Effective Discharge of the Oxygen
Dependant COPD Patient
Bob Messenger BS, RRT
Manager, Respiratory Education
Invacare Corporation
Disclosures
• Relevant Disclosures
– Employed by the Invacare Corp.
– A version of this lecture has been accepted for
publication in Professional Case Management
30-Day Readmissions Hospital Directed Reform
 Provision of PPACA (Section 3025)
 Penalty for excessive 30-day Potentially Preventable
Readmits




Bottom 25th percentile – Penalized on ALL Medicare receipts
 CMS payments (1% in 2012, 2% in 2013, 3% in 2014)
Risk adjustment
Moving target
 Diagnosis specific
 Effective Oct. 1, 2012
 CHF, AMI, Pneumonia
 Effective Oct. 1, 2015
 COPD, Angioplasty,
CABG & vascular diseases
30-Day Readmission Rates
Readmission Chains
• A sequence of readmissions that are all
related to a single initial discharge
– Essentially an episode of related hospitalizations
– Provides a more precise description of the
readmission pattern associated with the care
given during & after specific types of initial
discharges
Example of a Readmission Chain
Initial Admission:
Readmission:
Readmission:
CABG Surgery
Post-op Wound Infection
PTCA
• Without Readmission Chains: readmission sequence is a CABG
discharge with one readmission followed by an unrelated PTCA
admission
• With Readmission Chains: a CABG discharge and two related
readmissions
– Post-op infection and PTCA are related to initial CABG surgery
Test Your Understanding…
• A readmission for diabetes following an initial
admission for diabetes
• Potentially Preventable Readmission?
• YES
Test Your Understanding…
• An admission for trauma following a discharge
for AMI
• Potentially Preventable Readmission?
• NO (unrelated acute event)
Test Your Understanding…
• A readmission for diabetes in a patient whose
initial admission was for an acute myocardial
infarction
• Potentially Preventable Readmission?
• YES
Test Your Understanding…
• A readmission for a broken hip in a patient whose
initial admission was for an exacerbation for COPD.
(NOTE: patient went home on O2 and tripped on the
oxygen tubing)
• Potentially Preventable Readmission?
• ???? Maybe
Defining “Readmissions”
• Potentially Preventable Readmission (PPR)
– Could have been prevented through:
• Improved quality of care in the initial hospitalization
• Better discharge planning
• Improved post-discharge follow-up
• Improved coordination inpatient/outpatient health care teams
What’s so
special about
the COPD
Patient?
US COPD Data
• In 2010 COPD costs the US est. $29.5 billion in direct
costs & $20.4 billion in indirect costs1
– 14.8 million Americans diagnosed with COPD2
– 150 million days of lost work annually1
– A person with COPD dies every 4-minutes in the US3
– 3rd leading of cause of death4
– 2nd leading cause of disability1
1. NHLBI: Morbidity and Mortality: 2007 Chartbook on Cardiovascular, Lung and Blood Diseases.
2. CDC Fast Facts: COPD. http://www.cdc.gov/nchs/fastats/copd.htm - accessed 3/17/11.
3. Extrapolated from CDC data: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm - accessed 3/24/11
4.
National Vital Statistics Reports Volume 59, Number 2. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_02.pd//f
More US COPD Data
• COPD ranks #3 in acute hospital admissions (DRG: 088)
– 672,000 COPD discharges in 20061
– Avg. annual hospitalized days 8.182
– Avg. LOS 5.1 days3
– Avg. per day cost $2,9594
– Avg. total cost/admission $15,0934
– Avg. payment/admission $19,6355
• There are an est. 1.5 million home oxygen users
1. CDC. National Hospital Discharge Survey, 1979-2006. 2006 Unpublished Data.
2. Schneider KM, O’Donnell BE, Dean D. Prevalence of multiple chronic conditions in the United States’ Medicare
population. Health Qual Life Outcomes. 2009;7:82.
3. http://www.health.ny.gov/nysdoh/hospital/drg/2009_siw.pdf
4. Dalal AA, Christensen L, Liu F, Riedel AA. Direct costs of chronic obstructive pulmonary disease among
managed care patients. Int J COPD 2010;5:341-49.
5. 2007 Medicare PPS Inpatient Hospital Discharge Data.
