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Beyond the Norm: Reviewing Complex Cases

of COPDEmily Pherson, PharmD., BCPS

Clinical Pharmacy Specialist – Internal MedicineThe Johns Hopkins Hospital

Baltimore, MD

Michael J. Cawley, PharmD., RRT, CPFT, FCCMProfessor of Clinical Pharmacy

Philadelphia College of PharmacyUniversity of the Sciences

Philadelphia, PA

DisclosuresMichael J. Cawley and Emily C. Pherson declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts,

stock holdings, and honoraria.

The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

• Target Audience: Pharmacists

• ACPE#: 0202-0000-17-100-L04-P

• Activity Type: Knowledge-based

Learning Objectives1. Develop an appropriate plan for the initiation,

titration, monitoring and altering of pharmacotherapy for COPD management

2. Discuss appropriate COPD management strategies in patients during transition of care

3. Describe examples of pharmacists’ activities that have been found to reduce hospital readmission rates for patients with COPD

1. When determining appropriate drug therapy for COPD which elements must be included in the assessment?

A. Exacerbation history B. Spirometry C. Symptoms and exacerbation history D. Symptoms, spirometry and exacerbation history

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2. What is the recommend first line treatment for a patient who is categorized as GOLD Group C?

A. Long-acting muscarinic antagonist (LAMA)B. Long-acting beta agonist (LABA) C. LAMA + LABAD. LABA + inhaled corticosteroid (ICS)

3. Which of the following is the MOST important pharmacist management strategy to reduce readmissions for COPD?

A. Making sure patients know the role of each medication

B. Assess the patients ability to understand the signs and symptoms of worsening of disease

C. Evaluate ability of patient to maintain medication adherence

D. All equally important

4. Which of the following metric(s) demonstrate the impact of outpatient pharmacist care in COPD?

A. Reduction of hospital admissionB. Decrease medication use C. Improve patient compliance with insurance copaysD. Recommend use of antibiotics in all patients

Assessment of COPD

2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 10

• Current level of patient symptoms• Modified Medical Research Council Questionnaire (mMRC)

• Measure of breathlessness

Grade Patient’s description of breathlessness Grade 0 I only get breathless with strenuous exercise Grade 1 I get short of breath when hurrying on the level or walking

up a slight hillGrade 2 I walk slower than people of the same age on the level

because of breathlessness or have to stop for breath when walking at my own pace on the level

Grade 3 I stop for breath after walking about 100 yards or after a few minutes on the level

Grade 4 I am too breathless to leave the house or I am breathless when dressing

Assessment of COPD• COPD Assessment Test (CAT)

• 8 item measure of health status impairment in COPD• Frequency of cough• Presence of mucus in chest • Chest tightness • Breathlessness when walking on an incline• Limitation in activities at home• Confidence in leaving home • Sleep satisfaction • Energy level

• COPD Control Questionnaire (CCQ)• 10 item self-administered questionnaire

112017 Global Initiative for Chronic Obstructive Lung Disease, Inc.

Assessment of COPD

• Severity of the spirometric abnormality • FEV1/FVC < 0.70: diagnostic of COPD

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Gold 1: Mild FEV1 > 80% predicted

Gold 2: Moderate 50% < FEV1 < 80% predicted

Gold 3: Severe 30% < FEV1 < 50% predicted

Gold 4: Very severe FEV1 < 30% predicted


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Assessment of COPD

• Exacerbation risk• Best predictor of having frequent exacerbations (2 or more per

year) is a history of previous treated events


Refined assessment tool

2016 Global Initiative for Chronic Obstructive Lung Disease, Inc. 2017 Global Initiative for Chronic Obstructive Lung Disease, Inc.

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2011 – 2016 2017Classification of airflow limitation

Present Removed

mMRC/CAT Present PresentExacerbation history Higher risk: > 2

Lower risk: 0 or 1 Higher risk: > 2 or > 1 leading to hospitalization

Lower risk: 0 or 1 not leading to hospitalization

Patient Case #1

VF is a 55 y/o male with a PMH significant for CAD (s/p PCI w/ placement of 2 DES in October 2014), hypothyroidism and COPD (FEV1 50% May 2016). He presents to the emergency room with malaise, shortness of breath, and cough. He is admitted for treatment of a COPD exacerbation.

