Preventing Untimely Hospital Re-admission in Patients With Chronic Obstructive Pulmonary Disease

1. Preventing Untimely Hospital Re-admission in Patients With Chronic Obstructive Pulmonary Disease George G Burton, M.D.* *From: Depts of Pulmonary Medicine and Respiratory Care Kettering Medical Center Dayton, OH 45429

2. Goals of This Presentation Discuss/Review: • Transformation of the traditional care environment • The PPAC Act of 2010 and value-based purchasing (VBP) • Reduction of hospital re-admissions as a goal • COPD in the spotlight • Literature (on and off) the subject • Remedies: Strategies and tactics • Role of Pulmonary Rehabilitation • Role of the Advanced Respiratory Care Practitioner • Where do we go from here?

3. Evolving US Health Care Delivery System Patient Protection and Affordable Care Act of 2010 • It’s the law of the land! Stated goals: • Increase access • Improve quality of health care outcomes • Improve patient safety • Eliminate duplication/waste • Enhance care coordination • Reduce rate of healthcare inflation to sustainable levels

4. The Evolving Health Care EnvironmentKey Attributes Traditional (Today) Tomorrow • Acute treatment • Cost unaware • Professional Prerogative • In-patient • Individual professions • Traditional practice • Patient passivity • Fee-for-service • Volume-based • Chronic disease mgmt • Cost-of-care the focus • Consumer responsive • Out-patient • Team • Evidence-based practice • Activated patients • Bundled/Episodic • Value-based Transformation well-underway - - Federally-funded demonstration Projects have shown significant improvement in chronic care outcomes & health care utilization

5. Value-Based Purchasing Programaka Pay-For-Performance (P4P) How will hospitals be evaluated? Total Performance Score (TPS) • Baseline performance data • Achievement (current compared to ALL hospitals’ baseline) • Improvement vs. achievement (my performance to my baseline) • Achievement points • Improvement points www.hospitalcompare.hhs.gov

6. The RAC*Demonstration Project(2005-2008) • > 500,000 overpayment determinations in study period… • ….valued at $693 million • 85% were related to inpatient hospital care *CMS Evaluation of Appropriateness of Medicare Payments

7. Unplanned Rehospitalizations NEJM April 2009: Jencks, SF et al October 1, 2003 through December 31, 2004 19.6% Medicare hospitalization due to the re-admission for same condition within 30 days of discharge • 2.3 million of 11.8 million total Diseases with highest recidivism rates: • CHF (27%); Psychosis (25%); Vascular surgery (24%) • COPD (23%); Pneumonia (20%) Cost impact - $17.4 billion and largely preventable! Primary contribution factor – poorly coordinated transition of care

8. Change and Transition are Always Fraught with DANGER! Examples: Childbirth Hand-off in Football Medical resident shift change hand-off Nursing shift change hand-off HOSPITAL DISCHARGE

9. 75% of Re-admitted COPD Patients Had Not Been Given A Follow-Up Appointment At Time of Discharge!!

10. Hospital Value-based Purchasing Program (2013) Carrot (Rewards): • Financial Rewards • Good Public Relations • Signal Diseases (2013): AMI CHF Pneumonia • Signal Diseases after 10/1/14: COPD

11. Hospital Value-based Purchasing Program (2013) Stick (Penalties): • Big$$$$! • Poor Public Relations Penalty Rate to Total Medicare Charges for the Index Year: 1.0% in FY 2013 2.0% in FY 2017 The general idea is: Reward $ = Penalty $* *This concept is already “under review”

12. An Important Definition Hospital Re-admission Rate # of Disease Specific Re-admissions /yr = # of Case-Mix Adjusted Disease-Specific Admissions /yr

13. How To Solve The Problem?(not really!) Keep the denominator as high as possible! CMS (2014): “Admissions for patients with an in-patient hospital death are excluded because they are not eligible for re-admission.” ??? Government stupidity or shrewdness ???

