pulls the trigger on copd in 2015cms将触发对慢性阻塞性肺疾病2015课件

CMS Pulls The Trigger on COPD In Fiscal Year 2015 Patrick J. Dunne, MEd, RRT, FAARC HealthCare Productions, Inc. Fullerton, CA 92838 2014 Annual Conference 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. Hospital Readmission Reduction Program Section 3025 Affordable Care Act Effective FY 2013 (10/1/12 - 9/30/13) v2nd of 2 new payment policies vFinancial penalties for excessive 30-day readmissions v3 Targeted conditions Acute MI (19.9%); CHF (24.5%); Pneumonia (18.2%) Additional conditions to be added in FY 2015 Hospitals identified nationwide vFY 2013 - - 2,213 hospitals w/ $280 million in penalties (up to 1%) vFY 2014 - - 2,225 hospitals w/ $227 million in penalties (up to 2%) vFY 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 Now, About COPD . . . . Definition: vA 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; 3rd Leading cause of death Airflow obstruction/alveolar destruction largely irreversible Primary cause: Long-term exposure to noxious inhalants vA largely preventable disease Fourth leading cause of recidivism Risk Factors for COPD Socio-economic status 2013 Global Initiative for Chronic Obstructive Lung Disease Genes Infections Aging Populations Cardiovascular Disease Lung Cancer Anxiety, Depression, Addiction Peripheral Muscle Wasting October 2006 vOnly 31% had confirmatory spirometry We must raise awareness of the need to confirm the diagnosis of COPD and its severity with spirometry Record review: 169 pts. with 1,664 care events Mularski RW, et al. Chest; December 2006 vSubjects 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 Inpatient COPD Care: The Evidence McCrory DC, et al. Chest; 2001 EFFICACY EVIDENCE EXISTSEFFICACY EVIDENCE LACKING Chest radiography/ABGsSputum analysis Oxygen therapyAcute spirometry Bronchodilator therapyMucolytic agents Systemic steroidsChest physiotherapy AntibioticsMethylxanthine bronchodilators Ventilatory support (as required)Leukotrine modifiers; Mast cell stablizers Level 1-2 evidence of efficacy = Recommended care Insufficient efficacy evidence = Non-recommended care Non-recommended care = Unnecessary care Under-treatment of COPD Record review: 69,820 records from 360 hospitals Lindenauer PK, et al. Ann Intern Med; June 2006 v66% 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 vNo pharmacotherapy 60% commercial, 70% Medicare vNo smoking cessation 82% commercial, 90% Medicare vNo 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 Under-treatment of COPD: Summary COPD - an expensive, chronic condition vIncidence is increasing vFinancial 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 FEV1/FVC 2 (or) CAT 10 Symptoms (mMRC or CAT score) Left (or) Right - - - Up (or) Down Fewer More Symptoms Symptoms 2 exacerbations 0-1 exacerbations Combined Assessment of COPD GOLD Guidelines (2013) Risk GOLD Classification of Airflow Limitation Risk Exacerbation history 2 1 0 (C)(D) (A)(B) mMRC 0-1 (or) CAT 2 (or) CAT 10 Symptoms (mMRC or CAT score) 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 Assessment of Symptoms GOLD Guidelines (2013) Both have been validated and relate well to other measures of health status and predict future mortality risk. Modified MRC (mMRC) Questionnaire GOLD Guidelines (2013) COPD Assessment Test (CAT) GOLD Guidelines (2013) COPD Assessment Test (CAT) GOLD Guidelines (2013) Combined Assessment of COPD Global Strategy for Diagnosis, Management and Prevention of COPD Risk Pre-2013 GOLD Classification of Airflow Limitation Risk Exacerbation history 2 1 0 (C)(D) (A)(B) mMRC 0-1 (or) CAT 2 (or) CAT 10 Symptoms (mMRC or CAT score) 2 50-80% PatientCharacteristicsSpirometric Classification Exacerbations per year mMRCCAT A Less Symptoms Low Risk