Transcript COPD - Go for the Gold - Case Western Reserve University

COPD - Go for the Gold
Theresa Kearns, MBA, RN, NE-BC
Director, HHVI System Ambulatory
Cardiovascular Services
Michelle Block, Esq.
Assistant General Counsel
Christy A. Cox BSN, RN
Rodney J Folz, MD, PhD
Chief, Division of Pulmonary, Critical Care and Sleep Medicine
Visiting Professor, Medicine – CWRU School of Medicine
Quality Improvement Nurse
Institute for Healthcare Quality & Innovation
University Hospitals Case Medical Center
Vincent Fazio
Crystal Mosca, MD
Clinical Application Analyst II
Sharon Family Physicians
Ambulatory EMR Physician Lead
Rebecca Lovejoy
Marianne Vest, MA, RN, CTTS
Clinical Application Analyst II, EMR Ambulatory
Senior Clinical Nurse
Cardiovascular and Pulmonary Rehabilitation
Harrington Heart & Vascular Institute
Robin Rowell, MSN, RN, CNP
Todd Zeiger, MD
VP, UH Primary Care Institute
Vice President, Harrington Heart & Vascular Institute
Associate Chief Nursing Officer for Licensed
Independent Practitioners
Disclosures
• Speakers in this presentation have no
disclosures.
Objectives
•
Introduce new UH COPD CareGuide and template note in AEMR.
•
Review interpretation of spirometry results and flow volume curves
•
•
•
Tobacco use/cessation
•
•
•
•
Understand specific criteria for diagnosis and classification of COPD using
spirometry
Determination of a quality test
Importance of assessing tobacco use history at every encounter
Discuss how to motivate patients to quit and methods of treating those motivated to
quit
Recognize available UH resources for smoking cessation
Vaccination
•
•
Review new guidelines on Pneumococcal Vaccination and high risk indications for
use under 65
Review Influenza Vaccination Protocols and discuss cost effectiveness of high
dose
COPD CareGuide
Crystal Mosca, MD
Sharon Family Physicians
Ambulatory EMR Physician Lead
High Reliability Medicine
• Reliability = consistent excellence over
long periods of time
• Zero patient harm
• Guidelines built into template
How to Access
• Choose diagnosis
–COPD
–Chronic Bronchitis
–Emphysema
–Click Recompile
CAT SCORE
• COPD Assessment Test
• Patient completed quality of life
assessment
• Numerical score of respiratory health
• Form will be embedded in EMR – will
allow for data collection in the future
Depression
• 40% of COPD patients are affected by
severe depressive symptoms
• Screening with PHQ-2 is embedded into the
HPI with option to pull in PHQ-9
• Prompts physicians to think about depression
as a comorbidity and further screen or treat as
needed
Orderables
• Orders
–Diagnostic testing
–Labs
• Instructions/Patient Education
• Rx
• Follow-ups and Referrals
screenshot
Rx
• Prescriptions are listed in order of
priority of treatment in COPD
• Under each category listed in order of
preferred use by UH formulary and cost
Examples
• screenshot
Spirometry
Rodney J Folz, MD, PhD
Chief, Division of Pulmonary, Critical Care and Sleep Medicine
Visiting Professor, Medicine – CWRU School of Medicine
G lobal Initiative for Chronic
O bstructive
L ung
D isease
http://www.goldcopd.org
Definition of COPD
• COPD is a preventable and treatable disease with
some significant extrapulmonary effects that may
contribute to the severity in individual patients.
• Its pulmonary component is characterized by airflow
limitation that is not fully reversible.
• The airflow limitation is usually progressive and
associated with an abnormal inflammatory response
of the lung to noxious particles or gases … 85% of the
time due to tobacco smoke.
MMWR 57:1221, 2008
Celebrities with COPD
Johnny Carson
Christy Turlington
Amy Winehouse
Dean Martin
Leonard Nimoy
Leonard Bernstein
Loni Anderson
Risk Factors for COPD
Nutrition
Infections
Socio-economic
status
Genetics
Aging Populations
Diagnosis of COPD
COPD Diagnostic Criteria
• Clinical diagnosis suspected
in any patient with:
•
•
•
•
Dyspnea
Chronic cough
Sputum production
History of exposure to risk
factors for COPD.
• Post bronchodilator
FEV1/FVC < 0.70
Caveats
• Characteristic symptoms
are chronic and
progressive.
