White Memorial Medical Center
January 31, 2014  Los Angeles  CA
COPD: Managing the Disease
Not The Symptoms
Patrick J. Dunne, MEd, RRT, FAARC
HealthCare Productions, Inc.
Fullerton, CA 92838
pjdunne@sbcglobal.net
Disclosure
Professional relationships with:
 Monaghan Medical Corporation
 Mylan Specialty, LP
 Ohio Medical Corporation
Objectives
 Review the provisions / timelines of Medicare’s Hospital
Readmission Reduction Program;
 List the clinical and economic impact of COPD and associated
comorbidities;
 List the evidence-based care guidelines for the inpatient
treatment of a COPD exacerbation, and
 Describe potential strategies to help reduce all-cause 30-day
COPD readmissions.
Hospital Readmission Reduction Program
Section 3025 Affordable Care Act
 Effective FY 2013 (10/1/12 - 9/30/13)
 2nd of 2 new payment policies
 Financial penalties for excessive 30-day readmissions
 3 Targeted conditions
 Acute MI (19.9%); CHF (24.5%); Pneumonia (18.2%)
 Additional conditions to be added in FY 2015
 Hospitals identified nationwide
 FY 2013 - - 2,213 hospitals w/ $280 million in penalties (up to 1%)
 FY 2014 - - 2,225 hospitals w/ $227 million in penalties (up to 2%)
 FY 2015 - - penalty up to 3% of total Medicare payments
Page 113: “We believe the COPD
measure warrants inclusion in
the Hospital Readmission
Reduction Program for FY 2015”
Fiscal Year 2015
October 1, 2014 – September 30, 2015
Index Years:
July 1, 2010 – June 30, 2011
July 1, 2011 – June 30, 2012
July 1, 2012 – June 30, 2013
Penalty in FY 2015:
Up to 3% of Medicare payments
Now, About COPD . . . .
 Definition:
 A progressive, inflammatory chronic disease characterized by
increasing airflow obstruction coupled with destruction of
pulmonary gas exchange areas. There are clinically relevant
extra-pulmonary effects secondary to systemic inflammation
 Prevalence is increasing; 3rd Leading cause of death
 Airflow obstruction/alveolar destruction largely irreversible
 Primary cause: Long-term exposure to noxious inhalants
 A largely preventable disease
 Fourth leading cause of recidivism
Risk Factors for COPD
Genes
Infections
Socio-economic status
Aging Populations
© 2013 Global Initiative for Chronic Obstructive Lung Disease
COPD is a Multisystem Disease
Anxiety, Depression, Addiction
Lung Cancer
Pulmonary Hypertension
Anemia
Cardiovascular Disease
Peripheral Muscle
Wasting & Dysfunction
Osteoporosis
Diabetes
Metabolic Syndrome
Peptic Ulcers
GI Complications
Cachexia
Adapted from Kao C, Hanania NA. Atlas of COPD. 2008.
COPD Comorbidities
COPD
Opportunities for Improvement
 Currently, care outcomes less than optimal
 Growing concern over high recidivism rate
 Unplanned re-admissions are costly
 30 day re-admits largely preventable
 COPD evidence-based care guidelines exist
 For both in-patient (exacerbation) and out-patient (Sx control)
 Use of evidence-based care guidelines is low
Under-treatment of COPD
 Record review: 553 pts. discharged with Dx of COPD
Darmella W, et al. Respir Care; October 2006
Only 31% had confirmatory spirometry
We must raise awareness of the need to confirm the diagnosis of
COPD and it’s severity with spirometry
 Record review: 169 pts. with 1,664 care events
Mularski RW, et al. Chest; December 2006
 Subjects received 55% of recommended care; Only 30%
with base-line hypoxemia received LTOT
The deficits and variability in processes of care for patients
with obstructive lung disease presents ample opportunity for
improvement
Inpatient COPD Care: The Evidence
McCrory DC, et al. Chest; 2001
EFFICACY EVIDENCE EXISTS
EFFICACY EVIDENCE LACKING
Chest radiography/ABGs
Sputum analysis
Oxygen therapy
Acute spirometry
Bronchodilator therapy
Mucolytic agents
Systemic steroids
Chest physiotherapy
Antibiotics
Methylxanthine bronchodilators
Ventilatory support (as required)
Leukotrine modifiers; Mast cell stablizers
Level 1-2 evidence of efficacy = Recommended care
Insufficient efficacy evidence = Non-recommended care
Non-recommended care = Unnecessary care
Under-treatment of COPD
 Record review: 69,820 records from 360 hospitals
Lindenauer PK, et al. Ann Intern Med; June 2006
 66% received all of recommended care; 45% received at least one
