Asthma  COPD  Coali�on:  Improving  Inpa�ent  and  

Outpa�ent  Treatment  of  COPD:  What  Local  Coali�ons  Can  Do?  

Sidney  S.  Braman  MD  FCCP  Professor  of  Medicine  

Mount  Sinai  School  of  Medicine  New  York,  NY  

 

Faculty  Disclosure  The  ACCP  remains  strongly  commi�ed  to  providing  the  best  available  evidence-­‐based  clinical  informa�on  to  par�cipants  of  this  educa�onal  ac�vity  and  requires  an  open  disclosure  of  any  poten�al  conflict  of  interest  iden�fied  by  our  faculty  members.  It  is  not  the  intent  of  the  ACCP  to  eliminate  all  situa�ons  of  poten�al  conflict  of  interest,  but  rather  to  enable  those  who  are  working  with  the  ACCP  to  recognize  situa�ons  that  may  be  subject  to  ques�on  by  others.  All  disclosed  conflicts  of  interest  are  reviewed  by  the  educa�onal  ac�vity  course  director/chair,  the  Con�nuing  Educa�on  Commi�ee,  or  the  Conflict  of  Interest  Review  Commi�ee  to  ensure  that  such  situa�ons  are  properly  evaluated  and,  if  necessary,  resolved.  The  ACCP  educa�onal  standards  pertaining  to  conflict  of  interest  are  intended  to  maintain  the  professional  autonomy  of  the  clinical  experts  inherent  in  promo�ng  a  balanced  presenta�on  of  science.  Through  our  review  process,  all  ACCP  CME  ac�vi�es  are  ensured  of  independent,  objec�ve,  scien�fically  balanced  presenta�ons  of  informa�on.  Disclosure  of  any  or  no  rela�onships  will  be  made  available  on-­‐site  during  all  educa�onal  ac�vi�es.    Sidney  S.  Braman,  MD,  FCCP  Consultant  fee,  speaker  bureau,  advisory  commi�ee,  etc.:  Genentech,  GlaxoSmithKline,  Novar�s,  Sunovion.  

Objec�ves  

  Recogni�on  of  the  COPD  Pa�ent    Improvements  In  Care  for  COPD    Impediments  to  Op�mal  Care  for  COPD    What  Can  COPD  Coali�ons  do  to  improve  outcomes?  

Recogni�on  of  the  COPD    

Under  Diagnosis  of  COPD  in  the  United  States  

70% <Age 65

30% ≥Age 65

1. Pleis et al. Vital Health Stat. 2006;132: 1-153. 2. Mannino et al. MMWR Surveill Summ. 2002;51:1-16. 3. Mannino et al. Proc Am Thorac Soc 2007;4:502-306.

  Over 12.7 million people in the United States have been diagnosed with COPD1

  Data from NHANES III indicate that approximately 24 million United States adults have evidence of impaired lung function indicative of COPD2,3

  Most (70%) of patients with undiagnosed COPD are <65 years of age

Percent with Undiagnosed COPD

COPD  Is  a  Major  Public  Health  Problem  

  15  million  office  visits  each  year  due  to  COPD  

  721,000  hospitaliza�ons  each  year  for  COPD  

–  21%  mortality  rate  at  one  year  a�er  being  hospitalized  for  an  exacerba�on  

  COPD  is  currently  the  4th-­‐leading  cause  of  death  in  the  United  States  

  On  average,  more  people  die  every  day  from  COPD  than  diabetes  or  breast  cancer  

–  357  per  day  from  COPD  –  208  per  day  from  diabetes  –  114  per  day  from  breast  cancer  

COPD  is  a  disease  that  develops  over  decades:  

Many  teen-­‐agers  have  cigare�e    addic�on  before  their  18th  birthday  

COPD  is  a  disease  that  develops  over  decades:  

The  disease  remains  silent  in  mid-­‐life  

COPD  

COPD  is  a  disease  that  develops  over  decades:  

The  disease  remains  silent  in  mid-­‐life  

COPD  

COPD  is  a  disease  that  develops  over  decades:  

COPD  

Symptoms  o�en  ignored:  ““I  am  just  ge�ng  older””    Lung  func�on  tes�ng  underu�lized  

COPD  

COPD  is  a  disease  that  develops  over  decades:  

The  disease  is  finally  recognized  at  an  advanced  age  

COPD  

COPD  

COPD  

How  can  we  improve  care  for  COPD?    

Evidence-­‐based  Measures  That  Improve  COPD  Outcomes  

  Reduce  risk  factors    Immuniza�ons    Medica�ons    Pulmonary  rehabilita�on    Supplemental  oxygen    Integrated  pa�ent  educa�on  programs  

Do  These  Measures    Work?  

