)
2004 Spiriva
Handihaler
2012 TudorzaPressair
2013 IncruseEllipta
2015 Seebri
Neohaler
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LAMAs
Block muscarinic receptors on
airway smooth muscle
Prevent muscle contraction
• Side effects:• Dry mouth • Sinusitis • Worsening of urinary
retention
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 33
Products
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Generic Brand DosingLong-actingTiotropium Spiriva HandiHaler
Spiriva Respimat
1 capsule once daily
2 inhalations once daily
Aclidinium Tudorza Pressair 1 inhalation twice daily
Umeclidinium Incruse Ellipta 1 inhalation once daily
Glycopyrronium Seebri Neohaler 1 capsule inhaled twice daily
Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
Differences• Efficacy
• All: improvements in symptoms, HRQL• Tiotropium: reduction in exacerbations and hospitalizations (outcome data
not yet available for other agents)• Adverse events
• No significant differences• Frequency of dosing
• Tiotropium and umeclidinium offer daily dosing• Cost
• Aclidinium < umeclidinium < tiotropium/glycopyrronium
352017 Global Initiative for Chronic Obstructive Lung Disease, Inc.
Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
Short-acting bronchodilators
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Generic Brand DosingAlbuterol Ventolin HFA
ProAir HFA1-2 inhalations every 4-6 hours as needed
Ipratropium Atrovent HFA 1-2 inhalations every 6 hours
Albuterol + Ipratropium CombiventRespimat
1 inhalation 4 times daily
Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
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Timeline:Combination Products
2000 Advair Diskus
2006 Symbicort
2010 Dulera
2013 Breo
Ellipta
2013 AnoroEllipta
2015 Utibron
Neohaler
2015 Stiolto
Respimat
2016 Bevespi
Aerosphere
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Long acting Beta2 Agonist (LABA) + Inhaled Corticosteroid (ICS)
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Generic Brand DosingSalmeterol/fluticasone
Advair 1 inhalation twice daily
Formoterol/budesonide
Symbicort 2 inhalations twice daily
Formoterol/mometasone
Dulera 1 inhalation twice daily
Vilanterol/fluticasone
Breo Ellipta 1 inhalation once daily
Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
Inhaled Corticosteriods(only in combination with LABAs)
• Reduce airway hyperresponsiveness
• Inhibit inflammatory cell migration and activation
• Block late phase reaction to allergens
• ICS use alone in COPD does not modify long-term decline of FEV1
• Side effects:• Oral candidiasis • Increased URI• Decrease in bone density -
controversial
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 39
Differences• Efficacy
• ICS + LABA together more effective then individual components in improving lung function, health status and reducing exacerbation
• No comparative data • Adverse events
• No differences • Frequency of dosing
• Fluticasone furoate/vilanterol offers once daily dosing• Cost
• Fluticasone furoate/vilanterol << fluticasone/salmeterol /budesonide/formoterol/mometasone/formoterol
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2016 Global Initiative for Chronic Obstructive Lung Disease, Inc. Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
Long-acting muscarinic antagonist (LAMA) + Beta2 Agonist (LABA)
Generic Brand DosingIndacterol/glycopyrronium Utibron Neohaler 1 capsule inhaled
twice daily
Vilanterol/umeclidinium Anoro Ellipta 1 inhalation once daily
Vilanterol/umeclidinium Stiolto Respimat 2 inhalations once daily
Glycoplyrrolate/formoterol BevespiAerosphere
2 inhalations twice daily
41Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
Differences • Efficacy
• Recommended as initial therapy for Group D patients• LABA/LAMA combination was superior to a LABA/ICS combination in
preventing exacerbations • Group D patients are at a higher risk of developing pneumonia when using
ICS• Adverse events
• No differences • Frequency of dosing
• Vilanterol/umeclidinium and vilanterol/umeclidinium offer once daily dosing• Cost
• Similar to LABA/ICS
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc.
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Roflumilast
Mechanism Inhibits breakdown of cAMPDosing 500 mcg by mouth once daily
Efficacy Improves FEV1 and reduces exacerbations in patientstreated with long-acting bronchodilators
Side effects Nausea, reduced appetite (weight loss), abdominal pain, diarrhea, sleep disturbances, and headache
Place in therapy FEV1 <50% predicted and patient has chronicbronchitis in combination with long-acting bronchodilators
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2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.
Patient Case #2
VF is now on hospital day 2 and his nebs have been weaned back to q6h PRN. The team is now trying to decide what maintenance therapy should be initiated for VF.