non-recommended care; Only 30% received Ideal Care
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
 Claims data review: 42,565 commercial, 8,507 Medicare
Make B, et al. Int J Chron Obstruct Pulmon Dis; January 2012
 No pharmacotherapy – 60% commercial, 70% Medicare
 No smoking cessation – 82% commercial, 90% Medicare
 No influenza vaccination – 83% commercial, 76% Medicare
This study highlights a high degree of undertreatment of COPD,
with most patients receiving no maintenance pharmacotherapy
or influenza vaccination
Under-treatment of COPD: Summary
 COPD - an expensive, chronic condition
 Incidence is increasing
 Financial liability is escalating
 Diagnostic spirometry is woefully under-used
 Use of evidence-based treatment guidelines is low
 Failure to control symptoms a precursor to exacerbations
 COPD hospital re-admissions are largely preventable
 Chronic disease management strategies a necessity
GOLD Guidelines
Pre-2013
IV: Very Severe
III: Severe
II: Moderate
I: Mild
• FEV1/FVC < 0.70
• FEV1 ≥ 80% predicted
• FEV1/FVC < 0.70
• 50% ≤ FEV1 < 80%
predicted
• FEV1/FVC < 0.70
• 30% ≤ FEV1 < 50%
predicted
• FEV1/FVC < 0.70
• FEV1 < 30% predicted
or FEV1 < 50%
predicted plus chronic
respiratory failure
Active reduction of risk factor(s); smoking cessation, flu vaccination
Add short-acting bronchodilator (as needed)
Add regular treatment with long-acting bronchodilators; Begin Pulmonary
Rehabilitation
Add inhaled glucocorticosteroids if repeated acute
exacerbations
Add LTOT for chronic
hypoxemia.
Consider surgical
options
Combined Assessment of COPD
GOLD Guidelines (2013)
4
(C)
(D)
≥2
3
Risk
Risk
GOLD Classification
of Airflow Limitation
Exacerbation
history
2
(A)
(B)
1
1
0
mMRC 0-1 (or) CAT < 10
mMRC > 2 (or) CAT >
10
Symptoms
(mMRC or CAT score)
Left (or) Right: Up (or) Down
> 2 exacerbations
0-1 exacerbations
Fewer
Symptoms
More
Symptoms
Assessment of Symptoms
GOLD Guidelines (2013)
 Modified British Medical Research Council (mMRC) Dyspnea
Questionnaire:
A 5-item measure of perceived dyspnea
Self-report on grade 0 – 5
(or)
 COPD Assessment Test (CAT):
An 8-item measure of health status impairment in COPD
Self-report on scale 0 – 5
Both have been validated and relate well to other measures of
health status and predict future mortality risk.
Modified MRC (mMRC) Questionnaire
GOLD Guidelines (2013)
COPD Assessment Test (CAT)
GOLD Guidelines (2013)
COPD Assessment Test (CAT)
GOLD Guidelines (2013)
Combined Assessment of COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Risk
(C)
(D)
3
4
30-50%
<30%
Pre-2013 GOLD
Classification of
Airflow Limitation
≥2
Risk
(A)
(B)
1
1
2
0
≥ 80%
50-80%
mMRC 0-1 (or) CAT < 10
mMRC > 2 (or) CAT > 10
Symptoms
(mMRC or CAT score)
Exacerbation
history
Combined Assessment of COPD
GOLD Guidelines (2013)
When assessing risk, choose the highest
risk according to GOLD grade or
exacerbation history
Patient
Characteristics
Spirometric
Classification
Exacerbations
per year
mMRC
CAT
A
Less Symptoms
Low Risk
GOLD 1-2
0-1
0-1
< 10
B
More Symptoms
Low Risk
GOLD 1-2
0-1
≥2
≥ 10
C
Less Symptoms
High Risk
GOLD 3-4
≥2
0-1
< 10
D
More Symptoms
High Risk
GOLD 3-4
≥2
≥2
≥ 10
COPD Maintenance Treatment by Airflow Limitation/Risk
GOLD Guidelines (2013)
FEV1
% PREDICTED
EXACERBATION
GRADE
TREATMENT
CONSIDERATIONS
(AIRFLOW LIMITATION)
(RISK)
≥ 80%
LOW
Smoking cessation; Vaccinations; SABA prn
50 – 80%
MEDIUM
Add to above: Nebulized LABA-LAMA daily;
Pulm Rehab; Exacerbation action plan
30 – 50%
HIGH
Add to above: ICS for exacerbation prone;
Referral to pulmonologist
≤ 30%
VERY HIGH
Add to above: long-term oxygen therapy;
Consider surgical options
Inpatient COPD Care: The Evidence
McCrory DC, et al. Chest; 2001
EFFICACY EVIDENCE EXISTS
EFFICACY EVIDENCE LACKING
Chest radiography/ABGs
Sputum analysis
Oxygen therapy
Acute spirometry
Bronchodilator therapy
Mucolytic agents
Systemic steroids
Chest physiotherapy
Antibiotics
Methylxanthine bronchodilators
Ventilatory support (as required)
Leukotrine modifiers; Mast cell stablizers
Acute Spirometry with COPD Exacerbation
Isn’t spirometry needed to Confirm Dx and Grade Airflow Limitation?
 Acute spirometry
 Hospitalized patients not ready for full PFT studies