Higher  Adherence  to  Therapy  Lowers  Risk    for  Hospitaliza�on  in  COPD  

0.88

1.13

0.0

0.2

0.4

0.6

0.8

1.0

1.2

≥80% <80%

Adapted from Simoni-Wastila, et al. Am J Geriatr Pharmacother. 2012;10:201-210.

Rate  of  Hospitalisa�on  

(per  pa�ent  year)  

Percent  of  Days  Covered  with  Prescribed  Medica�on  

P<0.05*  

*  based  on  95%  CI  for  rela�ve  risk  

0

5

10

15

20

25

30

0 12 24 36 48 60 72 84 96 108 120 132 144 156

Pro

bab

ility

of

Dea

th (

%)

Time to Death (weeks)

≤80

>80

P<0.001  

Number  at  Risk    ≤80%      1232                            1121                                          1018                                                              894  >80%      4880                          4798                                          4633                                                          4299  

26.4%  

11.3%  

Higher  Adherence  to  Therapy  Is  Associated  with  Decreased  Mortality  in  COPD  

Vestbo J. et al Thorax. 2009;64:939-943.

Good  adherence  was  associated  with  a  60%  mortality  risk  reduc�on  independent  of  study  therapy  

Reducing  Risk  Factors  for  COPD  Reduces  Exacerba�ons4  

.  

Underu�liza�on  of  Long  term  Oxygen  Therapy  is  Associated  with  Higher  Risk  of  Hospitaliza�on23  

  In  a  mul�variate  model  the  following  cause  higher  hospitaliza�on  rates:  

 v             Three  or  more  COPD  admissions  in  the                previous  year,  (OR  6.21  P=0.008)    

v         Underprescrip�on  of  long  term  oxygen            (OR  22.64)  P=0.007  

Pulmonary  Rehabilita�on  Reduces  Risk  of  Unplanned  Admission  

Overall (47/46)

Risk ratio (95% CI)

0.17 (0.04 to 0.69)

0.40 (0.09 to 1.70)

1.5

Risk of unplanned hospital admission

.5 1 .25

Favors usual care Favors rehabilitation

.75

Study (in rehabilitation/ usual care group)

Man (20/21)

Murphy (13/13)

Length of follow-up

3 months

6 months

Weight in %

44%

19%

0.29 (0.10 to 0.82) Behnke (14/12) 18 months 37%

0.26 (0.12 to 0.54) Chi-Squared 0.70, p=0.71

Following  Hospitaliza�on  for  an  Acute  Exacerba�on,  Walking  Time  Is  Reduced  

AE=acute exacerbation. Data are shown as box plots with the lower portion (dark blue) representing the 25% percentile, the center line reflecting the median, and the upper portion (light blue) representing the 75% percentile.

P<.01

P<.05

Mean in stable COPD

Wal

kin

g t

ime

(min

)

1 month after discharge

Day 7 AE Day 2 AE

25

0

50

75

100

125

150

175

N=17    

Relative Risk (95% CI)

COPD hospitalization

All-cause mortality

COPD hospitalization

All-cause mortality

Pneumococcal vaccination

Pneumococcal + influenza vaccination

0   0.2   0.4   0.6   0.8   1   1.2   1.4   1.6   1.8   2.0  

Pneumococcal  and  Influenza  Vaccina�ons    Reduce  COPD  Exacerba�ons  

 

Pa�ent  Educa�on  in  COPD  Reduces  Exacerba�ons  

-39.8

-57.1

-41

-58.9

-70

-60

-50

-40

-30

-20

-10

0

Red

uctio

n ve

rsus

Con

trol

(%)

.    

Hospital Admissions for Exacerbations

Hospital Admissions for Other Reasons

Emergency Department Visits

Unscheduled Physician Visits

Bourbeau    et  al.  Arch  Intern  Med.  2003;163:585-­‐591    

COPD  Exacerba�ons  Result  in  Hospitaliza�ons  

 In  US,  1.5  MM  Emergency  Department  visits    due  to  COPD  exacerba�ons  annually  

Emergency�Department�

Discharge�

Admission�

Medical Ward�

Intensive Care �

Discharge�

Patient returns to or makes

progress toward baseline in ED�

35%�

65%�90%�

10%�Admit based on clinical signs, patientʼs subjective needs, and assessment of home environment�

Mannino DM. Respir Care 2003;48:1185–91.�Based on market research data of healthcare providers within hospital settings, including ED, hospitalists, pulmonology (n=70).�

COPD  Exacerba�ons  Lead  to  Poor  Pa�ent  Outcomes  

.    