• Assessment information:• FEV1: 50% (May 2016) • CAT: 12
Patient Case #2
• Question 1:• What inhaled therapy would you recommend for VF?
• Question 2:• Would you consider recommending any oral therapies for VF? If
so, what therapies would you recommend? • Question 3:
• What can the pharmacist do prior to discharge to make sure VF will have a successful transition with his medication regimen once he goes home?
Question 1 • What inhaled therapy would you recommend for VF?
Question 1 • Group D
Considerroflumilast
Consider macrolide
LAMA + LABA + ICS
LAMA + LABA
LABA + ICS
Question 2 • Would you consider recommending any oral therapies for VF? If so,
what therapies would you recommend?
• Prior to admission medications: • clopidogrel 75 mg PO daily• ASA 81 mg PO daily• levothyroxine 50 mcg PO every morning• tiotropium 1 capsule inhaled once daily • albuterol MDI 2 puffs q4-6h PRN• azithromycin 250 mg PO daily (initiated June 2016)
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Question 2
• Consider continuing azithromycin but re-evaluating therapy at one year
• He is not yet on maximum inhaled therapy (LAMA + LABA + ICS) therefore would not consider addition of roflumilast
Question 3• What can the pharmacist do prior to discharge to make sure VF will
have a successful transition with his medication regimen once he goes home?
Question 3
• Checking outpatient formulary • Inhaler technique teaching while inpatient • Consider post-discharge pharmacy follow-up options
Patient Case # 3• Thomas is a 51‐year‐old male who presents to your pharmacy for a refill of an albuterol inhaler and new prescription for aclidinium bromide inhaler. He is a patient that was just discharged from the hospital due to a COPD exacerbation
• Medical problems include COPD x 1 year, HTN x 12 years and deuteranopia (color blindness) since birth
• Smoker (30 pack year history)
• Occupational history as a construction laborer x 20 years
• His only other medication includes amlodipine 5 mg daily
Would Thomas end up as another hospital readmission statistic?
Hospital Readmissions…….• Kaiser Permanente reviewed 523 readmissions across ~ 14 hospitals
• 250 (47%) determined to be potentially preventable• Average of 9 factors contributed to each readmission• 250 readmissions identified 1,867 factors responsible for readmission
• Medication Management• 28% of potentially preventable readmissions• Medication management was a factor in more than a quarter of readmissions• Among 189 interviewed patients and caregivers
• 32% expressed the need for more communication about medications• 73% said “the lack of information was a factor in their readmission”
Feigenbaum P et al. Medical Care 2012;50:599‐605
Center for Medicare and Medicaid Services (CMS) Statistics
• Medicare expects hospital penalties to total $528 million in 2016, about $108 million more than 2015
• CMS will penalize 2,597 facilities in 2017, five more than last year
• 49 hospitals will receive the maximum reduction in reimbursement or 3% of the Medicare rate. Up from 38 hospitals last year
• The average reduction to hospitals was 0.73% for each Medicare payment, up from 0.61% last year
Becker’s Infection Control & Clinical Quality.http://www.beckershospitalreview.com/quality/cms‐penalizes‐2‐6k‐hospitals‐for‐high‐readmissions‐5‐statistics.html. Accessed November 12, 2016
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Cause of High COPD 30‐day Readmission Rates
• Exacerbations are not frequently resolved at the time of discharge
• Disjointed patient management occurs across the continuum of care
• Patient training is inadequate
• Lack of professional follow‐up care occurs post discharge
• Equipment in the home is inadequate
• Lack of an exacerbation Rapid Action Plan
http://www.nonin.com/copdwhitepaper. Accessed November 2016
COPD Patient 30‐day Hospital Readmission Reduction Program.
Pharmacist Issues for COPD Readmission
• Multiple medications on discharge
• Potential discrepancies between hospital and community records
• Lack of communication between hospital and care givers in the community
• Community pharmacists and primary care physicians are often unaware of the complete list of medications for discharged patients
Carter BL et al. Am J Health Sys Pharm 2008;65(17): 1631‐1642
Transition of Care Demographics
• Nationally 1 in 5 Medicare patients is readmitted within 30 days of discharge
• Patients 45‐64 of age report having 2 or 3 chronic medical conditions
• 33% of disabled Medicaid beneficiaries who have 3 or more chronic conditions account for almost 70% of total spending
• 30 day readmission rates for Medicaid beneficiaries range from 13% with single condition to 36% with ten or more conditions
• 60% of medication errors occur during transitions of care
• Cost of readmissions is estimated at $26 billion annually with $17 billion in preventable expenses
Jackson CT et al. Health Affairs 2013;32(8): 1407‐1415Forster AJ et al. Ann Intern Med 2003;138(3): 161‐167Hitch B et al. N C Med J 2016;77(2);87‐92.
