Effective Discharge of the Oxygen Dependent COPD Patientc.ymcdn.com/sites/ · Effective Discharge of the Oxygen Dependent ... • Cognitive performance in patients with COPD. Respir

Effective Discharge of the Oxygen Dependant COPD PatientBob Messenger BS, RRT, FAARC

© Invacare Corporation, 2017

Effective Discharge of the Oxygen Dependent COPD Patient

Bob Messenger BS, RRT, FAARCGlobal Respiratory Insights Manager

Innovation & Engineering DepartmentInvacare Corporation

[email protected]

Disclosures

• Relevant Disclosures

– Employed by the Invacare Corp.

– Versions of this lecture have been published in;

– The Journal of Professional Case Management (2012;17(3):109-114)

– RT: For Decision Makers in Respiratory Care (Mar 2013; 8-11)

30% of Readmissions Come from 7 DRGs



30-Day Readmissions: Hospital Directed Reform

Penalties determined by formula based on National average readmission rates Socioeconomic and other factors of served population (risk adjustment) Achievement of targeted readmission goal

October 1, 2012 1st round of penalties (Measured Jan 1 – Dec 31, 2011) 2012 – capped at 1% of Medicare revenues Based on CHF, AMI and Pneumonia 44.5% of US hospitals penalized1 (2,217 out of 4985 in US2) 307 hospitals received the maximum penalty

October 1, 2013 Maximum penalty doubled to 2% 44.6% of hospitals penalized (2225 hospitals)2

18 hospitals received the maximum penalty

October 1, 2014 Maximum penalty capped at 3% 52.4% of hospitals penalized (2610 hospitals)3

39 hospitals received the maximum penalty3

Total penalties $428 million4

October 1, 2015 (Measured Jan 1 – Dec 31, 2014) COPD, elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) added to the “audit” list

Penalties applied to all DRGs

1. The New York Times. 11/26/12, Jordan Rau.2. Kaiser Health News. Accessed 8/5/20133. http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/4. Readmissions News, Volume 4, Number 1, January 2015

Zuckerman RB, et al. Readmissions, Observation, and the Hospital Readmissions Reduction Program. N Eng J Med. February 24, 2016

• Readmission to the hospital is considered an indicator of poor quality care and an inefficient use of resources– Hospitalizations are costly; accounting for 21% of all healthcare

expenditures ($250 billion in 2012)

• Almost one fifth (19.6%) of Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days1

– 34% rehospitalized within 90 days– 56.1% rehospitalized within 12 months– 22.6% (2009) 20.6% (2015) for COPD within 30 days

• Preventable readmissions are very costly– MedPAC estimates expenditures may be as high as $15 billion a

year2

– Jencks estimates the cost > $17 billion2

Why Readmission Matters

1Jencks S, et al. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. NEJM 2009;360:1418-282 Medicare Payment Advisory Commission (MedPAC), June 2005:83-103



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

COPD Prevalence by State

COPD Re-Admission Data• 22.6% of COPD patients are readmitted within 30-days1

• Key readmission predictors2

• 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.

2. Bahadori K. Int J COPD 2007;2(3):241-51.

3. Farrero E. Chest 2001;119(2):364-9.

4. Bourbeau J. Arch Intern Med 2003;163:585-91.

5. Ramani AA. J Care Mgmt 2010;11(4):249-53.

6. Carlin BW. Respir Care 2010; 55(11):1535.

7. Laher D. Respir Care 2003; 48(11):1116.

8. Stegmaier J. Respir Care 2006;51(11):1305.

Primary Secondary

Previous hospital admission Use of long-term oxygen therapy

Dyspnea Low health status

Oral corticosteroids Lack of routine physical activity

http://www.cdc.gov/nchs/fastats/copd.htm - accessed 3/17/11

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm



Roots of COPD

NOTT (Nocturnal Oxygen Therapy Trial)Ann Intern Med 1980;93(3):391-398

• 203 pts. randomized to continuous or nocturnal O2for 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 study203

Pedometer data available

157

No match (computer modeling to +/- 1%)