• dyspnea, cough, and
sputum.
• Cough and sputum may
precede airflow limitations
by many years.
• Airflow limitations may
develop without cough and
sputum.
Four ways to Assess COPD
1. Assessment of current symptoms
2. Assessment of severity of airflow
limitation
3. Assessment of exacerbation risk
4. Assessment of presence of comorbidities
1. Assessment of Symptoms
• Best way to assess symptoms is to use validated
questionnaires:
– Modified Medical Research Council dyspnea scale. 
MMRC
– COPD Assessment Test  CAT
2. Assessment of Airflow
Limitation Severity
Global Strategy for Diagnosis, Management and Prevention of COPD
(C)
or
> 1 leading
to hospital
admission
(D)
3
2
(A)
(B)
1
1 (not leading
to hospital
admission)
0
CAT < 10
CAT > 10
Symptoms
mMRC > 2
mMRC 0–1
Breathlessness
© 2015 Global Initiative for Chronic Obstructive Lung Disease
(Exacerbation history)
≥2
4
Risk
(GOLD Classification of Airflow Limitation)
Risk
Combined Assessment of COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
RECOMMENDED FIRST CHOICE
ICS + LABA
or
LAMA
GOLD 3
GOLD 2
GOLD 1
D
2 or more
or
> 1 leading
to hospital
admission
ICS + LABA
and/or
LAMA
A
B
SAMA prn
or
SABA prn
LABA
or
LAMA
1 (not leading
to hospital
admission)
0
CAT < 10
mMRC 0-1
CAT > 10
mMRC > 2
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Exacerbations per year
GOLD 4
C
Spirometry in Primary Care
Global Initiative for Chronic Obstructive
Lung Disease (GOLD) 2010
Spirometry - Introduction
• Spirometry is the gold standard for COPD
diagnosis
• Underuse leads to inaccurate COPD
diagnosis
• Widespread uptake has been limited by:
– Concerns over technical performance of operators
– Difficulty with interpretation of results
– Lack of approved local training courses
– Lack of evidence showing clear benefit when
spirometry is incorporated into management
What is Spirometry?
Spirometry is a method of
assessing lung function by
measuring the total volume of
air the patient can expel from
the lungs after a maximal
inhalation.
Why Perform Spirometry?
• Measure airflow obstruction to help make a
definitive diagnosis of COPD
• Confirm presence of airway obstruction
• Assess severity of airflow obstruction in COPD
• Detect airflow obstruction in smokers who may
have few or no symptoms
• Monitor disease progression in COPD
• Assess one aspect of response to therapy
• Assess prognosis (FEV1) in COPD
• Perform pre-operative assessment
Desktop Electronic
Spirometers
Small Hand-held Spirometers
Standard Spirometric Indicies
• FEV1 - Forced expiratory volume in one
second:
The volume of air expired in the first second the blow
• FVC - Forced vital capacity:
The total volume of air that can be forcibly exhaled breath
• FEV1/FVC ratio:
The fraction of air exhaled in the first second relative to the total
volume exhaled
Predicted Normal Values
Affected by:
 Age
 Height
 Sex
 Ethnic Origin
Criteria for Normal
Post-bronchodilator Spirometry
• FEV1: % predicted > 80%
• FVC: % predicted > 80%
• FEV1/FVC: > 0.7 - 0.8
(depending on age)
Normal Trace Showing FEV1
and FVC
FVC
Volume, liters
5
4
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1
1
2
3
4
Time, sec
5
6
SPIROMETRY
OBSTRUCTIVE
DISEASE
Spirometry: Obstructive
Disease
Normal
Volume, liters
5
4
3
FEV1 = 1.8L
2
FVC = 3.2L
1
FEV1/FVC = 0.56
1
2
3
4
5
Time, seconds
6
Obstructive
Spirometric Diagnosis of COPD
• COPD is confirmed by post–
bronchodilator FEV1/FVC < 0.7
• Post-bronchodilator FEV1/FVC
measured 15 minutes after
400µg salbutamol or equivalent
Bronchodilator Reversibility
Testing
• Provides the best achievable FEV1
(and FVC)
• Helps to differentiate COPD from
asthma
Must be interpreted with clinical
history - neither asthma nor COPD
are diagnosed on spirometry alone
SPIROMETRY
RESTRICTIVE
DISEASE
Criteria: Restrictive Disease
• FEV1: normal or mildly reduced
• FVC: < 80% predicted
• FEV1/FVC: > 0.7
Spirometry: Restrictive
Disease
Normal
Volume, liters
5
4
3
Restrictive
2
FEV1 = 1.9L
FVC = 2.0L
1
FEV1/FVC = 0.95
1
2
3
4
5
Time, seconds
6
