Reducing COPD Exacerbation Readmissions in a Community-Based

Teaching Hospital

Dawn Waddell, PharmD, BCPS Clinical Pharmacy Manager

Lisa Kingdon, PharmD, BCPS Clinical Pharmacy Specialist

Dawn Waddell Baptist Dawn WaddellMemorial

Hospital - Memphis No Conflicts of Interest

Chronic Obstructive Pulmonary Disease (COPD)

30-day readmission rate remains at 20%

across the country

3rd leading cause of death in the US

Affects close to 30

million Americans

Respir Med 2017;131:6-10.

Objective

• Devise a multi-faceted, multi-disciplinary approach to reduce COPD readmissions

– Current 30-day readmission rate: 25-30%

• Average length of stay on readmission: ~9 days

Inpatient COPD

Exacerbation Management

Smoking Cessation

Counseling

Disease State Education

Inhaler Technique Education

Improve Access to

Outpatient Inhalers

Inpatient COPD Exacerbation Care

• Conducted a MUE to evaluate current inpatient prescribing patterns:

Average length of steroid therapy:

3.9 days

Average amount received:

435 mg prednisone equivalents

45% IV Steroids 21% PO Steroids 15% both IV & PO

Average amount of prednisone

equivalents/day:

109 mg/day

Inpatient COPD Exacerbation Care

• Conducted a MUE to evaluate current inpatient prescribing patterns:

Average length of steroid therapy:

3.9 days

Average amount received:

435 mg prednisone equivalents

45% IV Steroids 21% PO Steroids 15% both IV & PO

Average amount of prednisone

equivalents/day:

109 mg/day

Guideline recommendation: Prednisone 40 mg PO daily x 5 days

Outpatient COPD Management

32% of patients discharged with

systemic steroids

Average length of steroid treatment:

12 days

Average amount:

25 mg of prednisone equivalents per day

14% of patients were discharged on

guideline-recommended inhalers

15% of patients filled inhalers prescribed at

discharge

New Inpatient Protocol

Steroids: Old Protocol

o Methylprednisolone 40 mg IV q8h

o Prednisone 40 mg PO daily

Steroids: New Protocol

o Prednisone 40 mg PO daily for 5 days

o Methylprednisolone 40 mg IV q8h for 72 hours then Prednisone 40 mg PO daily – Consider for patients who are

mechanically ventilated, critically ill, or receive systemic corticosteroids as an outpatient

Smoking Cessation Counseling

• Consults were being placed, but there was not any follow through

• Respiratory therapy (RT) designed a new workflow to incorporate counseling and documentation into the flowsheet

• Both physicians and pharmacists are able to place a “RT Smoking” consult

Disease State Education

• Non-adherence to inhaled and oral medications in COPD patients reported to be 41.3-57%

• Effective Interventions

– Brief counseling

– Monitoring & feedback about inhaler use

– Self-management of symptoms

• Cochrane Review evaluation of Action plans

– For every 19 provided action plans, one person would avoid a hospital stay for an exacerbation

Respiratory Research. 2013;14(109): 1-8. Cochrane Database of Systematic Reviews. 2016;12: CD005074.

Inhaler Technique Training

• One page education sheets created – www.use-inhalers.com

• Placebo inhalers obtained from drug representatives

• Education completed by the pharmacist with an observed teach back using the placebo inhaler

Barriers to Outpatient Inhalers

Obstacle (n=32) N (%)

No COPD discharge medications 5 (19%)

Did not pick up medications 11 (41%)

Expensive copay 7 (26%)

Prior authorization needed 5 (19%)

Prior authorization not completed 4 (15%)

14% of patients were discharged on

guideline-recommended inhalers

15% of patients filled inhalers prescribed at

discharge

Insurance Information

• Medicare/Medicaid

– Eligible only for free 30 day coupon card

– Unique formularies for each plan

• Commercial Insurance

– Eligible for all coupon cards

• No insurance

– Manufacturer assistance

91%

3%

6%

n=33

Medicare/Medicaid

Commercial

No insurance

“Equivalence” of Long Acting Inhalers

• Extensive literature search and critical evaluation of meta-analyses for LABA, LAMA, LABA/LAMA, and LABA/ICS inhalers

– Similar rates of exacerbation between all LABA inhalers

– Minimal variation found within LAMA inhalers

– No difference found within LABA/LAMA inhalers

– No difference found within LABA/ICS inhalers

Int J Chron Obstruct Pulmon Dis. 2017;12:367-381. Int J Chron Obstruct Pulmon Dis. 2015;10:2495-517. Int J Chron Obstruct Pulmon Dis. 2015;10:1863-81. Int J Chron Obstruct Pulmon Dis. 2014;9:469-79.

P&T Approval

• Proposal: Pharmacists can complete an automatic inhaler switch within same medication class to patient’s outpatient insurance formulary

Approved!

Identification of Patients

• Daily list of admitted patients

– Includes ~100 patients with COPD on problem list

– Ideal for intervening on readmitted patients

• Goal: identify patients on principal admission

– Collaboration with clinical documentation improvement (CDI) nurses who place a working DRG and ICD-10 code for all Medicare inpatients

– Request to Epic Build Team to allow this field to be viewed by pharmacists and physicians

ICD-10 CM Codes for COPD

Code Description

J42 Unspecified chronic bronchitis

J43.0-9 Emphysema

J44.0-9 Chronic obstructive pulmonary disease exacerbation

Codes included in cohort if combined with secondary diagnosis of J44

J96.0-92 Acute respiratory failure

R09.2 Respiratory arrest

Reviewing patients by their ICD-10 CM codes decreased the 100 patients/day to a more accurate 15-20 patients/month with a

true COPD exacerbation.

Review of Patients on Principal Admission

Process of Interventions

Patient Identification by

Working DRG

• Daily evaluation by a pharmacist

Patient evaluation

• Medication history

• Disease state education

• RT consult for smoking cessation

Ensure fill of outpatient inhalers

or change to formulary product

• Inhaler education with placebo

• Medication in hand prior to discharge

Full Interventions Beginning Mar 2018

16.8%

25.0%

8.6%

21.9%

15.4%

12.1%

27.6%

14.6% 18.9% 19.0% 18.5%

13.8%

13.6%

0%

5%

10%

15%

20%

25%

30%

JUN2017

JUL2017

AUG2017

SEP2017

OCT2017

NOV2017

DEC2017

JAN2018

FEB2018

MAR2018

APR2018

MAY2018

COPD ObservedReadmission Rate

Readmission Rate

Future Plans

• Continuation of interventions for patients admitted with COPD exacerbation

• Addition of a 48-72 hour phone call to ensure understanding of inhalers, receipt of inhalers, and use of action plan for symptoms