Pulling it together

Comprehensive COPD care should include standardized diagnosis and treatment, patient education, careful discharge planning and follow-up.

A few years ago, hospital administrators and others involved with the Pittsburgh Regional Health Initiative (PRHI) zeroed in on chronic obstructive pulmonary disease (COPD) as a leading preventable cause of hospital readmissions in western Pennsylvania. Yet despite data showing that COPD accounted for the second-highest volume of readmissions after congestive heart failure, most hospitals lacked a comprehensive system for managing COPD patients.

“Every doctor was treating patients his or her own way, which made it hard for hospital staff to organize appropriate support programs,” said Harold D. Miller, strategic initiatives consultant to the PRHI. “Because hospitals were treating COPD patients in an ad hoc fashion, there was no systematic way of measuring the effectiveness of care.”

Photo by Getty Images
Photo by Getty Images.

PRHI, a nonprofit collaborative made up of hospitals, physician groups, business leaders, insurers and others, set out to change that scenario. Funded by a foundation grant, the group launched a pilot program in January 2007 in two hospitals that required physicians to identify COPD patients at admission and follow a set treatment protocol up to discharge and beyond. The goal was to engage hospitals in a coordinated network of chronic disease care. The hospitals tracked patients on computerized registries; provided patient education and improved patient communication; created standardized discharge templates; and forged stronger ties with primary care physicians and other outside clinicians.

After two years, the project yielded impressive results. At UPMC St. Margaret hospital, affiliated with the University of Pittsburgh Schools of Health Sciences, readmissions of COPD patients within 30 days of discharge were cut nearly in half between January and November 2009 (from 12.9% to 6.9%) compared with the same period in 2008, according to the PRHI's 2009 report on the pilot. A similar decrease was seen in 2010, said Mr. Miller. Premier Medical Associates, which comprises 12 hospitalists based at Western Pennsylvania Hospital-Forbes Regional Campus and 30 office-based primary care physicians, also saw low readmission rates after putting the COPD plan into practice. While baseline data are not available, the group tracked its COPD-related readmissions within 30 days during 2009 and reported a 5.8% rate, low enough to suggest that the program was effective, the PRHI report said.

Based on these results, the hospitals adopted the pilot practices permanently. Meanwhile, other facilities, like the Mayo Clinic in Rochester, Minn., are also stepping up efforts to care for COPD patients in a comprehensive way that starts in the hospital and extends into the patient's home. Elements include improving the initial diagnosis of COPD, standardizing treatment based on the best available evidence, educating patients on self-treatment, and coordinating with outpatient physicians and other health workers so quality care continues after discharge.

“It's not just a matter of fixing [COPD patients] up and getting them out the door,” Mr. Miller said. “It is an opportunity to stop and think about what's going on with this patient, why they are here and how it can be avoided in the future.”

Standardizing diagnosis and treatment

Identifying patients early in their hospital visit is critical to improving COPD care, said James Costlow, MD, an internist and partner of Premier Medical Associates.

“We ask hospitalists to identify patients as they come in, which isn't always easy since patients do not always present with obvious exacerbations of COPD,” said Dr. Costlow. “They could have mild congestive heart failure that is a product of exacerbation or urosepsis that debilitated to the point where COPD became a bigger problem.”

In order to spot patients without obvious exacerbation symptoms, hospitalists must probe a bit, Dr. Costlow said. For example, if a patient is admitted for another reason, ask about shortness of breath and smoking history; also ask about prior diagnosis of COPD and current medications. Since Premier physicians have access to an electronic prescription database of Premier patients, they can look up allergies or medications—but even with that, the process isn't always seamless, he said.

“It comes down to the point where sometimes hospitalists are busy and just trust what the patient gives them [about allergies and medications],” said Dr. Costlow. “But we reinforce the importance of [using the database] every time.”

After flagging a patient with a diagnosis of COPD, hospitalists at Premier and UPMC St. Margaret follow evidence-based treatment guidelines set by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Recent research supports the importance of adhering to GOLD guidelines on drug treatment for exacerbations, noted Gulshan Sharma, MD, MPH, pulmonary and critical care specialist at the University of Texas Medical Branch in Galveston. One study found that low-dose steroids administered orally are as effective as high-dose intravenous therapy, which is consistent with GOLD recommendations to treat with 40 mg to 60 mg of prednisone orally once a day. Yet most hospitalized patients with acute exacerbations are given high doses administered intravenously, according to a study by Peter K. Lindenauer, FACP, and colleagues published in the June 16, 2010 Journal of the American Medical Association (JAMA).

“A low dose is as effective as a high dose in addition to short-acting bronchodilators,” said Dr. Sharma. Another large observational study by Dr. Lindenauer published in the May 26, 2010 JAMA concluded that patients who received antibiotics for acute exacerbations—also consistent with current guidelines—had shorter stays and better outcomes. However, physicians “have been slow to adopt these guidelines,” the study authors said, noting that fewer than 80% of patients in the study sample received antibiotics in the first two days of hospitalization.

The Mayo Clinic is also standardizing treatment in the hospital in order to improve COPD care, said Roberto Benzo, MD, senior associate consultant in Mayo's division of pulmonary and critical care. A diagnosis of COPD at admission—or during a patient's stay—triggers an evidence-based clinical pathway based on GOLD guidelines, he said. Physicians treat severe symptoms of COPD during the patient's stay, educate her on treatment and engage her in her own care, Dr. Benzo said. They use care managers to follow up after discharge, as well, he said.