Unable to exert maximal effort; Repeat maneuvers
Pre-post bronchodilator response of limited value
 Make appointment for 4-6 weeks post recovery
 What about peak inspiratory flow?
 Not a demanding test but insightful
 Ability to use a DPI

Generate ≥ 40 L/min PIF
Secretion Retention with COPD Exacerbation
Can Contribute to Airflow Obstruction;  WOB
 Chest physiotherapy
 An airway clearance technique (ACT)

Secretion retention, ineffective cough problematic

Trendelenburg position contraindicated in COPD
 Proven alternate ACT techniques in use for CF

ACBT, AD, HFCWO, IPV, OPEP
 Which to consider for COPD?

OPEP Rx a viable regimen

Inexpensive, non-invasive

Alone or in combo with SVN
Medication Nebulizers
Not all jet-nebulizers are created equal!
Respirable Dose 10%
Respirable Dose 15%
Respirable Dose 30%
Higher respirable dose = Quicker onset of action!
Higher respirable dose = Shorter treatment times!
Quicker onset/less time = Better RT deployment!
Dynamic Hyperinflation
Dynamic
hyperinflation
Breath Actuated Nebulizer in COPD
Haynes J. Respir Care; Sept 2012
 Prospective, randomized controlled trial
 Objective: compare bronchodilator response w/ BAN to
standard SVN
 Patients admitted w/ COPD exacerbation
 N = 40 of 46; Similar baseline characteristics
 Dyspnea secondary to dynamic hyperinflation
 Medication regimen
 2.5 mg albuterol/0.5 mg ipratropium (3 mL) Q4H

2.5 albuterol Q2H prn

Common adverse effects monitored during/after each Rx
 Data collected 2 hrs post 6th scheduled Rx (collector blinded)
 Inspiratory capacity; dyspnea; RR
Breath Actuated Nebulizer in COPD
Haynes J. Respir Care; Sept 2012
 Findings:
 Both groups received same # Rxs (6.25; 6.20)
 IC higher in BAN v. SVN (1.83 L v. 1.42 L; P .03)

Change in IC greater BAN v. SVN
 RR lower in BAN v. SVN (19/min v. 22/min; P = .03)
 No difference in BORG or LOS
Breath Actuated Nebulizer in COPD
Haynes J. Respir Care; Sept 2012
 Conclusions:
 In this cohort of patients with ECOPD, the AeroEclipse II BAN was
more effective in reducing lung hyperinflation and respiratory rate
than traditional SVN.
 It may be that the BAN group simply received more medication
because of the breath activated mode…Aerosols with MMAD of
3.0 μm produce the highest physiological response in terms of
FEV1 and airway conductance.
Role of Nebulized Therapy in COPD
Dhand R, et al. COPD; Feb 2012
RECOMMENDATION: Many patients, especially elderly patients
with COPD, are unable to use their pMDIs and DPIs in an optimal
manner. For such patients, nebulizers should be employed on
a domiciliary basis. . .
Nebulizers are more forgiving to poor inhalation technique,
especially poor coordination with pMDIs and the requirement to
generate adequate peak inspiratory flows with DPIs.
Nebulized Therapy at Home
 Ease of use; simple technique
 Addresses inconvenience issue
 Effective and reliable drug delivery
 Use not limited by disease severity
or mental acuity
 Device & medications covered under
Medicare Part B
Managing Stable COPD
Goals of Therapy
 Relieve airflow obstruction
 Improve exercise tolerance
Reduce symptoms
 Improve health status
 Relieve airflow obstruction
 Improve exercise tolerance
Reduce risk
 Improve health status
Reduced symptoms + Reduced risk = Successful disease management
Improving COPD Care Outcomes
Summary
 A new COPD care pathway essential
 COPD pts. will impact hospital’s revenue
 Pt. volume will vary by institution
 1-2/month up to 6-8/month
 Allocate resources accordingly

Re-design current workload
 Advocate evidence-base care
 Start small; Expand accordingly
 Appoint, anoint, elect one departmental COPD Guru
 Let pt. volume drive program development
 Determine risk grade per 2013 GOLD Guidelines
 Use CAT (or) mMRC
 Ensure proper controller medications prescribed
 Appointment for follow-up MD appointment 5-7 days
AARC Resources
Domain of Likely COPD Performance Measures
Timely and Effective Care
 Performance measures tied to readmission penalties
 Already required under Physician Quality Reporting System
(PQRS)
 Documented evidence in medical record of:
 Smoking cessation (discussed at every visit)
 Spirometry (within past 2-3 yrs.)
 Bronchodilator therapy (esp. controller medications)
 Immunizations (pneumococcal, influenza)
White Memorial Medical Center
January 31, 2014  Los Angeles  CA
COPD: Managing the Disease
Not The Symptoms
Patrick J. Dunne, MEd, RRT, FAARC
HealthCare Productions, Inc.
Fullerton, CA 92838
pjdunne@sbcglobal.net