Traditional Medical Care Model
Transition of Care: The ProblemCore Tenets of a Transitional Care Model
• Comprehensive medication management
• Face‐to‐face self‐management education for patients and families
• Timely outpatient follow‐up with a medical home that has been fully informed about the hospitalization and any clinical or social issues that complicates the patient’s care
Jackson CT et al. Health Affairs 2013;32(8):1407‐1415.
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Transition Planning
• Hospital discharge• Admission medication reconciliation• Prescription access
• Affordability (insurance, co‐pays, deductibles)• Insurance barriers (prior authorizations, early refills)• Transportation to pharmacy
Discharge Planning
•Discharge medication reconciliation
• Face‐to face discharge counseling• Follow‐up with phone call after discharge•Allows patient to demonstrate use of respiratory delivery device
•Discharge medication list provided to patient
Post‐Discharge Planning
•Appropriate follow‐up appointments•Primary care physician•Medical home•Primary care clinics
•Outpatient pharmacy medication reconciliation
Barriers to Pharmacists in Transition of Care
• Patient identification
• Patient no shows
• Information gathering
• Standardization of services
• Administrative support
• Reimbursement
• Time
• Perceptions
Melody KT et al. Integrated Pharm Research and Practice 2016:5;43‐51
Transition of Care: The Solution
1 Care System1 Medical Record
Patient Case # 3• Thomas is a 51-year-old male who presents to your pharmacy
for a refill of an albuterol inhaler and new prescription for aclidinium bromide inhaler. He is a patient that was just discharged from the hospital due to a COPD exacerbation
• Medical problems include COPD x 1 year, HTN x 12 years and deuteranopia (color blindness) since birth
• Smoker (30 pack year history)• Occupational history as a construction laborer x 20 years• His only other medication includes amlodipine 5 mg daily
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Patient Case #3Question #1
As the pharmacists, determine three questions you would ask Thomas about his hospital discharge….
Question #2
If a long‐acting anticholinergic agent was appropriate would the aclidinium bromide device inhaler be a wise choice?
Question #3
What other information from the hospital would help you make a better decision for respiratory delivery device selection?
Patient Case #3
Question #1
As the pharmacists, name three questions you would ask Thomas about his hospital discharge….
Patient Case #3
• Did you receive discharge medication counseling?• Were you told how much the aclidinium inhaler will cost?• Did you receive instruction on your inhaler devices?• Have you used other respiratory medications? What has/has not worked?
• Do you understand why you take your medications?• Did you receive smoking cessation counseling?• When did you receive your last influenza or pneumococcal vaccines?
• Is there a plan to follow‐up with your primary care physician?• Is there a plan if you experience an exacerbation event?
Patient Case #3
Question #2
If a long‐acting anticholinergic agent was appropriate would the aclidinium bromide device inhaler be a wise choice?
Patient Case #3
• Thomas has deuteranopia (color blindness) since birth• Would he be able to identify if the dose was inhaled
correctly?
Patient Case #3
Question #3
What other information from the hospital would help you make a better decision for COPD assessment and respiratory delivery
device selection?
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Assessment of COPDAssessment of Airflow Limitations
2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 73
Gold 1:
FEV1 > 80% predicted
Gold 2:
50% < FEV1 < 80% predicted
Gold 3:
30% < FEV1 < 50% predicted
Gold 4:
FEV1 < 30% predicted
Assessment of symptoms/risk of exacerbation
Patient Case #3 – Assessment of COPDPatient Group Recommended
First ChoicePersistent Symptoms
A • SAMA or SABA PRN
• LAMA or LABA
• Continue, stop or try alternative class of bronchodilator
B • LABA or LAMA • LAMA + LABA
C • LAMA • LAMA + LABA
• LABA + ICS
D • LABA + LAMA
• LABA + ICS
• LABA + LAMA + ICS
• LABA + LAMA + ICS + roflumilast
• LABA + LAMA + ICS + roflumilast + macrolide
Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/gold‐2017‐global‐strategy‐diagnosis‐management‐prevention‐copd/. Accessed December 2016
Patient Case # 4• Jennifer is a 44-year-old female who presents to your pharmacy
for new prescriptions for tiotropium and albuterol inhalers. Jennifer tells you she was discharged from the hospital 2 days ago for treatment of pneumonia. She believes only one of the prescription medications would be needed to get her feeling better.