• Prior to admission medications: clopidogrel 75 mg PO daily, ASA 81 mg PO daily, levothyroxine 50 mcg PO every morning, tiotropium 1 capsule inhaled once daily, albuterol MDI 2 puffs q4‐6h PRN, azithromycin 250 mg PO daily (initiated June 2016)

• Social history: has been smoke‐free since October 2014, drinks alcohol socially, works in the warehouse at the amazon distribution center

Pharmacist’s Patient Care Process

• Collect

• Assess

• Plan

• Implement

• Follow-up: Monitor and Evaluate

https://www.pharmacist.com/sites/default/files/files/PatientCareProcess.pdf

Patient Case #1

• Question 1: • What workup needs to be done to properly assess VF’s COPD?

• Question 2: • What group (number) and grade (letter) score would you give VF?

Question 1

• What workup needs to be done to properly assess VF’s COPD?

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Question 1

• PFTs• FEV1 50% May 2016

• mMRC/CAT• CAT = 12

• History of exacerbations • Hospitalized once in June 2016, no clinic visits with exacerbations

Question 2

• What group (number) and grade (letter) score would you give VF?

Question 2

Grade = 2 Group = D

1 Mild FEV1 > 80% predicted

2 Moderate 50% < FEV1 < 80% predicted

3 Severe 30% < FEV1 < 50% predicted

4 Very severe FEV1 < 30% predicted

> 2 or > 1 leading to hospital admission

C D

0 or 1 (not leading to hospital admission)

A B

mMRC 0 – 1 CAT < 10

mMRC > 2CAT > 19

Symptoms

Exac

erba

tion

Hist

ory

Prevention of Exacerbations

Characteristic AzithromycinN = 558

PlaceboN = 559

Gold stage – %IIIIIIV

264034

264033

Medications for COPD - %Inhaled ICS + LABAsInhaled ICS + LABAs + LAMAs

1949

2246

Entry Criteria - %Exacerbation in past 12 months* Systemic steroids in past 12 monthsLong-term oxygen

508460

518559

N Engl J Med 2011;365:689-98. 22

*requiring ED visit or hospitalization

Prevention of Exacerbations

N Engl J Med 2011;365:689-98. 23

57% vs. 68%

Prevention of Exacerbation

N Engl J Med 2011;365:689-98. 24

Characteristic AzithromycinN = 558

PlaceboN = 559

P value

Audiogram-confirmed hearing decrement - %

25 20 0.04

Nasopharyngealcolonization - %

12 31 <0.001

Resistance to macrolides pre-study - %

52 57 0.64

Resistance to macrolidespost-study - %

81 41 <0.001

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Management of Stable COPD

Group A

A bronchodilator

Continue, stop or try alternative class of bronchodilator

Group B

LABA orLAMA

LAMA +LABA

LAMA orLABA

2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 25Indicates preferred therapy

Management of Stable COPD

Group C

LAMA + LABA

LABA + ICS

LAMA

Group D

Considerroflumilast

Consider macrolide

LAMA + LABA + ICS

LAMA + LABA

LABA + ICS

2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. 26Indicates preferred therapy

Medications

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Timeline: Long-acting Beta2 Agonist

1994 SereventDiskus®

2001 Foradil

Aerolizer®

2006 Brovana®

2011 Arcapta

Neohaler®

2014 Striverdi

Respimat®

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Beta2-agonists Stimulation of

beta2 adrenergic receptors

Increase in cyclic AMP

Smooth muscle

relaxation

• Side effects:• Sinus tachycardia• Arrhythmias • Tremor


Products Generic Brand DosingLong-actingSalmeterol Serevent Diskus 1 inhalation

twice dailyFormoterol Foradil Aerolizer 1 capsule inhaled

twice dailyArformoterol Brovana 1 nebulization

twice dailyIndacaterol Arcapta Neohaler 1 capsule inhaled

once dailyOlodaterol Striverdi Respimat 2 inhalations

once daily

Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016. 30

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Differences • Efficacy:

• All: • No effect on mortality or rate of decline of lung

function• Improve FEV1, quality of life, exacerbation rate

• Salmeterol: reduces rate of hospitalization• Adverse events:

• Indacaterol: significant cough (24% of patients) • Frequency of dosing:

• Indacaterol/olodaterol: once daily • Cost:

• Formoterol/olodaterol: least expensive

31

2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.