Patient education

Hospitalization provides a valuable opportunity to educate patients about the use of their inhalers, noted Dr. Sharma. That means going beyond running through a yes/no checklist with the patient at discharge to actually demonstrating proper administration of medications.

“It's important that a doctor or nurse monitor the patient's techniques of using the inhaler,” he said. “Older people, especially, often have issues with dexterity and coordination” and sometimes need to be prescribed a spacer (which allows pumping instead of breathing in) in order to use the inhaler properly.

PRHI pilot data revealed that 79% of patients did not know how to use their inhalers properly and that many were confused about the distinctions between different types of inhalers. For example, said Mr. Miller, patients who had trouble paying for their medications tended to keep only a short-acting bronchodilator, or rescue inhaler, because that's what they used when they became short of breath. They didn't understand that the long-acting inhaler could prevent them from having to use the rescue inhaler.

“They would tend to give up on the long-acting bronchodilator, which is the thing most likely to keep them out of the hospital,” said Mr. Miller. “The education process we set up tried to explain to them the value of different inhalers and direct them to where to get help.”

The Mayo Clinic emphasizes the critical role of patients in their own care while they are in the hospital so they go home prepared to manage their disease, said Dr. Benzo. As part of a National Institutes of Health-funded initiative, Mayo will soon start using motivational interviewing techniques to enhance COPD patients' involvement in specific parts of their care, and giving them written action plans for treating exacerbations at home, he said.

Many COPD patients leave the hospital at risk of being readmitted for the same reason they were initially admitted, said Dr. Benzo. “A lot of times patients enter the hospital very sick, get treated and go home, but there is no down time for the patient to absorb knowledge that will translate into behaviors like coping better with symptoms, being more active and knowing what to do when COPD exacerbates.”

Medication at discharge: A huge opportunity

Most hospitalists correctly diagnose COPD exacerbations, which there is no need to confirm by spirometry initially, said Antonio Anzueto, MD, a pulmonary and critical care specialist at the University of Texas Health Sciences Center in San Antonio who serves on the executive and scientific committee of GOLD. COPD is considered when the ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is less than 70%, and based on the FEV1 percent of the predicted value can establish the severity of the disease, according to GOLD.

However, hospitalists often don't probe deeper to establish if a patient has a prior diagnosis or is currently taking medications. Consequently, the patient is placed on a short-acting beta-agonist (such as albuterol) to manage the exacerbation but is taken off any maintenance medications that may have been taken before admission, he noted.

When a patient is admitted with an exacerbation, Dr. Anzueto advised, follow one of these three pathways:

  • If previously diagnosed with COPD, prescribe maintenance medications at discharge.
  • If newly diagnosed with COPD, prescribe long-acting bronchodilators at discharge. Patients should have a spirometry test within three months to confirm their diagnosis, and therapy should be adjusted based on disease severity.
  • If previously diagnosed but admitted for reasons unrelated to COPD, ensure that the patient continues on his or her long-acting medications while in the hospital.

“The big issue with readmissions has to do with patients leaving the hospital receiving inappropriate therapy,” said Dr. Anzueto. “They are admitted using long-acting beta-2 agonists, long-acting anticholinergics and/or inhaled glucocorticosteroids, but they don't leave the hospital with those medications, so they end up being readmitted. Therefore, patients should be put back on their maintenance medications as soon as possible while they are hospitalized and at discharge.”

Beyond the hospital

Coordination with outpatient physicians is a critical component of a hospital's COPD plan, noted Dr. Sharma. In a study of more than 62,000 Medicare patients admitted for COPD, discharge planning that stressed early outpatient follow-up with a patient's primary care physician or pulmonologist was associated with fewer ED visits and hospital readmissions within 30 days of discharge, reported Dr. Sharma and colleagues in the Oct. 11, 2010 Archives of Internal Medicine.

Hospitalists should also consider referring patients to pulmonary rehabilitation following an acute exacerbation, said Michael Campos, FACP, assistant professor of medicine, division of pulmonary and critical care medicine at the University of Miami Miller School of Medicine. “It can be as important as any medication” and has been shown to reduce readmissions, he said. For example, a study in the May 2010 Thorax found that, compared with usual care, outpatient pulmonary rehabilitation was associated with lower readmissions over the following three months (33% in the usual care group were readmitted vs. 7% in the rehabilitation group).

At Premier Medical Associates, hospitalists ensure that patients receive instruction on how to use their inhalers correctly, that their medications are up to date, and that their primary care physicians receive a list of those medications, said Dr. Costlow. At discharge, patients leave with an appointment to see their primary care physician within seven days. Hospitalists also meet regularly with a care manager to discuss any problems that arise during or after discharge. The manager contacts the patient during his or her stay and follows up with him or her after discharge, including paying a home visit to evaluate his or her living situation.

Care managers involved with the PRHI pilot discovered unanticipated problems during home visits, said Mr. Miller. “One man was using a spacer that was covered with black mold because he kept it in the bathroom where he took hot showers,” he said. Another was washing his nebulizer every day and putting it in a plastic bag while wet, creating a perfect breeding ground for the bacteria that likely caused his pneumonia.

“Those are the kind of things you don't know until you actually see them at home,” said Mr. Miller. “A call wouldn't pick up on them because if a person was asked if they were using the inhaler correctly, they would probably just say yes.”