30 day COPD Readmissions- a medical directors prospective Jill Ohar MD - Professor of Medicine
Rate of readmission for COPD is high and increasing 3rd leading cause for all readmission 4th leading cause for 30d readmission Jencks S. NEJM 2009 pp: 1418-28 Shah T. Chest 2015 pp: 1219-26
COPD costs to the economy Exacerbation (70%) New Clinic Visit (1%) COPD readmit costs 1.5X the original admit Emergency (7%) Anticipated cost for COPD in 2020 $90.6 billion c/w $59.3billion in 2010 Hospitalization (92%) Miravitlles M. Chest2002pp:1449-55. Lau C. Int J Chron Obstruct Pulmon Dis 2017 pp 1891 -1902.
Enhanced transitions in care are critical but insufficient to reduce readmissions
Interventions that may decrease 30d readmits • Patient self-management • Early outpatient follow-up • Pulmonary rehabilitation • Receipt and filling of all respiratory medications at discharge • Inhaler device training • Pharmacist-supervised medication reconciliation Shah T. Chest 2016pp:916-26
Pulmonary rehab and clinic attendance was low Ohar JA. EurResp J 2016: PA551
52% of AECOPD have suboptimal PIFR Loh C. Ann Am ThoracSoc2017 pp: 1305- 11
Diagnostic Uncertainty 21% no PFTs, 12% unable to perform, 11% normal FEV1/FVC European COPD Audit showed 49.7% have spirometry on admission for AECOPD Wu H. CHEST 2017p1263-71 Hartl S. EurResp J 2016 pp: 113-121
Dilemma of Diagnosis • PNA • CHF 1,2 • Pneumothorax • Arrhythmia • VTE/PE (20% who present w/o Sx of infection)3 • Cardiac ischemic/infarction • Bronchitis 1Mueller C. J Int Med. 2005 p77. 2Tung RH. An Emer Med. 2006 p75. 3Tillie-Leblond I. An Intern Med. 2006 p390.
Clinical assessment can be deceiving – therefore inpatient spirometry • sensitivity - 94.4% (119/126) • specificity - 24.2% (8/33) • positive predictive value - 82.6% (119/144) • negative predictive value - 53.3% (8/15) Correlation of In- and Outpatient spirometry Receiver operator curve AUC 0.82 Loh C. ChronObstrucPulm Dis 2018 pp: 124-33
Cause for readmission is often a co-morbidity 27.6% Readmit cause is COPD in just 32.6% Medicare claims 2003-2004 Medicare claims 2006-2010 in 7 states Jencks S. NEJM 2009pp:1418-28 Shah T. Chest2015pp:1219-26
Readmits and mortality share risks Medicare beneficiaries > 65Yr 30d readmit is associated with 68% greater mortality risk CatalunaJJ.Thorax 2005pp: 925-31 Genao L. Ann Am ThoracSoc 2015 pp:1805-12 Hartl S. EurResp J 2016 pp:113 - 21
Mortality • Average inpatient mortality rate for AECOPD is 6.7% increasing to 15.6% in the post discharged period 1 • 25% are dead in a year 2,3 • Therefore initiate palliative and hospice services • 1 Hoogendoorn M. ERJ 2011 p508. 2Lykkegaard J Resp Med 2012. 3Groenewegen KH Chest 2003.
Putting it into practice - A comprehensive plan to reduce AECOPD readmits • Respiratory therapist directed • Focused on the 4 pillars of COPD inpatient care • Diagnosis & treatment of COPD • Diagnosis & treatment of co-morbidities • Enhanced transitions in care • Recognition of the dying patients and initiation of hospice and palliative care services
A comprehensive care plan reduces 30day readmissions and death Ohar JA. EurResp J 2016: PA551
A big thank you to all those who helped show that... A comprehensive plan that employs Diagnosis and treatment of COPD Diagnosis and treatment of comorbidities Enhanced transitions in care Referral for palliative and hospice services Works!