Timeline:Long-acting muscarinic antagonists (LAMA)

2004 Spiriva

Handihaler

2012 TudorzaPressair

2013 IncruseEllipta

2015 Seebri

Neohaler

32

LAMAs

Block muscarinic receptors on

airway smooth muscle

Prevent muscle contraction

• Side effects:• Dry mouth • Sinusitis • Worsening of urinary

retention


Products

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Generic Brand DosingLong-actingTiotropium Spiriva HandiHaler

Spiriva Respimat

1 capsule once daily

2 inhalations once daily

Aclidinium Tudorza Pressair 1 inhalation twice daily

Umeclidinium Incruse Ellipta 1 inhalation once daily

Glycopyrronium Seebri Neohaler 1 capsule inhaled twice daily

Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.

Differences• Efficacy

• All: improvements in symptoms, HRQL• Tiotropium: reduction in exacerbations and hospitalizations (outcome data

not yet available for other agents)• Adverse events

• No significant differences• Frequency of dosing

• Tiotropium and umeclidinium offer daily dosing• Cost

• Aclidinium < umeclidinium < tiotropium/glycopyrronium



Short-acting bronchodilators

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Generic Brand DosingAlbuterol Ventolin HFA

ProAir HFA1-2 inhalations every 4-6 hours as needed

Ipratropium Atrovent HFA 1-2 inhalations every 6 hours

Albuterol + Ipratropium CombiventRespimat

1 inhalation 4 times daily


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Timeline:Combination Products

2000 Advair Diskus

2006 Symbicort

2010 Dulera

2013 Breo

Ellipta

2013 AnoroEllipta

2015 Utibron

Neohaler

2015 Stiolto

Respimat

2016 Bevespi

Aerosphere

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Long acting Beta2 Agonist (LABA) + Inhaled Corticosteroid (ICS)

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Generic Brand DosingSalmeterol/fluticasone

Advair 1 inhalation twice daily

Formoterol/budesonide

Symbicort 2 inhalations twice daily

Formoterol/mometasone

Dulera 1 inhalation twice daily

Vilanterol/fluticasone

Breo Ellipta 1 inhalation once daily


Inhaled Corticosteriods(only in combination with LABAs)

• Reduce airway hyperresponsiveness

• Inhibit inflammatory cell migration and activation

• Block late phase reaction to allergens

• ICS use alone in COPD does not modify long-term decline of FEV1

• Side effects:• Oral candidiasis • Increased URI• Decrease in bone density -

controversial


Differences• Efficacy

• ICS + LABA together more effective then individual components in improving lung function, health status and reducing exacerbation

• No comparative data • Adverse events

• No differences • Frequency of dosing

• Fluticasone furoate/vilanterol offers once daily dosing• Cost

• Fluticasone furoate/vilanterol << fluticasone/salmeterol /budesonide/formoterol/mometasone/formoterol

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Long-acting muscarinic antagonist (LAMA) + Beta2 Agonist (LABA)

Generic Brand DosingIndacterol/glycopyrronium Utibron Neohaler 1 capsule inhaled

twice daily

Vilanterol/umeclidinium Anoro Ellipta 1 inhalation once daily

Vilanterol/umeclidinium Stiolto Respimat 2 inhalations once daily

Glycoplyrrolate/formoterol BevespiAerosphere

2 inhalations twice daily

41Lexicomp Online, Lexi-Drugs, Hudson, Ohio: Lexi-Comp, Inc.; April 4, 2016.

Differences • Efficacy

• Recommended as initial therapy for Group D patients• LABA/LAMA combination was superior to a LABA/ICS combination in

preventing exacerbations • Group D patients are at a higher risk of developing pneumonia when using

ICS• Adverse events

• No differences • Frequency of dosing

• Vilanterol/umeclidinium and vilanterol/umeclidinium offer once daily dosing• Cost

• Similar to LABA/ICS


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Roflumilast

Mechanism Inhibits breakdown of cAMPDosing 500 mcg by mouth once daily

Efficacy Improves FEV1 and reduces exacerbations in patientstreated with long-acting bronchodilators

Side effects Nausea, reduced appetite (weight loss), abdominal pain, diarrhea, sleep disturbances, and headache

Place in therapy FEV1 <50% predicted and patient has chronicbronchitis in combination with long-acting bronchodilators

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Patient Case #2

VF is now on hospital day 2 and his nebs have been weaned back to q6h PRN. The team is now trying to decide what maintenance therapy should be initiated for VF.