SPIROMETRY
Flow Volume
Flow Volume Curve
• Standard on most desk-top spirometers
• Adds more information than volume time
curve
• Less understood but not too difficult to
interpret
• Better at demonstrating mild airflow
obstruction
Flow Volume Curve
Expiratory
flow rate
Maximum
expiratory flow
(PEF)
L/sec
TLC
FVC
Inspiratory
flow rate
L/sec
Volume (L)
RV
Flow Volume Curve Patterns
Obstructive and Restrictive
Severe obstructive
Volume (L)
Reduced peak flow,
scooped out mid-curve
Restrictive
Expiratory flow rate
Expiratory flow rate
Expiratory flow rate
Obstructive
Volume (L)
Steeple pattern,
reduced peak flow,
rapid fall off
Volume (L)
Normal shape, normal
peak flow, reduced volume
PRACTICAL SESSION
Performing Spirometry
Spirometry Training
• Training is essential for operators to learn correct
performance and interpretation of results
• Training for competent performance of spirometry
requires a minimum of 3 hours
• Acquiring good spirometry performance and
interpretation skills requires practice, evaluation, and
review
• Spirometry performance (who, when and where)
should be adapted to local needs and resources
• Training for spirometry should be evaluated
Obtaining Predicted Values
• Independent of the type of spirometer
• Choose values that best represent the
tested population
• Check for appropriateness if built into
the spirometer
Optimally, subjects should rest 10 minutes
before performing spirometry
Withholding Medications
Before performing spirometry,
withhold:
 Short acting β2-agonists for 6 hours
 Long acting β2-agonists for 12 hours
 Ipratropium for 6 hours
 Tiotropium for 24 hours
Optimally, subjects should avoid caffeine and cigarette
smoking for 30 minutes before performing spirometry
Volume, liters
Reproducibility - Quality of Results
Time, seconds
Three times FVC within 5% or 0.15 litre (150 ml)
Spirometry - Quality Control
• Most common cause of inconsistent
readings is poor patient technique
 Sub-optimal inspiration
 Sub-maximal expiratory effort
 Delay in forced expiration
 Shortened expiratory time
 Air leak around the mouthpiece
• Subjects must be observed and
encouraged throughout the procedure
Equipment Maintenance
• Most spirometers need regular calibration to
check accuracy
• Calibration is normally performed with a 3 litre
syringe
• Some electronic spirometers do not require
daily/weekly calibration
• Good equipment cleanliness and anti-infection
control are important; check instruction manual
• Spirometers should be regularly serviced; check
manufacturer’s recommendations
Troubleshooting
Examples - Unacceptable
Traces
Unacceptable Trace – Stop
Early
Volume, liters
Normal
Time, seconds
Unacceptable Trace - Coughing
Volume, liters
Normal
Time, seconds
Some Spirometry Resources
• Global Initiative for Chronic Obstructive Lung
Disease (GOLD) - www.goldcopd.org
• Spirometry in Practice - www.brit-thoracic.org.uk
• ATS-ERS Taskforce: Standardization of
Spirometry. ERJ 2005;29:319-338
www.thoracic.org/sections/publications/statements
• National Asthma Council: Spirometry
Handbook
www.nationalasthma.org.au
Immunization Update for the
COPD patient
Todd Zeiger, MD
Vice President, University Hospitals Primary Care Institute
Purpose of review
• Acute exacerbations of chronic obstructive pulmonary
disease (COPD) are a major cause of morbidity and
mortality worldwide.
• Most acute exacerbations are triggered by communityacquired respiratory infections.
• Medications to treat COPD exacerbations are limited;
therefore, identifying and executing effective ways to
prevent exacerbations are needed.
• Influenza and pneumococcal vaccines are currently
recommended for all persons with COPD. However,
current immunization rates are low
Vaccination of the COPD
patient
• Tdap vaccine to protect against whooping cough and
tetanus
• Influenza vaccine each year to protect against seasonal
flu
• Pneumococcal polysaccharide vaccine to protect against
pneumonia and other pneumococcal disease
Influenza Vaccination: How
well does it work?