Pa�ents  with  Frequent  Exacerba�ons  

Higher  Mortality  

Faster  Decline  in  Lung  Func�on  

Poorer  Quality  of  Life  

Weight  loss  and    

decondi�oning  

Total estimated direct costs of COPD in the US� are $29.5 Billion1�

Direct  Costs  for  COPD  

68.5%

21.8%

7.9%

1.8%

Hospital admissions

Outpatient visits

Prescribed drugs

Emergency room visits

25�

Direct medical expenditures in COPD patients2�

The costs that are presented here are not exclusively related to COPD exacerbations�

1.  National Heart, Lung, and Blood Institute. National Institutes of Health. Morbidity and Mortality: 2009 Chartbook on Cardiovascular, Lung and Blood Diseases. www.nhlbi.nih.gov/resources/docs/2009_Chartbook.pdf. Accessed October 13, 2011�

2.  Strassels SA et al. CHEST. 2001;119:344-52.�

CMS  Readmissions  Reduc�on  Program  

  Readmission  occurs  when  a  pa�ent  is  discharged  from  a  hospital  and  then  readmi�ed  to  the  same  hospital  or  another  hospital  within  a  �me  period  specified  by  the  Secretary  of  Health  and  Human  Services  (HHS).    

   In  2012,  CMS  will  reduce  Medicare  payments  to  hospitals  with  excessive  readmissions  of  pa�ents  admi�ed  for  heart  a�ack,  heart  failure,  or  pneumonia.  

   In  2013,  the  list  will  expand  to  include  COPD,  bypass  surgery,  and  other  heart  and  vascular  procedures    

  The  reduc�on  in  payments  will  begin  in  2013    

30-­‐Day  Readmission  Rates  Among  COPD  Pa�ents  in  15  States  

Percentage of Index Admissions Followed by a Readmission�

COPD is Principle Diagnosis� COPD is Any Diagnosis� All-Cause Readmissions�

Total� 7.1% � 17.3% � 20.5% �40-64 years of age� 7.8% � 16.2% � 19.8% �

≥65 years of age� 6.8% � 17.9% � 20.8% �

Male� 7.6% � 18.6% � 21.6% �

Female� 6.7% � 16.3% � 19.6% �

Race/ethnicity (data from 12 states that provide information on patientʼs race)�

White� 7.2% � 17.8% � 20.5% �

Black� 8.0% � 17.6% � 23.1% �

Hispanic� 6.1% � 15.1% � 20.4% �

� 6.1% � 15.2% � 19.1% �

Median household income�

1st quartile (lowest income)� 7.8% � 17.9% � 21.5% �

2nd quartile� 7.1% � 17.1% � 20.2% �

3rd quartile� 6.6% � 16.8% � 19.6% �

4th quartile (highest income)� 6.4% � 17.1% � 20.2% �

Elixhauser A, et al. Healthcare Cost and Utilization Project (HCUP) Statistical Brief #121. Rockville (MD): Agency for Health Care Policy and Research (US). 2011. �

Barriers  to  Improved  Care  for  COPD  

Barriers  to  Improved  Care  for  COPD  

  Failure  to  communicate  to  pa�ent  need  for  medical  treatment    

  Poor  pa�ent  self-­‐management  skills      Inadequate  follow-­‐up  in  the  post-­‐discharge  se�ng      Community  infrastructure  and  awareness  problems      Insufficient  pa�ent  support,  including  support  from  family  caregivers  

  Medica�on  discrepancies  that  occur  during  an  ini�al  admission  or  following  a  discharge  and  which  may  result  in  illness  or  harm  to  a  pa�ent.    

Persistence  with  Inhaled  Medica�ons  Declines  to  About  50%  within  6  Months  of  Ini�a�on  

Penning-van Beest F, et al. Respir Med. 2011;105:259-265.

0.0  

0.2  

0.4  

0.6  

0.8  

1.0  

0.0   0.5   1.0   1.5   2.0   2.5   3.0  

Propor�o

n  of  Persistent  U

sers  

Time  Since  Start  (Years)  

LABA  

LABA-­‐ICS  EDC  

LAMA  

Persistence  with  any  inhaler  was  36%,  23%,  and  17%  at  years  1,  2,  and  3,  respec�vely  

The  Most  Common  Reason  for  Nonadherence  in  COPD  Pa�ents  Is  Lack  of  Symptoms  

Restrepo  RD,  et  al.  Int  J  Chron  Obstruct  Pulmon  Dis.  2008;3(3):371-­‐384.    