COPD Re-Admission Data
• 22.6% of COPD patients are readmitted within 30-days1
• Key readmission predictors2
– Use of long-term oxygen therapy
– Low health status
– Lack of routine physical activity
• Key components to reducing readmissions3-8
– Comprehensive pre-discharge planning
– Patient-centric education
• Medications and compliance (including LTOT)
• AODL
• Recognition and response to exacerbation
– Education reinforcement
– Transportation, medication and nutritional support
1. Jencks SF. N Eng J Med 2009;360:1418-28.
5. Ramani AA. J Care Mgmt 2010;11(4):249-53.
2. Bahadori K. Int J COPD 2007;2(3):241-51.
6. Carlin BW. Respir Care 2010; 55(11):1535.
3. Farrero E. Chest 2001;119(2):364-9.
7. Laher D. Respir Care 2003; 48(11):1116.
4. Bourbeau J. Arch Intern Med 2003;163:585-91.
8. Stegmaier J. Respir Care 2006;51(11):1305.
COPD Hospitalization Rates
Holt JB, et al. Geographic disparities in COPD hospitalization among Medicare beneficiaries in the United States.
CDC. Intern J of COPD 2011;6:321-328.
Roots of COPD
NOTT (Nocturnal Oxygen Therapy Trial)
Ann Intern Med 1980;93(3):391-398
• 203 pts. randomized to continuous or nocturnal O2
for 5-years
– Enrollment criteria
– Continuous Group averaged 17.7  4.8 h/d
– Nocturnal Group averaged 12.0  2.5 h/d
• After 3½ years the mortality for nocturnal O2 group
was 1.94 times that for the continuous O2 group
– Continuous O2 therapy reduces mortality
– Basis for current LTOT standards
NOTT Study (Revisited)
Petty TL, Bliss PL. Respir Care 2000;45(2):204-211
Patients in study
203
Pedometer data
available
157
No match (computer
modeling to +/- 1%)
77
Nocturnal
oxygen therapy low walk
22
Matched patients (age,
sex, severity of
disease)
80
Continuous
oxygen therapy low walk
18
Nocturnal
oxygen therapy high walk
22
Continuous
oxygen therapy high walk
18
NOTT Study (Revisited)
Petty TL, Bliss PL. Respir Care 2000;45(2):204-211
100%
90%
High Walk COT
Survivor Fraction
80%
70%
High Walk NOT
Low Walk COT
60%
50%
40%
Low Walk NOT
30%
20%
10%
0%
0
0.5
1
1.5
2
Years in Study
2.5
3
3.5
4
NOTT Study (Revisited)
Petty TL, Bliss PL. Respir Care 2000;45(2):204-211
Average Per Patient Annual Duration of Hospitalization
8
7
7.2
Matched Data
6
Days
5
5.5
4.7
4
3
2.2
2
1
0
Low Walk NOT
Low Walk COT
High Walk NOT
High Walk COT
Since long-term oxygen is so good
for COPD patients, they must all be
very compliant… Right?
Compliance with O2 Prescription
• Pepin1 et al.
– 930 LTOT patients on O2 for at least 36-mos.
– Mean daily duration of O2 prescribed 16±3 hrs.
– Only 45% of pts used O2 for 15 hrs or > per day.
• Peckham2 et al.
– RCT: 86 pts (45 treatment & 41 control)
– Treatment group received additional clinician training
– Daily O2 use for 15 hrs or more after 6-months:
• Treatment group
• Control group
1.
2.
82%
44%
Long-term oxygen therapy at home: compliance with medical prescription and effective use of
therapy. Chest 1996;109:1144-50.
Improvement in patient compliance with long-term oxygen therapy following formal assessment and
training. Respir Med 1998;92(10):1203-6.
Device Related Saturation Shortfalls
Uncovered During Rehab Visits
Gaps Between Titration Settings at Discharge vs. Titration
on Home Device
Premier pulmonary rehab reviewed 65
patients post discharge:
•Treadmill test to evaluate ability of home device to
meet 90% saturation goal.
•60% did not meet target: 20% needed setting
adjusted upward; 40% could not be titrated at any
setting (replaced device).
Why are patients sent home on sub-standard device?
Source: Changes in Supplemental Oxygen Prescription in Pulmonary Rehabilitation, Limberg et al, Resp Care Nov 06; Vol 51 (11), pg 1302.
Now let’s get to
know our COPD
Patients
Characteristics of COPD Patients
• 80-90% of COPD results from cigarette smoking1
• Prevalence of those who smoke
– Education2
• < High school education
• High school education
• College graduates
32%
29.3%
13.3%
– Income2
• Below poverty level
• At or near poverty level
• Above poverty level
36.5%
32.8%
22.5%
• Average age when started on LTOT: 74±8 years3
1.
2.
3.
American Lung Association: http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html
(accessed 2/4/2011).
CDC – Morbidity & Mortality Weekly Report. January 14, 2011 / 60(01);109-113.
Ekstrom MP, Wagner P, Strom KE. Trends in cause-specific mortality in oxygen-dependent COPD. AJRCCM articles in press.
Published 1/7/2011. doi:10.1164/rccm.201010-1704OC.