• Flu vaccination also has been shown to be
associated with reduced hospitalizations
among people with diabetes (79%) and
chronic lung disease (52%).
• A study that looked at flu vaccine
effectiveness over the course of three flu
seasons estimated that flu vaccination
lowered the risk of hospitalizations by 61% in
people 50 years of age and older.
2015-2016 Influenza Vaccine
Preparations
• Intramuscular (IM) vaccines will be available in
both trivalent and quadrivalent formulations.
• High dose vaccines(IM) will all be trivalent this
season
• For people who are 18 through 64 years old, a jet
injector can be used for delivery of one particular
trivalent flu vaccine (AFLURIA® by bioCSL Inc.).
• Nasal spray vaccines will all be quadrivalent this
season.
• Intradermal vaccine will all be quadrivalent
2015-2016 Influenza Vaccine
• Contains the following 4 viral strains for
2015/2016 northern hemisphere season
– A/California/7/2009 (H1N1) pdm09-like virus
(same strain as was used for 2009 H1N1
monovalent vaccines)
– A/Switzerland/9715293/2013 (H3N2)-like
virus (new strain for 2015/2016)
– B/Phuket/3073/2013-like virus (B/Yamagata
lineage) (new strain for 2015/2016)
– B/Brisbane/60/2008-like virus (B/Victoria
lineage vaccine virus)
Who Should Receive Influenza
Vaccine?
EVERYONE
Who Should Not Receive
Influenza Vaccine?
• Severe hypersensitivity (eg, anaphylaxis) to
any component of the vaccine, including egg
protein, or following a previous administration
of any influenza vaccine
• Persons with hives-only allergy to eggs, can
receive the inactivated influenza vaccine
• History of Guillain-Barre within 6 weeks of
influenza vaccination
High-Dose vs Standard-Dose
• Increased Immunological response
• ? Improved clinical efficacy
• Recent data- high dose Fluvax may show increased
clinical utility in Nursing home patients – to be presented
Oct
• A study published in the New England Journal of
Medicine (08/2014) indicated that the high-dose vaccine
was 24.2% more effective in preventing flu in adults 65
years of age and older relative to a standard-dose
vaccine. The confidence interval for this result was 9.7%
to 36.5%).
Pneumococcal Vaccination:
PPSV23 Vaccine
• Vaccine strains account for 88% of
bacteremic pneumococcal disease
• 75% efficacy against invasive disease
• 30% efficacy against pneumonia
• Duration of immunity at least 6 years
File TM, et al. Infect Dis Clin Pract. 2012; 20:3-9
Adult PPSV23 Vaccine
Recommendations
• All Adults 65 years of age and older
• Adults 19-64 (immunocompetent)
• Chronic illness (heart, lung, liver, diabetes,
alcoholism, CSF leaks, cochlear implants)
• Asthma
• Cigarette smoking
Pneumococcal Vaccination:
PCV13
• CAPiTA trial
• demonstrated 45.6% efficacy of PCV13
against vaccine-type pneumococcal
pneumonia
• 45.0% efficacy against vaccine-type
nonbacteremic pneumococcal pneumonia
• 75.0% efficacy against vaccine-type IPD
among adults aged ≥65 years
PCV13 Vaccine in Adults
• Pneumococcal (PPSV23) vaccine naïve subjects:
• An evaluation of immune response after a
second pneumococcal vaccination administered
1 year after the initial study doses showed that
subjects who received PPSV23 as the initial
study dose had lower antibody responses after
subsequent administration of PCV13 than those
who had received PCV13 as the initial dose
followed by a dose of PPSV23, regardless of the
level of the initial response to PPSV23
COPD:
PCV13 and PPSV23 before age 65
Summary
• Pneumococcal disease results in significant
clinical and economic burden
• Current vaccines are effective in preventing
invasive pneumococcal disease (IPD)
• Despite proven efficacy and safety of
vaccines, <20% of at-risk adults < 65 years of
age are vaccinated
Summary
• Advances of vaccines often caused by refusals
due to irrational beliefs
• Responsible healthcare professionals must
increase education of public and encourage usage
• Practice what we preach
• Be vaccine champions
• “You are going to get your x shot today”
Tobacco Cessation
Marianne Vest, MA, RN, CTTS
Senior Clinical Nurse
Cardiovascular and Pulmonary Rehabilitation
Harrington Heart & Vascular Institute
Tobacco Dependence
• Tobacco dependence is a chronic disease that
often requires repeated intervention and
multiple attempts to quit.