• Medical problems include newly diagnosed COPD • Smoker (2 – 2.5 packs per day)• Jennifer is scared for her health since her mother died of COPD at
the age of 51. She feels the doctors do not take the time to talk to her since they are so busy and there is nobody that she can turn to for help.
Patient Case #4
Question #1
As the pharmacists, what are some questions you would ask Jennifer ….
Question #2
What are some recommendations to discuss with Jennifer to prevent hospital readmission?
Patient Case #4
Question #1
As the pharmacists, what are some questions you would ask Jennifer ….
Patient Case #4
• Do you want to quit smoking?
• Did you ever receive smoking cessation counseling?
• Where you ever prescribed medications to help you stop smoking?
• When did you receive your last influenza or pneumococcal vaccines?
• Is there a plan to follow‐up with your primary care physician?
• Is there a plan if you experience an exacerbation event?
• Have you used other respiratory medications? What has/has not worked?
• Do you understand why you take your medications?
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Patient Case #4
Question #2
What are some recommendations to discuss with Jennifer to prevent hospital readmission?
Patient Case #4
• Have patient come back to the pharmacy in a few days to address the following: (may require second visit)
• Smoking cessation strategies including pharmacological and support groups and implement a plan for initiation
• Review inhaler technique, medication use including compliance, timely refills and adverse effects
• Administer influenza vaccine and discuss pneumococcal vaccine
• Talk to your doctor about yearly spirometry tests
• Talk to your doctor about preventing exacerbation• Discuss a plan for COPD exacerbations with your doctor
Pharmacists Management Strategies to Reduce Readmission of COPD
• Make sure patients understand the role of each medication • Describing how and when to take each medication• Encourage smoking cessation if the patient is ready• Update necessary vaccines• Make sure patient can demonstrate use of inhaler devices
• Assess the patient’s ability to understand signs and symptoms of worsening of disease
• Evaluate ability of patient to maintain medication adherence• Insurance barriers• Refill reminders • Inhaler device use• Transportation considerations• Adverse effects
Pharmacists Role in Reducing Readmissions in COPD: The Evidence Does Exist
Objective: A systematic review of the impact of pharmacists care in outpatient COPD
Methods: PubMed, EMBASE, CINAHL, CBMDisc, Cochrane registry
Results: Fourteen studies were evaluated. Pharmacist care associated with reduction in hospital admission (6 studies – 684 patients); RR 0.50 (95% CI 0.39‐0.64).
Pharmacist care improved medication compliance (4 studies – 743 patients); RR 1.23 (95% CI 1.11 – 1.36) while reducing health related costs (3 studies – 318 patients)
No difference in ED visits, lung function or health‐related QOL
Zhong H et al. Int J Clin Pharm 2014;36:1230‐1240
Pharmacists Role in Reducing Readmissions in COPD: The Evidence Does Exist
Reference Population Intervention Results
Cur Med Res and Opin:2016:32;229‐239
20 community pharmacies encompassing 88 patients
Inhalation instructionMedication informationMotivational interviewingSmoking cessation, CCQ
After 1 yr mean CCQ decreased0.12 and 38% showed clinical improvement. ‐0.82 decrease in exacerbation
Ann of Pharmaco 2014;48:203‐208
29 patients 65 yrs and older admitted with COPD exacerbation
30 day readmission rate Length of stay Cost of admission
4 were readmitted within 30 days of discharge. 30 day readmission rate lower than baseline (16% vs 22.2%). Length of stay decreased and small increase in cost
Int J Pharm Prac 2015;23:83‐85 21 community pharmaciesscreened 238 patients
COPD assessment questionnaire and spirometry performed
135 patients identified with potential COPD. Smoking cessation provided a gain of 38.62 life yrs and cost savings of £392.67 per patient screened
Zhong H et al. Int J Clin Pharm 2014;36:1230‐1240
Pharmacists Role in Reducing Readmissions in COPD: The Evidence Does ExistReference Population Intervention Results
Int J Clin Pharm 2012:34:53‐62 133 patients randomizedassigned to intervention or control group
Education and management of COPD delivered to intervention group and followed for 6 months
66 patients ‐ COPD knowledge (p<0.001); medication adherence (p<0.05), hospital admission rates (p<0.05)
Br J Clin Pharmacol2009;68:588‐598
173 patients randomized into intervention and control group
Education on disease state, medications and breathing techniques and followed up at 6 and 12 months
86 patients – ED visits decreased by 50% (p=0.02) andhospitalization by 60% (p=0.01). Knowledge scores better in interventional group (75 vs 59.3; p=0.001) and medication adherence (77.8% vs 60%, p=0.019)
J Thor Dis 2014;6:656‐662 235 patients randomized into pharmaceutical care and usual group
Pharmaceutical care of individualized education and phone counseling for 6 months and 1 yr follow‐up
60 acute exacerbations in the usual group and 37 in pharmaceutical group at 1 yrfollow up (p=0.01). Hospital admissions in pharmaceutical group were 56% less than usual care group (p=0.01)
Zhong H et al. Int J Clin Pharm 2014;36:1230‐1240
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Collaboration in Action
• Community‐based Care Transition Program• Tests models for improving care transitions
from the hospital to other settings and
reducing readmissions for high‐risk Medicare
patients.