Patients started on oxygen in 2012
• Were born in 1930 – 1946
• Turned 18 yrs old in 1948 – 1964
– 1948: 35% graduated HS, 7% college (4-years)
– 1964: 49% graduated HS, 12% college (4-years)
Barriers to Teaching Older Adults
• Vision Changes
– Pupil admits 50% less light for a person of 50 than
for someone that is 20.
• Hearing Changes
– Primarily caused by atrophy of inner ear
structures.
– Higher frequencies go first.
– Effect very prominent in cigarette smokers.
Neuropsychologic Impairment and
Severity of COPD
• 4 groups matched for age & education
–
–
–
–
Control (n=99)
Mild COPD (n=86)
Moderate COPD (n=155)
Severe COPD (n=99)
• Memory and neuro-performance tests compared
to control
Group
Mild
Performance deficit
27%
Moderate
Grant I, et al. Arch Gen Psychiatry 1987;44(11):999-1006
Severe
61%
Additional Confounding Factors
• 17% of Alzheimer’s patients have COPD1.
– One in eight people aged 65 and older (13%) has Alzheimer’s disease.
– Nearly half of people aged 85 and older (43%) have Alzheimer’s disease.
– Smoking almost doubles the risk of Alzheimer’s disease2.
• The prevalence of depression in COPD is 26%3.
• Racial, ethnic & cultural influences.
1.
2.
3.
Alzheimer’s Association website. Alzheimer’s disease and chronic health conditions: the real challenge for 21st
century medicine. www.alz.org/national /documents/report_chroniccare.pdf. Accessed 2/4/2011.
Janine K. Cataldo, Judith J. Prochaska, Stanton A. Glantz. Cigarette Smoking is a Risk Factor for Alzheimer's Disease:
An Analysis Controlling for Tobacco Industry Affiliation. Journal of Alzheimer's Disease, 2010;10:2010-40.
Hanania NA, Müllerova H, Locantore NW, et al. Determinants of depression in the ECLIPSE chronic obstructive
pulmonary disease cohort. Am J Respir Crit Care Med 2011;183(3):604-611.
Can we overcome these
training obstacles and improve
outcomes?
• Absolutely
• No freaking way!
LTOT Outcome Studies
• Ringbaek TJ, Viskum K, Lange P. “Does long-term oxygen
therapy reduce hospitalization in hypoxemic chronic
obstructive pulmonary disease? Eur Respir J. 2002
– Cohort study; n=246 10-mos. Pre vs. 10-mos. Post LTOT
– LTOT period compared with the pre-oxygen period
•
•
•
Hospital admission rate
hospital days
"ever hospitalized"
 23.8%
 43.5%
 31.2%
– Author’s conclusion: “This study shows that in hypoxemic
chronic obstructive pulmonary disease patients, long-term
oxygen therapy is associated with a reduction in
hospitalization.”
Can Homecare Providers Influence the
30-Day Readmission Rates for COPD?
• Retrospective analysis
• Regional (Western PA) 30-day COPD readmit rate  25%
• 180 pts enrolled in program (10 months)
– Referrals from 23 area hospitals
• Program components
– Pre-discharge assessment
– Home RT visits (days 2, 7 and 30)
– 12 Care Coordinator phone calls
• 30-day readmission rate reduced to 3%
BW Carlin, Wiles K, Easley D. Respir Care 2010;55(11):1535 (abstract)
Prevalence of HME Provider Programs
• Role of the Management Pathway in the Care of Advanced COPD
Patient in Their Own Homes. Ramani AA, et al. Care Manag J.
2010;11(4):249-53.
• Effect of a Homecare Respiratory Therapist Education Program on
30 Day Hospital Readmissions of COPD Patients. Kaufman LM, Smith
AP. Respir Care 2011;56(10):1691 (abstract)
• Healthspring Medicare Advantage Plan Comprehensive Case
management Respiratory Program. Prince D, Davidson M, Watson F.
Respir Care 2011;56(10):1690 (abstract)
• 2011 AARC Congress
– 5 symposia & 6 abstracts
• HME News poll of 120 HME Providers (2011;17(7) (July))
– 97 (81%) Have no program in place to address COPD readmissions!
• HME Providers – Opportunity
• Acute Care Providers – Need to vet your providers
Vetting a Respiratory HME Provider
• What is the location of the nearest office?
– Is the phone answered locally?
– Can I visit the office?
• Do they routinely provide OGPE? If yes,
– On which patients?
– Is it only for travel?
– Does it have to be specifically prescribed?
• Do they have RTs on staff? If yes,
– How many work out of local office?
– Do they provide clinical services or marketing?
• What is the process for patient education?
Questions
bmessenger@invacare.com