&


Patrick J. Dunne, MEd, RRT, FAARC
HealthCare Productions, Inc.
Fullerton, CA 92838 pjdunne@sbcglobal.net

I have a professional relationship with

Monaghan Medical Corporation

Mylan LP

Ohio Medical Corporation

 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.

Section 3025 Affordable Care Act
 Effective FY 2013 (10/1/12 - 9/30/13)
 2 nd 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

 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; 3 rd 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

Genes
Infections
Socio-economic status
Aging Populations
© 2013 Global Initiative for Chronic Obstructive Lung Disease

Anxiety, Depression, Addiction
Lung Cancer
Pulmonary Hypertension
Anemia
Diabetes
Metabolic Syndrome
Cachexia
Cardiovascular Disease
Peripheral Muscle
Wasting & Dysfunction
Osteoporosis
Peptic Ulcers
GI Complications
Adapted from Kao C, Hanania NA. Atlas of COPD. 2008.

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

 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

McCrory DC, et al. Chest; 2001
EFFICACY EVIDENCE EXISTS
Chest radiography/ABGs
Oxygen therapy
Bronchodilator therapy
Systemic steroids
Antibiotics
Ventilatory support (as required)
EFFICACY EVIDENCE LACKING
Sputum analysis
Acute spirometry
Mucolytic agents
Chest physiotherapy
Methylxanthine bronchodilators
Leukotrine modifiers; Mast cell stablizers
Level 1-2 evidence of efficacy = Recommended care
Insufficient efficacy evidence = Non-recommended care
Non-recommended care = Unnecessary care

 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

 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

Pre-2013
IV: Very Severe
III: Severe
II: Moderate
I: Mild
•
FEV
1
/FVC < 0.70
• FEV
1
≥ 80% predicted
• FEV
1
/FVC < 0.70
• 50% ≤ FEV
1 predicted
< 80%
•
FEV
1
/FVC < 0.70
• 30% ≤ FEV
1 predicted
< 50%
Active reduction of risk factor(s); smoking cessation, flu vaccination
Add short-acting bronchodilator (as needed)
•
FEV
1
/FVC < 0.70
•
FEV
1
< 30% predicted or FEV
1
< 50% predicted plus chronic respiratory failure
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

GOLD Guidelines (2013)
4
3
Risk
GOLD Classification of Airflow Limitation 2
1
(C)
(A)
(D) ≥ 2
(B)
Risk
1
Exacerbation history
0 mMRC 0-1 (or) CAT < 10 mMRC > 2 (or) CAT >
10
Symptoms
(mMRC or CAT score )

Fewer
Symptoms
More
Symptoms
> 2 exacerbations
0-1 exacerbations

GOLD Guidelines (2013)
4
3
Risk
GOLD Classification of Airflow Limitation 2
1
(C)
(A)
(D) ≥ 2
(B)
Risk
1
Exacerbation history
0 mMRC 0-1 (or) CAT < 10 mMRC > 2 (or) CAT >
10
Symptoms
(mMRC or CAT score )

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.

GOLD Guidelines (2013)

GOLD Guidelines (2013)

GOLD Guidelines (2013)

Global Strategy for Diagnosis, Management and Prevention of COPD
Risk
Pre-2013 GOLD
Classification of
Airflow Limitation
(C) (D) ≥ 2
3
30-50%
4
<30%
(A) (B)
1
≥ 80%
2
50-80% mMRC 0-1 (or) CAT < 10 mMRC > 2 (or) CAT > 10
Symptoms
(mMRC or CAT score )
0
Risk
1
Exacerbation history

GOLD Guidelines (2013)
When assessing risk, choose the highest risk according to GOLD grade or exacerbation history
A
B
C
D
Patient Characteristics
Less Symptoms
Low Risk
More Symptoms
Low Risk
Less Symptoms
High Risk
More Symptoms
High Risk
Spirometric
Classification
GOLD 1-2
GOLD 1-2
GOLD 3-4
Exacerbations per year mMRC
0-1
0-1
0-1
≥ 2
≥ 2 0-1
CAT
< 10
≥ 10
< 10
GOLD 3-4
≥ 2 ≥ 2 ≥ 10

GOLD Guidelines (2013)
FEV1
% PREDICTED
(AIRFLOW LIMITATION)
≥ 80%
50 – 80%
30 – 50%
≤ 30%
EXACERBATION
GRADE
(RISK)
LOW
MEDIUM
HIGH
VERY HIGH
TREATMENT
CONSIDERATIONS
Smoking cessation; Vaccinations; SABA prn
Add to above: Nebulized LABA-LAMA daily;
Pulm Rehab; Exacerbation action plan
Add to above: ICS for exacerbation prone;
Referral to pulmonologist
Add to above: long-term oxygen therapy;
Consider surgical options

McCrory DC, et al. Chest; 2001
EFFICACY EVIDENCE EXISTS
Chest radiography/ABGs
Oxygen therapy
Bronchodilator therapy
Systemic steroids
Antibiotics
Ventilatory support (as required)
EFFICACY EVIDENCE LACKING
Sputum analysis
Acute spirometry
Mucolytic agents
Chest physiotherapy
Methylxanthine bronchodilators
Leukotrine modifiers; Mast cell stablizers

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 valu e
 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

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

R ESPIRATORY C ARE: December 2013
ACT is not recommended for routine use in COPD.
ACT may be considered in COPD patients with symptomatic secretion retention.

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

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 6 th scheduled Rx (collector blinded)
 Inspiratory capacity; dyspnea; RR

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

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
FEV
1 and airway conductance.

Dhand R, et al. COPD; Feb 2012
RECOMMENDATION : Many patients, especially elderly patients with COPD , are unable to use their p MDIs 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 p MDIs and the requirement to generate adequate peak inspiratory flows with DPIs .

 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

Goals of Therapy
 Relieve airflow obstruction
 Improve exercise tolerance
 Improve health status
Reduce symptoms
 Prevent disease progression
 Prevent & treat exacerbations Reduce risk
 Reduce mortality
Reduced symptoms + Reduced risk = Successful disease management

Summary
 A new COPD care pathway essential
 COPD patients will impact hospital’s revenue
 Patient volume will vary by institution (1-2/month to 6-8/month)
 Advocate evidence-base care
 Re-design current workload
 Allocate resources accordingly
 Start small; Expand as necessary
 Appoint, anoint, elect one departmental COPD Guru
 Let patient volume drive program development
 Determine risk grade per 2013 GOLD Guidelines
 Use CAT (or) mMRC
 Ensure proper controller medications prescribed
 Recommend follow-up MD appointment within 5-7 days

Summary
 Two distinct programs
 Value-based Purchasing Program (VBP)


Bonus payment (or) penalty
Based on Core Performance Measures reported for:
• AMI, CHF, Pneumonia
 Hospital Readmission Reduction Program (HRRP)
 Penalty only
 Based on historic readmission rates for:
• AMI, CHF, Pneumonia
 Additional conditions to be added in FY 2015
 COPD for HRRP
 COPD Core Performance Measures coming for VBP?

Timely and Effective Care
 Performance measures tied to bonus or penalty payments
 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 ( LABA vs. SABA -only)
 Immunizations (pneumococcal, influenza)
 Demonstrate your value
 Help your hospital achieve bonus payments!!!!

&


CMS Pulls The Trigger on COPD
In Fiscal Year 2015
Patrick J. Dunne, MEd, RRT, FAARC
HealthCare Productions, Inc.
Fullerton, CA 92838 pjdunne@sbcglobal.net