• Assessment information:• FEV1: 50% (May 2016) • CAT: 12

Patient Case #2

• Question 1:• What inhaled therapy would you recommend for VF?

• Question 2:• Would you consider recommending any oral therapies for VF? If

so, what therapies would you recommend? • Question 3:

• What can the pharmacist do prior to discharge to make sure VF will have a successful transition with his medication regimen once he goes home?

Question 1 • What inhaled therapy would you recommend for VF?

Question 1 • Group D

Considerroflumilast

Consider macrolide

LAMA + LABA + ICS

LAMA + LABA

LABA + ICS

Question 2 • Would you consider recommending any oral therapies for VF? If so,

what therapies would you recommend?

• Prior to admission medications: • clopidogrel 75 mg PO daily• ASA 81 mg PO daily• levothyroxine 50 mcg PO every morning• tiotropium 1 capsule inhaled once daily • albuterol MDI 2 puffs q4-6h PRN• azithromycin 250 mg PO daily (initiated June 2016)

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Question 2

• Consider continuing azithromycin but re-evaluating therapy at one year

• He is not yet on maximum inhaled therapy (LAMA + LABA + ICS) therefore would not consider addition of roflumilast

Question 3• What can the pharmacist do prior to discharge to make sure VF will

have a successful transition with his medication regimen once he goes home?

Question 3

• Checking outpatient formulary • Inhaler technique teaching while inpatient • Consider post-discharge pharmacy follow-up options

Patient Case # 3• Thomas is a 51‐year‐old male who presents to your pharmacy for a refill of an albuterol inhaler and new prescription for aclidinium bromide inhaler. He is a patient that was just discharged from the hospital due to a COPD exacerbation

• Medical problems include COPD x 1 year, HTN x 12 years and deuteranopia (color blindness) since birth

• Smoker (30 pack year history)

• Occupational history as a construction laborer x 20 years

• His only other medication includes amlodipine 5 mg daily

Would Thomas end up as another hospital readmission statistic?

Hospital Readmissions…….• Kaiser Permanente reviewed 523 readmissions across ~ 14 hospitals

• 250 (47%) determined to be potentially preventable• Average of 9 factors contributed to each readmission• 250 readmissions identified 1,867 factors responsible for readmission

• Medication Management• 28% of potentially preventable readmissions• Medication management was a factor in more than a quarter of readmissions• Among 189 interviewed patients and caregivers

• 32% expressed the need for more communication about medications• 73% said “the lack of information was a factor in their readmission”

Feigenbaum P et al. Medical Care 2012;50:599‐605

Center for Medicare and Medicaid Services (CMS) Statistics

• Medicare expects hospital penalties to total $528 million in 2016, about $108 million more than 2015

• CMS will penalize 2,597 facilities in 2017, five more than last year

• 49 hospitals will receive the maximum reduction in reimbursement or 3% of the Medicare rate. Up from 38 hospitals last year

• The average reduction to hospitals was 0.73% for each Medicare payment, up from 0.61% last year

Becker’s Infection Control & Clinical Quality.http://www.beckershospitalreview.com/quality/cms‐penalizes‐2‐6k‐hospitals‐for‐high‐readmissions‐5‐statistics.html. Accessed November 12, 2016

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Cause of High COPD 30‐day Readmission Rates

• Exacerbations are not frequently resolved at the time of discharge

• Disjointed patient management occurs across the continuum of care

• Patient training is inadequate

• Lack of professional follow‐up care occurs post discharge

• Equipment in the home is inadequate

• Lack of an exacerbation Rapid Action Plan

http://www.nonin.com/copdwhitepaper. Accessed November 2016

COPD Patient 30‐day Hospital Readmission Reduction Program.

Pharmacist Issues for COPD Readmission

• Multiple medications on discharge

• Potential discrepancies between hospital and community records

• Lack of communication between hospital and care givers in the community

• Community pharmacists and primary care physicians are often unaware of the complete list of medications for discharged patients

Carter BL et al. Am J Health Sys Pharm 2008;65(17): 1631‐1642

Transition of Care Demographics

• Nationally 1 in 5 Medicare patients is readmitted within 30 days of discharge

• Patients 45‐64 of age report having 2 or 3 chronic medical conditions

• 33% of disabled Medicaid beneficiaries who have 3 or more chronic conditions account for almost 70% of total spending

• 30 day readmission rates for Medicaid beneficiaries range from 13% with single condition to 36% with ten or more conditions

• 60% of medication errors occur during transitions of care

• Cost of readmissions is estimated at $26 billion annually with $17 billion in preventable expenses

Jackson CT et al. Health Affairs 2013;32(8): 1407‐1415Forster AJ et al. Ann Intern Med 2003;138(3): 161‐167Hitch B et al. N C Med J 2016;77(2);87‐92.