• Effective treatments exist that can significantly
increase rates of long-term abstinence.
• However, first the question must be asked!
Are you using any form of tobacco?
Importance of Regularly
Assessing Tobacco Use
• Clinicians can make a difference with minimal
intervention (<3 minutes)
• Research has shown a relation between
intensity of intervention and cessation
outcome
• Even if a patient is not ready to quit at that
time, a brief intervention may enhance
motivation & increase the likelihood of future
quit attempts
• The average number of quit attempts prior to
being successful = SIX!
Tobacco Cessation Counseling by
physicians, nurses, and other clinicians
all are of proven benefit.
Estimated abstinence at 5+
months
With help from a clinician, the odds of quitting approximately doubles.
30
n = 29 studies
Compared to patients who receive no assistance from a clinician, patients who receive
assistance are 1.7–2.2 * times as likely to quit successfully for 5 or more months.
20
2.2
1.7
10
1.0
1.1
0
No clinician
Self-help
material
Nonphysician
clinician
Physician
clinician
* Odds ratios
Type of Clinician
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Team work is effective: Counseling by more
than one clinician (e.g. physician and nurse)
is better than either one alone!
Estimated abstinence rate at 5+ months
Compared to smokers who receive assistance from no clinicians, smokers who
receive assistance from two or more types of clinicians are 2.4–2.5* times as
likely to quit successfully for 5 or more months.
30
n = 37 studies
20
2.5
2.4
Two
Three or more
1.8
10
1.0
0
None
One
Number of Clinician Types
Number of Clinician Types
* Odds ratios
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence
Physiological
The addiction to nicotine
Treatment
Medications for cessation
Behavioral
The habit of using tobacco
Treatment
Behavior change program
Treatment should address the physiological and the behavioral
aspects of dependence.
Behavioral Change: The Spirit
of Motivational Interviewing
• Partnership – Not confrontation
• Acceptance – Not judgement
• Compassion – Not indifference
• Evocation – Not advice
A meta-analysis of 14 randomized trials
showed that compared to brief advice or
usual care, MI increased 6-month cessation
rates by about 30%
Lai et al, Cochrane Database Syst Rev 2010
Motivational Interviewing
• Express empathy
- use open ended questions to explore
- use reflective listening to seek shared
understanding
• Develop discrepancy
- between present behavior & expressed goals
• Roll with resistance
• Support self-efficacy
-offer options for achievable small steps toward
change
Elicit-Provide- Elicit
• Elicit: ask what the patient knows or would like
to know (pharmacotherapy, relapse, etc)
• Ask permission: ‘Do you mind if I share with
you some of what we know?’
• Provide: information in a neutral,
nonjudgemental fashion (‘research suggests
that….)
• Elicit: patient’s interpretation (‘what does this
mean to you?’ ‘how can I help?’ ‘do you have
any questions?’)
Suggestions for Behavioral
(habit) Change
• Only smoke in one room of the home
• Put cigs in trunk of car when driving
• Change the routine: coffee in the AM
• Put cigs in basement/not normal room
• Change cigarette brands
• Use a straw or toothpick in mouth
instead of cig
Behavioral Change
KEY POINTS
• Position yourself as the beginning of the process,
not the provider of the entire cessation program
• You want the patient to talk themselves into
changing rather than you telling them they have
to change!
• Offer treatment
“Quitting smoking can be hard, but there is good
treatment available and I can help. Would you like to try?”
Pharmacologic Methods:
First-line therapies
Three general classes of FDA-approved
drugs for tobacco cessation:
• Nicotine replacement therapy (NRT)
 Nicotine patch, gum, lozenge, nasal spray, inhaler
• Psychotropics
 Sustained-release bupropion administered twice daily
• Partial nicotinic receptor agonist
 Varenicline
**E-cigarettes and related products are NOT currently FDA
approved for tobacco cessation.