14. COPD - - The Numbers Prevalent yet treatable disease • Affects 12-24 million Americans 126,000 deaths/yr • 3rd leading cause of death Mortality now greater in women than men 64,000 vs 60,000 deaths in 2007 Mortality after 2nd hospitalization in 1 year is approx. 60% Huge economic impact • $49.6 billion in 2010; $29.5 billion for direct care 4th leading cause of 30-day hospital re-admissions

15. Inpatient COPD Care: The Evidence* * Mc Crory DC, et al. Chest; April 2001

16. Under treatment of COPD: A Retrospective Analysis of US Managed Care and Medicare Patients* “In 42,565 patients with commercial insurance and 8,507 Medicare Patients, COPD controller medications were NOT prescribed for 66.3% of commercial patients and 70.9% of Medicare patients…” This study highlights a high degree of undertreatment of COPD With most patients receiving no maintenance pharmacotherapy. *Make B, et al. Int J Chron Obstruct Pulmon Dis; January 2012

17. The Quality of Obstructive Lung Disease Care for Adults in the US as Measured by Adherence for Recommended Processes* “Americans with obstructive lung disease receive only 55% of recommended care… Only 30% of patients discharged with chronic hypoxemia receive supplemental oxygen.” *Mularski RW, et al. Chest; December 2006

18. Quality of Care for Patients Hospitalized for Acute Exacerbation of Chronic Obstructive Pulmonary Disease* “In this study of nearly 70,000 patients hospitalized with acute exacerbation of COPD, we identified widespread opportunities to improve quality of care and to reduce costs by addressing problems of underuse, overuse and misuse of resources, and by reducing variation in practice.” *Lindenauer PK, et al. Ann Intern Med; June 2006

19. COPD Care or Lack of It!* • Simple diagnostic tests were underutilized: CHF: 78% had 2-D Echocardiogram COPD: 31% ever had spirometry * Darharla W, et al. : Resp Care 2006

20. Strategies Vs. Tactics • Strategy: The science or art of military command • as applied to overall planning and conduct of large scale operations. • Depends on RESOURCES. • Tactic: An expedient for achieving a goal • Depends on PEOPLE. “Tactics are used to win an engagement; strategies to win a war.” Bull of Atomic Scientists

21. The Re-admission Issue Strategy #1: Question: “Are we in Trouble?” Or “Are we in Trouble Yet?” Answer: Hard to find out! • ? Ignorance ? Fear ? IT weakness • Lack of consensus on (how close is close)? Absolute vs. Trended Data • Guesstimate of length of remediation time

22. Data From our Hospitals“Are we in Trouble Yet?”

23. Solution #1: Remediation Strategies and Tactics WHAT HAS BEEN TRIED TO REMEDIATE THE COPD RE-ADMISSION PROBLEM? What has worked? What has not? The literature paints a grim picture!

24. Part 1 Literature Review: Interventions to Reduce Hospitalizations Following Exacerbations of COPD – 1966-2013* • 5 Studied (out of 913) meet evidence-based criteria (1393 participants) • All were RCT’s • Primary outcome: Rehospitalization at 6 or 12 months • No study examined 30-day all-caused rehospitalization rate • All tested a different set of interventions

25. Part 2 Literature Review: Interventions to Reduce Hospitalizations Following Exacerbations of COPD – 1966-2013* • Two studies (one in Canada, one in Spain/Belgium showed a decrease • in rehospitalization rate (45% /yr vs. 67% /yr • Two US studies showed no signification change between groups • One US study (VAH) found a 22% higher risk of mortality in the • intervention group and no significant change in rehospitalization rate. • Unclear which interventions were effective or harmful • “CMS penalties are unjustified.”

26. Part 3 Literature Review: Interventions to Reduce Hospitalizations Following Exacerbations of COPD – 1966-2013* Timing: Pre-Discharge 2 of 5 Transition (bridging) 2 of 5 Post-Discharge 5 of 5 All Three 2 of 5

27. Part 4 Literature Review: Interventions to Reduce Hospitalizations Following Exacerbations of COPD – 1966-2013* Which?: Common to all: • Patient Education • Exacerbation Response Planning (Action Plan) • Telephone Hotline Common to 4 of 5: • Above Plus… • General Health Counseling • Coordination with PCP

28. Part 5 Literature Review: Interventions to Reduce Hospitalizations Following Exacerbations of COPD – 1966-2013* Which?: Common to 3 of 5: • Above plus smoking cessation assistance • Social services referral 1 of 5: • USE OF PULMONARY REHABILITATION • USE OF RCPs ON “TEAM” IN NONE: • PROVISION OF 10 DAYS WORTH OF MEDICATION • WRITTEN CONTRACT WITH DME PROVIDER • SCHEDULED FOLLOW-UP PHYSICIAN APPOINTMENT *Pritao-Centurion, V et al.: Ann. Am. Thorac. Society Jan. 14, 2014 Epub. ahead of print

29. Part 6 Literature Review: Interventions to Reduce Hospitalizations Following Exacerbations of COPD – 1966-2013* Note: Only 40% of the patients assigned to the pulmonary rehabilitation arm of the study completed the required 75% of a priori definition of compliance.