Traditional Medical Care Model

Transition of Care: The ProblemCore Tenets of a Transitional Care Model

• Comprehensive medication management

• Face‐to‐face self‐management education for patients and families

• Timely outpatient follow‐up with a medical home that has been fully informed about the hospitalization and any clinical or social issues that complicates the patient’s care

Jackson CT et al. Health Affairs 2013;32(8):1407‐1415.

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Transition Planning

• Hospital discharge• Admission medication reconciliation• Prescription access

• Affordability (insurance, co‐pays, deductibles)• Insurance barriers (prior authorizations, early refills)• Transportation to pharmacy

Discharge Planning

•Discharge medication reconciliation

• Face‐to face discharge counseling• Follow‐up with phone call after discharge•Allows patient to demonstrate use of respiratory delivery device

•Discharge medication list provided to patient

Post‐Discharge Planning

•Appropriate follow‐up appointments•Primary care physician•Medical home•Primary care clinics

•Outpatient pharmacy medication reconciliation

Barriers to Pharmacists in Transition of Care

• Patient identification

• Patient no shows

• Information gathering

• Standardization of services

• Administrative support

• Reimbursement

• Time

• Perceptions

Melody KT et al. Integrated Pharm Research and Practice 2016:5;43‐51

Transition of Care: The Solution

1 Care System1 Medical Record

Patient Case # 3• Thomas is a 51-year-old male who presents to your pharmacy

for a refill of an albuterol inhaler and new prescription for aclidinium bromide inhaler. He is a patient that was just discharged from the hospital due to a COPD exacerbation

• Medical problems include COPD x 1 year, HTN x 12 years and deuteranopia (color blindness) since birth

• Smoker (30 pack year history)• Occupational history as a construction laborer x 20 years• His only other medication includes amlodipine 5 mg daily

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Patient Case #3Question #1

As the pharmacists, determine three questions you would ask Thomas about his hospital discharge….

Question #2

If a long‐acting anticholinergic agent was appropriate would the aclidinium bromide device inhaler be a wise choice?

Question #3

What other information from the hospital would help you make a better decision for respiratory delivery device selection?

Patient Case #3

Question #1

As the pharmacists, name three questions you would ask Thomas about his hospital discharge….

Patient Case #3

• Did you receive discharge medication counseling?• Were you told how much the aclidinium inhaler will cost?• Did you receive instruction on your inhaler devices?• Have you used other respiratory medications? What has/has not worked?

• Do you understand why you take your medications?• Did you receive smoking cessation counseling?• When did you receive your last influenza or pneumococcal vaccines?

• Is there a plan to follow‐up with your primary care physician?• Is there a plan if you experience an exacerbation event?

Patient Case #3

Question #2

If a long‐acting anticholinergic agent was appropriate would the aclidinium bromide device inhaler be a wise choice?

Patient Case #3

• Thomas has deuteranopia (color blindness) since birth• Would he be able to identify if the dose was inhaled

correctly?

Patient Case #3

Question #3

What other information from the hospital would help you make a better decision for COPD assessment and respiratory delivery

device selection?

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Assessment of COPDAssessment of Airflow Limitations


Gold 1:

FEV1 > 80% predicted

Gold 2:

50% < FEV1 < 80% predicted

Gold 3:

30% < FEV1 < 50% predicted

Gold 4:

FEV1 < 30% predicted

Assessment of symptoms/risk of exacerbation

Patient Case #3 – Assessment of COPDPatient Group Recommended

First ChoicePersistent Symptoms

A • SAMA or SABA PRN

• LAMA or LABA

• Continue, stop or try alternative class of bronchodilator

B • LABA or LAMA • LAMA + LABA

C • LAMA • LAMA + LABA

• LABA + ICS

D • LABA + LAMA

• LABA + ICS

• LABA + LAMA + ICS

• LABA + LAMA + ICS + roflumilast

• LABA + LAMA + ICS + roflumilast + macrolide

Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/gold‐2017‐global‐strategy‐diagnosis‐management‐prevention‐copd/. Accessed December 2016

Patient Case # 4• Jennifer is a 44-year-old female who presents to your pharmacy

for new prescriptions for tiotropium and albuterol inhalers. Jennifer tells you she was discharged from the hospital 2 days ago for treatment of pneumonia. She believes only one of the prescription medications would be needed to get her feeling better.

