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