Common  causes  of  poor  adherence.  Gold  bars  indicate  the  top  three  reasons.    

0 5 10 15 20 25 Percent Reporting

Family  problems  interfered  

Insufficient  funds  to  purchase  medica�ons  

Confused  over  schedule  and  decided  not  to  dose  

Socially  inconvenient  

Believed  medica�on  was  not  effec�ve  or  did  not  …  

Believed  immune  to  medica�on:  decided  not  to  dose  

Ran  out  of  medicine  

Side  effects  

Change  in  normal  rou�ne:  unexpected  

Change  in  normal  rou�ne:  planned  

Interrupted  prior  to  doing  and  forgot  

Absorbed  in  ac�vity  and  forgot  

Felt  good  and  forgot  to  dose  

Felt  good  and  decided  not  to  dose  

Pa�ent-­‐related  Factors:  Belief  in  Treatment  Efficacy  Is  Associated  with  

Higher  Adherence  

Khdour  MR,  et  al.  Eur  J  Clin  Pharmacol.  2012  April  5.  [Epub  ahead  of  print].  

0%  

10%  

20%  

30%  

40%  

50%  

60%  

70%  

80%  

Totally  or  most  effec�ve   Li�le  or  not  effec�ve  

Percentage  of  Respondents  

High  adherence  Low  adherence  

N=173  

Improving  Care  for  COPD    Pa�ents  An  Integrated  Goal-­‐directed  Program  

1.  Develop  COPD  registry  of  all  pa�ents  admi�ed  with  acute  exacerba�on  

2.  Pa�ents  will  be  iden�fied  by  Respiratory  Care  Department  when  called  for  treatments  

3.  At  discharge,  pa�ents  are  referred  to  follow  up  with  mul�disciplinary  hospital  COPD  Care  Team  (physician,  therapist,  case  manager?)  

4.  This  single  visit  will  take  place  approximately  one  week  post  discharge  

5.  Follow  up  phone  calls  will  be  done  a�er  visit  by  COPD  Care  Team  

Improving  Care  for  COPD    An  Integrated  Goal-­‐directed  Program  

During  visit  COPD  Care  Team  will:  –  Confirm  diagnosis  and  staging  with  spirometry  –  Establish  goals  and  review  care  plan  for  recovery  period  –  Confirm  smoking  cessa�on  efforts/avoidance  of  risk  factors  

–  Confirm  immuniza�on  (influenza/pneumovax)  –  Review  medica�on  list  and  pa�ent  adherence  –  Teach  proper  technique  with  inhaled  medica�ons  –  Teach  proper  breathing  and  cough  techniques  –  Assure  adherence  to  oxygen  prescrip�on  –  Assess  eligibility  for  pulmonary  rehabilita�on  

Improving  Care  for  COPD    An  Integrated  Goal-­‐directed  Program  

During  visit  COPD  Care  Team  will:  –  Assess  for  uncontrolled  co-­‐morbidi�es  including:  

  Depression  (administer  depression  scale)    Obstruc�ve  sleep  apnea  (Epworth  sleep  assessment)    Osteoporosis  (assure  recent  bone  density  test)  

–  Review  ac�on  plans  for  next  exacerba�on  and  for  stress  –  Discuss  appropriate  advanced  direc�ves  –  Confirm  next  appointment  with  primary  care  prac��oner  or  specialist  and  communicate  with  this  personal  physician  

–  Send  le�er  to  personal  care  provider  with  sugges�ons  for  ongoing  care  

Adapted  from  Jarab  AS,  et  al  Int  J  Clin  Pharm.  2012;34:53-­‐62.  

0  10  20  30  40  50  60  70  80  90  100  

Medica�on  Adherence   Medica�on  Beliefs   Hospital  Admissions  

Interven�on  

Control  

%  of  Pa�ents  

P=0.031  

P=0.008  

P=0.0.017  

N=133  

Pharmacist-­‐Led  COPD  Self-­‐Management  Program:  Increased  Belief  in  Treatment,  Be�er  Adherence,  and  Fewer  Hospitaliza�ons    

What  Can  COPD  Coali�ons  do  to  improve  outcomes?  

What  Can  COPD  Coali�ons  do  to  improve  outcomes?  

   To  increase  COPD  awareness  and  educa�on  by  connec�ng  individuals  with  tools  and  resources  that  will  improve  their  quality  of  life.    To  impact  state  and  local  government,  employer  and  insurer  policies  related  to  COPD    Improve  and  expand  COPD  surveillance  and  data  collec�on  and  research