• Medical problems include newly diagnosed COPD • Smoker (2 – 2.5 packs per day)• Jennifer is scared for her health since her mother died of COPD at

the age of 51. She feels the doctors do not take the time to talk to her since they are so busy and there is nobody that she can turn to for help.

Patient Case #4

Question #1

As the pharmacists, what are some questions you would ask Jennifer ….

Question #2

What are some recommendations to discuss with Jennifer to prevent hospital readmission?

Patient Case #4

Question #1

As the pharmacists, what are some questions you would ask Jennifer ….

Patient Case #4

• Do you want to quit smoking?

• Did you ever receive smoking cessation counseling?

• Where you ever prescribed medications to help you stop smoking?

• When did you receive your last influenza or pneumococcal vaccines?

• Is there a plan to follow‐up with your primary care physician?

• Is there a plan if you experience an exacerbation event?

• Have you used other respiratory medications? What has/has not worked?

• Do you understand why you take your medications?

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Patient Case #4

Question #2

What are some recommendations to discuss with Jennifer to prevent hospital readmission?

Patient Case #4

• Have patient come back to the pharmacy in a few days to address the following: (may require second visit)

• Smoking cessation strategies including pharmacological and support groups and implement a plan for initiation

• Review inhaler technique, medication use including compliance, timely refills and adverse effects

• Administer influenza vaccine and discuss pneumococcal vaccine

• Talk to your doctor about yearly spirometry tests

• Talk to your doctor about preventing exacerbation• Discuss a plan for COPD exacerbations with your doctor

Pharmacists Management Strategies to Reduce Readmission of COPD

• Make sure patients understand the role of each medication • Describing how and when to take each medication• Encourage smoking cessation if the patient is ready• Update necessary vaccines• Make sure patient can demonstrate use of inhaler devices

• Assess the patient’s ability to understand signs and symptoms of worsening of disease

• Evaluate ability of patient to maintain medication adherence• Insurance barriers• Refill reminders • Inhaler device use• Transportation considerations• Adverse effects

Pharmacists Role in Reducing Readmissions in COPD: The Evidence Does Exist

Objective: A systematic review of the impact of pharmacists care in outpatient COPD

Methods: PubMed, EMBASE, CINAHL, CBMDisc, Cochrane registry

Results: Fourteen studies were evaluated. Pharmacist care associated with reduction in hospital admission (6 studies – 684 patients); RR 0.50 (95% CI 0.39‐0.64).

Pharmacist care improved medication compliance (4 studies – 743 patients); RR 1.23 (95% CI 1.11 – 1.36) while reducing health related costs (3 studies – 318 patients)

No difference in ED visits, lung function or health‐related QOL

Zhong H et al. Int J Clin Pharm 2014;36:1230‐1240

Pharmacists Role in Reducing Readmissions in COPD: The Evidence Does Exist

Reference Population Intervention Results

Cur Med Res and Opin:2016:32;229‐239

20 community pharmacies encompassing 88 patients

Inhalation instructionMedication informationMotivational interviewingSmoking cessation, CCQ

After 1 yr mean CCQ decreased0.12 and 38% showed clinical improvement. ‐0.82 decrease in exacerbation

Ann of Pharmaco 2014;48:203‐208

29 patients 65 yrs and older admitted with COPD exacerbation

30 day readmission rate Length of stay Cost of admission

4 were readmitted within 30 days of discharge. 30 day readmission rate lower than baseline (16% vs 22.2%). Length of stay decreased and small increase in cost

Int J Pharm Prac 2015;23:83‐85 21 community pharmaciesscreened 238 patients

COPD assessment questionnaire and spirometry performed

135 patients identified with potential COPD. Smoking cessation provided a gain of 38.62 life yrs and cost savings of £392.67 per patient screened


Pharmacists Role in Reducing Readmissions in COPD: The Evidence Does ExistReference Population Intervention Results

Int J Clin Pharm 2012:34:53‐62 133 patients randomizedassigned to intervention or control group

Education and management of COPD delivered to intervention group and followed for 6 months

