Effective Discharge of the Oxygen Dependant COPD Patient

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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.
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Effective Discharge of the Oxygen Dependant COPD PatientBob Messenger BS, RRTManager, Respiratory EducationInvacare CorporationDisclosures
  • 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 RatesReadmission 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 ChainInitial Admission: CABG SurgeryReadmission: Post-op Wound InfectionReadmission: 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
  • NHLBI: Morbidity and Mortality: 2007 Chartbook on Cardiovascular, Lung and Blood Diseases.
  • CDC Fast Facts: COPD. http://www.cdc.gov/nchs/fastats/copd.htm - accessed 3/17/11.
  • Extrapolated from CDC data: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a4.htm - accessed 3/24/11
  • 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
  • CDC. National Hospital Discharge Survey, 1979-2006. 2006 Unpublished Data.
  • 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.
  • http://www.health.ny.gov/nysdoh/hospital/drg/2009_siw.pdf
  • 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.
  • 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
  • Jencks SF. N Eng J Med 2009;360:1418-28.
  • Bahadori K. Int J COPD 2007;2(3):241-51.
  • Farrero E. Chest 2001;119(2):364-9.
  • Bourbeau J. Arch Intern Med 2003;163:585-91.
  • Ramani AA. J Care Mgmt 2010;11(4):249-53.
  • Carlin BW. Respir Care 2010; 55(11):1535.
  • Laher D. Respir Care 2003; 48(11):1116.
  • Stegmaier J. Respir Care 2006;51(11):1305.
  • COPD Hospitalization RatesHolt 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 COPDNOTT (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):204-211NOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211High Walk COTHigh Walk NOTLow Walk COTLow Walk NOTNOTT Study (Revisited)Petty TL, Bliss PL. Respir Care 2000;45(2):204-211Average Per Patient Annual Duration of HospitalizationSince 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%
  • 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 VisitsGaps 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 PatientsCharacteristics 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
  • 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
  • Grant I, et al. Arch Gen Psychiatry 1987;44(11):999-1006Additional 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.
  • 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  23.8%
  • hospital days  43.5%
  • "ever hospitalized"  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?
  • Questionsbmessenger@invacare.com
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