GOLD 1-20-10-1 10 B More Symptoms Low Risk GOLD 1-20-1 2 10 C Less Symptoms High Risk GOLD 3-4 20-1 10 D More Symptoms High Risk GOLD 3-4 2 2 10 Combined Assessment of COPD GOLD Guidelines (2013) When assessing risk, choose the highest risk according to GOLD grade or exacerbation history COPD Maintenance Treatment by Airflow Limitation/Risk GOLD Guidelines (2013) Inpatient COPD Care: The Evidence McCrory DC, et al. Chest; 2001 EFFICACY EVIDENCE EXISTSEFFICACY EVIDENCE LACKING Chest radiography/ABGsSputum analysis Oxygen therapyAcute spirometry Bronchodilator therapyMucolytic agents Systemic steroidsChest physiotherapy AntibioticsMethylxanthine bronchodilators Ventilatory support (as required)Leukotrine modifiers; Mast cell stablizers Acute Spirometry with COPD Exacerbation Isnt spirometry needed to Confirm Dx and Grade Airflow Limitation? Acute spirometry vHospitalized patients not ready for full PFT studies Unable to exert maximal effort; Repeat maneuvers Pre-post bronchodilator response of limited value vMake appointment for 4-6 weeks post recovery What about peak inspiratory flow? vNot a demanding test but insightful vAbility to use a DPI Generate 40 L/min PIF Secretion Retention with COPD Exacerbation Can Contribute to Airflow Obstruction; WOB Chest physiotherapy vAn airway clearance technique (ACT) Secretion retention, ineffective cough problematic Trendelenburg position contraindicated in COPD vProven 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 Airway Clearance Therapy: The Evidence RESPIRATORY CARE: December 2013 ACT is not recommended for routine use in COPD. ACT may be considered in COPD patients with symptomatic secretion retention. Medication Nebulizers Not all jet-nebulizers are created equal! Higher respirable dose = Quicker onset of action! Higher respirable dose = Shorter treatment times! Quicker onset/less time = Better RT deployment! Respirable Dose 10% Respirable Dose 30% Respirable Dose 15% Dynamic hyperinflation Dynamic Hyperinflation Breath Actuated Nebulizer in COPD Haynes J. Respir Care; Sept 2012 Prospective, randomized controlled trial Objective: compare bronchodilator response w/ BAN to standard SVN Patients admitted w/ COPD exacerbation vN = 40 of 46; Similar baseline characteristics vDyspnea secondary to dynamic hyperinflation Medication regimen v 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 6th scheduled Rx (collector blinded) v Inspiratory capacity; dyspnea; RR Breath Actuated Nebulizer in COPD Haynes J. Respir Care; Sept 2012 Findings: vBoth groups received same # Rxs (6.25; 6.20) vIC higher in BAN v. SVN (1.83 L v. 1.42 L; P .03) Change in IC greater BAN v. SVN vRR lower in BAN v. SVN (19/min v. 22/min; P = .03) vNo difference in BORG or LOS Breath Actuated Nebulizer in COPD Haynes J. Respir Care; Sept 2012 Conclusions: vIn this cohort of patients with ECOPD, the AeroEclipse II BAN was more effective in reducing lung hyperinflation and respiratory rate than traditional SVN. vIt may be that the BAN group simply received more medication because of the breath activated modeAerosols with MMAD of 3.0 m produce the highest physiological response in terms of FEV1 and airway conductance. Role of Nebulized Therapy in COPD Dhand R, et al. COPD; Feb 2012 RECOMMENDATION: Many patients, especially elderly patients with COPD, are unable to use their pMDIs 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 pMDIs 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 Expand as necessary vAppoint, anoint, elect one departmental COPD Guru vLet patient volume drive program development Determine risk grade per 2013 GOLD Guidelines vUse CAT (or) mMRC vEnsure proper controller medications prescribed vRecommend follow-up MD appointment within 5-7 days New CMS Payment Mo