• 27 participating sites which will run for 5
years 2012‐2017
• WellTransitions (Walgreens)• Maryland, Florida and Indiana
Centers for Medicare & Medicaid Services. https://innovation.cms.gov/initiatives/CCTP/ . Accessed November 15, 2016WellTransitions. https://www.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions. Accessed November 12, 2016
COPD Monitoring Recommendations
• Periodic phone calls to assess adverse effects and compliance
• Inhaler technique for accuracy should be done face‐to‐face
• Smoking cessation monitoring
• Spirometry testing
• CAT or mMRC score to assess symptoms
• Monitoring of comorbidities
• Vaccine update (influenza and pneumococcal)
• Risk of exacerbations (role of antibiotics)
CAT – COPD Assessment Test; mMRC – Modified Medical Research Council
Key Points
• COPD is a chronic respiratory disease requiring a focus on preventing exacerbations and maintaining improved quality of life
• GOLD 2017 provides updates in terms of assessment and appropriate drug therapy
• Pharmacists have demonstrated success in transition of care models improving quality metrics
• Transitioning care of the COPD patient requires a unified single health system approach to optimize health care outcomes
• Pharmacists must continue to demonstrate their value in the prevention of COPD hospital readmissions in documenting outcomes
1. When determining appropriate drug therapy for COPD which elements must be included in the assessment?
A. Exacerbation history B. Spirometry C. Symptoms and exacerbation history D. Symptoms, spirometry and exacerbation history
2. What is the recommend first line treatment for a patient who is categorized as GOLD Group C?
A. Long-acting muscarinic antagonist (LAMA)B. Long-acting beta agonist (LABA) C. LAMA + LABAD. LABA + inhaled corticosteroid (ICS)
3. Which of the following is the MOST important pharmacist management strategy to reduce readmissions for COPD?
A. Making sure patients know the role of each medication
B. Assess the patients ability to understand the signs and symptoms of worsening of disease
C. Evaluate ability of patient to maintain medication adherence
D. All equally important
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4. Which of the following metric(s) demonstrate the impact of outpatient pharmacist care in COPD?
A. Reduction of hospital admissionB. Decrease medication use C. Improve patient compliance with insurance copaysD. Recommend use of antibiotics in all patients
References• Feigenbaum P et al. Medical Care 2012;50:599-605• Becker’s Infection Control & Clinical Quality.http://www.beckershospitalreview.com/quality/cms-penalizes-2-6k-hospitals-for-high-readmissions-5-statistics.html• COPD Patient 30-day Hospital Readmission Reduction Program. http://www.nonin.com/copdwhitepaper• Carter BL et al. Am J Health Sys Pharm 2008;65(17): 1631-1642• Jackson CT et al. Health Affairs 2013;32(8): 1407-1415• Forster AJ et al. Ann Intern Med 2003;138(3): 161-167• Hitch B et al. N C Med J 2016;77(2);87-92.• Melody KT et al. Integrated Pharm Research and Practice 2016:5;43-51• Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/gold-2017-
global-strategy-diagnosis-management-prevention-copd/• Zhong H et al. Int J Clin Pharm 2014;36:1230-1240• Centers for Medicare & Medicaid Services. https://innovation.cms.gov/initiatives/CCTP/• WellTransitions.https://www.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions• Albert R et al. N Engl J Med 2011;365:689-98.