30. WINNING STRATEGY #1 • Involve/Re-Energize use of pulmonary rehabilitation - Inpatient, transition, and outpatient • Think of inpatient stay as a “Teachable Moment” • Evidence DOES support this…

31. WINNING STRATEGY #2 Improve the Situation at a National Level • Support AARC/CoARC’s development of Advanced Practice RCPs (APRCs) • Encourage Congress to pass HR 2619 (Medicare Respiratory • Therapist Act of 2013)* • Support local state legislation empowering RCPs * Editorials (Point/Counterpoint): Chest 145(2): 211-218 (2014)

32. WINNING STRATEGY #3 Improve the Situation at Home • Take personal ownership of the re-admission problem • Encourage use of Evidence-Based Medical Practice Guidelines • Insist in the use of TDPs in your hospital • Participate in discussions regarding “Transitional Care” • Advocate use of supplying patients with 7-10 days of medications • at time of discharge • Consider use of a “Wallet Biopsy” regarding affordability of discharge medications

33. WINNING STRATEGY #4 Improve the Situation at Home With respect to respiratory care EQUIPMENT-LINKED* hospital discharges • Has DME Contract been accomplished? • Will the equipment be at the patient’s home when he/she arrives? • Will the patient (or a caregiver) know how to operate it? • Is the patient at high risk for EQUIPMENT-LINKED problems? *O2, aerosol generators, MDIs, ventilators, positive airway pressure devices, percussions

34. PART 1 Evidence-based Literature Review: Pulmonary Rehabilitation Following Exacerbations of COPD* • (ALL RCTs which included at least physical conditioning) • Nine (9) trials: 432 patients • Significantly reduced hospital re-admissions over 25 weeks (range= 3-18 months) • Improved health-related quality of life • Improved exercise capacity * The Cochrane Collaboration: Puhan MA et all John Wiley and Sons, LTD, 2011, Issue 10, Article NO. CD005305

35. Evidence-based Literature Review: Pulmonary Rehabilitation Following Exacerbations of COPD In Pulmonary Rehabilitation (PR): STRATEGY DRIVES TACTICS Tactical Suggestions (part 1): • Mandate involvement of PR by TDP in all hospitalized COPD patients • In sicker patients (Gold III-IV) mandate inpatient PR consultation • Task PR with responsibility for DME liaison when appropriate • Staff Transition Clinic with P-competent RCPs and APRCs • Develop-implement PR Protocols if not already available

36. Evidence-based Literature Review: Pulmonary Rehabilitation Following Exacerbations of COPD Tactical Suggestions (Part 2): • Involve RCPs at all levels of the process Literature supports use of RCPs in • Shortening the duration of invasive and • Non-invasive ventilation • Via TDPs insuring proper cost affective • utilization of respiratory care services • Educating patients in COPD self-management

37. Evidence-based Literature Review: Pulmonary Rehabilitation Following Exacerbations of COPD Tactical Suggestions (Part 3): • Involve RCPs at all levels of the process “All levels of the process” includes: • Planning • In hospital respiratory care and discharge • planning • At time of transition • Post hospitalization ALL AT THE FACE TO FACE LEVEL: Tactical Suggestions (Part 4) • Consider development of Transitional Care Unit (TCU)

38. Pulmonary or Cardiopulmonary Transitional Care Units (TCUs) The TCU is a facility that provides patient-centered services noted for: • Coordination and structuring • Continuous availability • Comprehensive care • Compassion • Cultural effectiveness • Competent employees Services are available in the first several months after discharge in conjunction with the patient’s PCP*. * Chest 145(1): 149-155, 2014

39. Tactics For Physicians • Evaluate ED and “24-Hour Holding Units” Care of COPD patients. • can the # of admissions be reduced at the source? • Encourage the use of Evidence-Based practice guidelines and TDPs • throughout the hospital particularly in the care of COPD patients • Encourage the use of specialized consultation in COPD patients, especially • GOLD III-IV and those with co-morbilities • Develop institution-specific, culturally appropriate COPD patient education • materials • Develop/implement a co-morbility screening instrument to be used for all • COPD patients in your practice and in every hospitalized COPD patient

40. In Closing… The Re-admission Penalty Problem WILL NOT GO AWAY! So: JOIN THE BATTLE! - Thank You! -

41. …With Thanks To: Trina M. Limberg, BS, RRT Judith A. Tietsort, RN, RRT Patrick J. Dunne, MED, RRT Dennis A. Cortese, MD Richard Hamrick, MD Roger Rickel, RRT, MHA