Long-term (6 month) Quit Rates
for Available Cessation Medications
30
Active drug
Placebo
25
23.9
20.2
Percent quit
20
19.0
18.0
17.1
16.1
15.8
15
11.8
11.3
10.3
10
11.2
9.1
9.9
8.1
Nicotine
patch
Nicotine
lozenge
5
0
Nicotine gum
Nicotine
nasal spray
Nicotine
inhaler
Bupropion
Varenicline
Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008).
Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev
Combination
Pharmacotherapy
• Combination NRT
Long-acting formulation (patch)
• Produces relatively constant levels of nicotine
PLUS
Short-acting formulation (gum, lozenge)
• Allows for acute dose titration as needed for
nicotine withdrawal symptoms
• Bupropion SR + NRT
Relative Efficacy/Safety of Tobacco
Dependence Pharmacotherapy
• Varenicline is superior to NRT monotherapy or
Bupropion
• NRT monotherapy & Bupropion are of about
equal efficacy
• Combination NRT may be as efficacious as
Varenicline
UH Resources
• Harrington Heart & Vascular Institute
-experienced Certified Tobacco Treatment
Specialists
-referral for patients who have failed at least 1
recent trial of pharmacotherapy by primary or
specialty physician
-accessible via outpatient AEMR orders
• Beat the Pack – employee program
• Plan Q Mobile app – Pfizer
• LMS Tobacco Cessation education online course
-will go live 10/1/2015
AEMR Order
COPD System Steering
Committee
Theresa Kearns, MBA, RN, NE-BC
Director, HHVI System Ambulatory
Cardiovascular Services
COPD System Steering
Committee
• Reduce readmission rate of the PNA and COPD
patient population
• Institute best practices from literature review
• Collaborate with pharmaceutical company to enhance
medication accessibility for COPD patients
• Develop innovative interventions and sustainable
outcomes to decrease LOS and prevent
readmissions
• Prevent CMS penalties
• Representation from all system hospitals
Readmission Reduction
Program Definition
• 30-day unplanned readmission to any U.S. hospital
• Populations: AMI, CHF, PN, COPD, Elective Hip/Knee
Replacement
• Includes Traditional Medicare only
• Includes ages 65 and older only
• Excludes transfers to another short-term general hospital
• Excludes critical access hospitals (Conneaut & Geneva)
• Risk-adjusted by secondary conditions, demographics, and
procedures
• Your hospital’s results are compared to similar hospitals
(severity)
Readmissions Reduction Program – COPD
Discharges July-2011 to June-2014. Medicare FY 2016
Eligible
Discharges
Number of
30-Day
Readmits
Observed
Adjusted
Rate
Expected
Readmission
Rate
Readmission
Ratio (>1.0 = higher
than expected)
National
Observed
Rate
Ahuja
217
40
18.7%
18.8%
0.9923
20.2%
Case
239
56
22.2%
21.3%
1.0428
20.2%
Elyria
813
191
22.5%
20.0%
1.1224
20.2%
Geauga
262
56
22.0%
22.4%
0.9792
20.2%
Parma
748
171
22.6%
22.0%
1.0271
20.2%
Regional
260
61
21.8%
20.6%
1.0616
20.2%
Portage
259
50
18.8%
18.5%
1.0176
20.2%
St. John
486
108
21.9%
21.5%
1.0187
20.2%
Hospital
FY 2015 was the 1st year for the program
Patient Type
EMERGENCY
UH System
COPD Volumes
Facility
UH Case Medical Center
UH Regional Hospitals Bedford Campus
UH Conneaut Medical Center
UH Geauga Medical Center
UH Geneva Medical Center
UH Regional Hospitals Richmond Campus
UH Ahuja Medical Center
UH Parma Medical Center
UH Elyria Medical Center
Total Cases
233
125
138
74
181
129
192
166
405
1,643
Facility
UH Case Medical Center
UH Regional Hospitals Bedford Campus
UH Conneaut Medical Center
UH Geauga Medical Center
UH Geneva Medical Center
UH Regional Hospitals Richmond Campus
UH Ahuja Medical Center
UH Parma Medical Center
UH Elyria Medical Center
Total Cases
396
118
22
211
63
139
149
394
622
2,114
Facility
UH Case Medical Center
UH Regional Hospitals Bedford Campus
UH Conneaut Medical Center
UH Geauga Medical Center
UH Geneva Medical Center
UH Regional Hospitals Richmond Campus
UH Ahuja Medical Center
UH Parma Medical Center
UH Elyria Medical Center
Total Cases
92
13
20
16
11
65
38
47
136
438
Total
Patient Type
Jul-2014 to Jun-2015
INPATIENT
ADMITS THRU
THE ED