77

Matched patients (age, sex, severity of

disease)80

Nocturnaloxygen therapy -

low walk22

Continuousoxygen therapy -

low walk18

Nocturnaloxygen therapy -

high walk22

Continuousoxygen therapy -

high walk18

Low Walk < 3,590 ft/day > High Walk




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 0.5 1 1.5 2 2.5 3 3.5 4

Su

rviv

or

Fra

cti

on

Years in Study

High Walk COT

High Walk NOTLow Walk COT

Low Walk NOT


7.2

5.5

4.7

2.2

0

1

2

3

4

5

6

7

8

Low Walk NOT Low Walk COT High Walk NOT High Walk COT

Days

Matched Data

Average Per Patient Annual Duration of Hospitalization

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 82%

• Control group 44%

1. Long-term oxygen therapy at home: compliance with medical prescription and effective use of therapy. Chest 1996;109:1144-50.

2. Improvement in patient compliance with long-term oxygen therapy following formal assessment and training. Respir Med 1998;92(10):1203-6.

Why are patients sent home on sub-standard device?

Device Related Saturation Shortfalls Uncovered During Rehab Visits

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).

Gaps Between Titration Settings at Discharge vs. Titration on Home 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 32%

• High school education 29.3%

• College graduates 13.3%

– Income2

• Below poverty level 36.5%

• At or near poverty level 32.8%

• Above poverty level 22.5%

• Average age when started on LTOT: 74±8 years3

1. American Lung Association: http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html(accessed 2/4/2011).

2. CDC – Morbidity & Mortality Weekly Report. January 14, 2011 / 60(01);109-113.3. Ekstrom MP, Wagner P, Strom KE. Trends in cause-specific mortality in oxygen-dependent COPD. AJRCCM 2011; 183(8):1032-

1036.

Patients started on oxygen in 2017

• Were born in 1935 – 1951

• Turned 18 yrs old in 1953 – 1969

• High school graduation rates 36 – 77%

Source: http://voteview.com/High_School_Graduation_Rates.htm-accessed 11/01/2013

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.

http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html



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 Moderate Severe

Performance deficit 27% 61%

Grant I, et al. Arch Gen Psychiatry 1987;44(11):999-1006

Cognitive Impairment in COPD

• Cognitive decline among patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2009;180:134-137.

• Cognitive performance in patients with COPD. RespirMed 2004;98(4):351-356.

• Association of chronic obstructive pulmonary disease with cognitive decline in very elderly men. Dement Geriatr Cogn Disord Extra 2012;2:219-228.

• Brain structure and function in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2012;186(3):240-245.

• COPD and cognitive impairment: the role of hypoxemia and oxygen therapy. Int J COPD 2010;5:263-269.

• Cognitive function in COPD. Eur Respir J 2010;35:913-922.

Cognitive Dysfunction in COPDPrevalence by Domains

Dodd JW. Cognitive function in COPD. Eur Respir J 2010;35:913-22.

Domain Patients Dysfunction

Attention 795/827 96%

Perception 409/430 95%

Memory & learning 709/781 90%

Verbal & language 613/689 89%

Construction 594/648 92%

Concept formation & reasoning 579/629 92%

Executive 463/492 94%

Motor 726/776 94%



Can we overcome these training obstacles and improve

outcomes?

• Absolutely

• No freaking way!

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)

• 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

• “While 75% of respondents to a recent HME News poll admit they could be doing a better job educating patients about their therapies, many say they just don’t have the resources.” – HME News, February 19, 2016

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?

Reducing Readmissions:General Pearls

• Not all efforts should be disease specific

– Promote activity

– Deep breathing

– General nutrition (do they have food and are they eating?)

– Do they have and take ALL their meds?

– Are their activities limited relative to pre-hospitalization?

– Are they able to think as clearly as before?



• Hospitals are being forced to reduce readmissions or face a financial penalty.

• Reducing COPD readmission rates has been tied to ongoing training and support.

• Promoting and supporting patient ambulation with oxygen may reduce readmissions and improve QOL.

• Hospitals need to find ways, and partners, to help reduce readmissions.

Conclusions

Questions

[email protected]

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Effective Discharge of the Oxygen Dependent COPD Patientc.ymcdn.com/sites/ · Effective Discharge of the Oxygen Dependent ... • Cognitive performance in patients with COPD. Respir