66 patients ‐ COPD knowledge (p<0.001); medication adherence (p<0.05), hospital admission rates (p<0.05)

Br J Clin Pharmacol2009;68:588‐598

173 patients randomized into intervention and control group

Education on disease state, medications and breathing techniques and followed up at 6 and 12 months

86 patients – ED visits decreased by 50% (p=0.02) andhospitalization by 60% (p=0.01). Knowledge scores better in interventional group (75 vs 59.3; p=0.001) and medication adherence (77.8% vs 60%, p=0.019)

J Thor Dis 2014;6:656‐662 235 patients randomized into pharmaceutical care and usual group

Pharmaceutical care of individualized education and phone counseling for 6 months and 1 yr follow‐up

60 acute exacerbations in the usual group and 37 in pharmaceutical group at 1 yrfollow up (p=0.01). Hospital admissions in pharmaceutical group were 56% less than usual care group (p=0.01)


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Collaboration in Action

• Community‐based Care Transition Program• Tests models for improving care transitions

from the hospital to other settings and

reducing readmissions for high‐risk Medicare

patients.

• 27 participating sites which will run for 5

years 2012‐2017

• WellTransitions (Walgreens)• Maryland, Florida and Indiana

Centers for Medicare & Medicaid Services. https://innovation.cms.gov/initiatives/CCTP/ . Accessed November 15, 2016WellTransitions. https://www.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions. Accessed November 12, 2016

COPD Monitoring Recommendations

• Periodic phone calls to assess adverse effects and compliance

• Inhaler technique for accuracy should be done face‐to‐face

• Smoking cessation monitoring

• Spirometry testing

• CAT or mMRC score to assess symptoms

• Monitoring of comorbidities

• Vaccine update (influenza and pneumococcal)

• Risk of exacerbations (role of antibiotics)

CAT – COPD Assessment Test; mMRC – Modified Medical Research Council

Key Points

• COPD is a chronic respiratory disease requiring a focus on preventing exacerbations and maintaining improved quality of life

• GOLD 2017 provides updates in terms of assessment and appropriate drug therapy

• Pharmacists have demonstrated success in transition of care models improving quality metrics

• Transitioning care of the COPD patient requires a unified single health system approach to optimize health care outcomes

• Pharmacists must continue to demonstrate their value in the prevention of COPD hospital readmissions in documenting outcomes

1. When determining appropriate drug therapy for COPD which elements must be included in the assessment?

A. Exacerbation history B. Spirometry C. Symptoms and exacerbation history D. Symptoms, spirometry and exacerbation history

2. What is the recommend first line treatment for a patient who is categorized as GOLD Group C?

A. Long-acting muscarinic antagonist (LAMA)B. Long-acting beta agonist (LABA) C. LAMA + LABAD. LABA + inhaled corticosteroid (ICS)

3. Which of the following is the MOST important pharmacist management strategy to reduce readmissions for COPD?

A. Making sure patients know the role of each medication

B. Assess the patients ability to understand the signs and symptoms of worsening of disease

C. Evaluate ability of patient to maintain medication adherence

D. All equally important

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4. Which of the following metric(s) demonstrate the impact of outpatient pharmacist care in COPD?

A. Reduction of hospital admissionB. Decrease medication use C. Improve patient compliance with insurance copaysD. Recommend use of antibiotics in all patients

References• Feigenbaum P et al. Medical Care 2012;50:599-605• Becker’s Infection Control & Clinical Quality.http://www.beckershospitalreview.com/quality/cms-penalizes-2-6k-hospitals-for-high-readmissions-5-statistics.html• COPD Patient 30-day Hospital Readmission Reduction Program. http://www.nonin.com/copdwhitepaper• Carter BL et al. Am J Health Sys Pharm 2008;65(17): 1631-1642• Jackson CT et al. Health Affairs 2013;32(8): 1407-1415• Forster AJ et al. Ann Intern Med 2003;138(3): 161-167• Hitch B et al. N C Med J 2016;77(2);87-92.• Melody KT et al. Integrated Pharm Research and Practice 2016:5;43-51• Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/gold-2017-

global-strategy-diagnosis-management-prevention-copd/• Zhong H et al. Int J Clin Pharm 2014;36:1230-1240• Centers for Medicare & Medicaid Services. https://innovation.cms.gov/initiatives/CCTP/• WellTransitions.https://www.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions• Albert R et al. N Engl J Med 2011;365:689-98.

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