Total
Patient Type
OBSERVATION
Total
Source: Premier. Principal Diagnosis of COPD
Current Work
• Tobacco Cessation
• Home Care Pilot
• e-vouchers
• Monthly chart review by Dr. Schilz
• RN Discharge Clinic
• PFT ordering focus
Best Practice: Tobacco
Cessation Process
Goal: System standardization and education for tobacco cessation
process
• Standardized resource pamphlet(s)
• Utilize unbranded education resources
• Coding/reimbursement education to capture lost revenue
– LMS Educational video available 10/2015
• Pilot UHCMC inpatient initiation of tobacco cessation consult for
COPD patients
– Train additional educators
COPD Admissions - % Active Tobacco Use
Jul-2014 to Jun-2015
Patient Type
Facility
INPATIENT
UH
UH
UH
UH
UH
UH
UH
UH
UH
Total
Active
Tobacco
Cases
Case Medical Center
Regional Hospitals Bedford Campus
Conneaut Medical Center
Geauga Medical Center
Geneva Medical Center
Regional Hospitals Richmond Campus
Ahuja Medical Center
Parma Medical Center
Elyria Medical Center
190
51
9
89
38
50
58
118
221
824
Source: Premier. Principal Diagnosis of COPD
Total
Admissions
486
156
26
253
103
169
204
488
664
2,549
% Active
Tobacco Users
39%
33%
35%
35%
37%
30%
28%
24%
33%
32%
UHCMC Home Care Services
PNA & COPD Pilot
Goals
• Enhance the quality of care for patients diagnosed with PNA
and/or COPD
• Reduce readmissions
Patient Eligibility
• Patient w/o insurance for home care or ineligible for traditional
homecare
• PNA admit/diagnosis during hospitalization with or w/o COPD
• COPD exacerbation/diagnosis during admit with/without PNA
• If patient declines home care visit, referral to RN DC clinic for a
one time visit with same program goals as pilot.
Funding
• Home care visit funded by UHCMC, billed at $145/visit.
Medication Management
Spiriva eVoucher Program -- 5/2015
• Give eVoucher to COPD patients with order for Spiriva
for a free 30 day supply of medication
• Involve key leads from across UH to roll out to other
facilities
– Parma and Geneva
• Review/explore additional pharmaceutical
opportunities
Chart Review Summary
COPD Readmissions to UHCMC
April 2014 – May 2015
• 80% of our COPD Admissions Represent African American Patients
• Readmissions are evenly spread through the 30 days following
discharge (28% in first week)
• 42% of our COPD readmit events represent multiple (2-6) readmits
from only 16 patients, 14 of 16 only admitted for COPD
• Initial MICU admission does not seem to be an indicator of future
readmission either to MICU or to UHCMC
• COPD represents the major reason for 30 day readmission (57%)
• CHF is the second leading reason for 30 day readmission (17%)
Suggested Action Items
• Continue data review – consider initial coding review
• Understand population demographic
• Focus initially on 16 patients
• Focus on CHF management in complex patients, may independently
look at this population
• Suggest pulmonary consult for:
– All readmits with primary readmit diagnosis of COPD
– All GOLD III and IV patients (this will include oxygen dependent
patients)
– All MICU patients with COPD as admitting diagnosis to MICU
(although there is some evidence that this is already done on both
code white and current patients)
Best Practices: Patient ‘touch’
moments
• Respiratory Therapist:
ˉ Educate patients during treatments on tobacco cessation
ˉ Utilize Skylight video as reinforce healthy living
ˉ Leverage order sets for EMR - PNA and COPD
ˉ Appropriate dx and treatment
• Pharmacy
ˉ Investigate opportunities to partner with retail pharmacy
(Giant Eagle)
• Home Care
ˉ Educate Care Coordinators regarding home care services
pilot enrollment criteria
UH System COPD
Findings (Jul-2014 to Jun-2015)
• No statistically significant trends up or down in
admissions
• 1,643 emergency encounters / treat & release
• 2,114 admissions through the emergency dept.
• 17% of admissions are direct admits
• 32% of admissions with active tobacco use (per coding)
• 36.2% of admissions had a PFT in previous 5 years
• 83% COPD admits are thru the ED