Managing and preventing acute exacerbation of COPD (AECOPD) is an important component in reducing hospital readmission rates for chronic lung disease. Proper diagnosis, classification of severity, and proper treatment for AECOPD through pharmacological and nonpharmacological therapies can improve disease management and prevent excess financial penalties for hospitals from Medicare due to readmissions.
By Timothy Op’t Holt, EdD, RRT, AE-C, FAARC
The Centers for Medicare and Medicaid Services (CMS) has begun financially penalizing hospitals if their 30-day readmission rates are higher than expected. In FY 2014, readmission for COPD will be added to those diagnoses already on the list: heart attack, heart failure, and pneumonia. Respiratory therapists must play an active role in reducing acute exacerbation of COPD (AECOPD) and readmission, to decrease the number of so-called “frequent flyers.”
Part One of this two-part article (RT, October 2013) defined and discussed the causes of AECOPD, how COPD is diagnosed and classified, and how pharmacological therapies, if administered appropriately, have been shown to prevent exacerbation.
In Part Two, effective nonpharmacologic therapies for stable COPD will be discussed, including smoking cessation and pulmonary rehabilitation. Treatment strategies for COPD also will be broken down by GOLD group classification. In addition, exacerbation prevention, current problems with exacerbation and readmission, and strategies for hospitals to avoid readmission are discussed.
As discussed in Part One, there are a number of pharmacologic treatment options for the prevention and management of AECOPD. Those that were covered included short-acting ?-2 adrenergic bronchodilators; long-acting ?-2 adrenergics; anticholinergic bronchodilators; inhaled corticosteroids (ICS), alone or with a combination LABA; low-dose theophylline; phosphodiesterase-4 inhibitors, such as roflumilast; antibiotic therapies, such as azithromycin or moxifloxacin; influenza vaccination; long-term oxygen therapy; and smoking cessation drugs, such as varenicline, bupropion, and nortriptyline.
Because pharmacologic therapy effectively treats the symptoms and not the underlying causes of COPD, additional nonpharmacologic therapy options are warranted.
Smoking cessation counseling is very effective in increasing the chances of quitting when combined with a pharmacologic aid. In addition to the drugs used, recommendations have been advanced to help RTs and clinicians assist the patient to quit.1 In addition, there are brief strategies to help the patient willing to quit, known as the Five A’s: Ask, Advise, Assess, Assist, and Arrange.2 Implementation of the Five-A model directs providers to:
- Ask the patient about their tobacco use status and to document the same.
- All tobacco users are Advised to quit.
- The willingness of the tobacco user to quit is Assessed.
- The tobacco user is Assisted to quit by the provider, as the provider should provide both counseling and pharmacologic support to quit.
- Finally, the provider should Arrange for follow-up to determine the patient’s progress.
In addition to smoking cessation, pulmonary rehabilitation is very effective in helping the patient reduce symptoms, improve quality of life, and increase physical and emotional participation in everyday activities. There are many benefits of pulmonary rehabilitation (see Table 1).
Pulmonary rehabilitation is recommended by GOLD for all group B-D patients. The components of pulmonary rehabilitation are: exercise training, assessment of functional status, assessment of severity of dyspnea, assessment of motivation, smoking cessation, disease management education, and nutrition counseling.2 These elements of patient education and pulmonary rehabilitation are discussed in detail by Gardenner3 and Heuer.4
Therapy for COPD by Group
For each group of patients (A to D), an initial pharmacotherapy is recommended by GOLD. A key point in avoiding exacerbation is to assure that patients who leave the office or are being discharged from the hospital have been appropriately classified and have the drugs or prescriptions for the drugs, and some assurance that the patient or caregiver will fill the prescriptions and see that the patient is adherent to the plan of care. (Proper diagnosis and classification of severity of COPD is discussed in Part One.) All too often, the patient leaves with prescriptions in hand, but they are not filled, as they were forgotten, or were too expensive. Should this be the case, readmission is almost assured.
Patients in group A should have a short-acting bronchodilator, or a combination product (albuterol + ipratropium). Patients in group B should have, in addition to a short-acting bronchodilator, a long-acting bronchodilator (LABA or long-acting anticholinergic). If patients in group B have more severe breathlessness, a combination of LABA and long-acting anticholinergic is an alternative.
For patients in group C, the first choice is an ICS plus a LABA or long-acting anticholinergic. Patients in group D should have the same as those in group C. A phosphodiesterase-4 inhibitor such as roflumilast may be added, provided the patient has chronic bronchitis.
Nonpharmacologic treatment in group A includes smoking cessation, physical activity, and flu and pneumonia vaccines, depending on local recommendations. These might be administered in the clinic or hospital before leaving. Nonpharmacologic treatments in groups B-D include smoking cessation counseling, pulmonary rehabilitation, physical activity, and the vaccinations.5
Respiratory therapists play very important roles in caring for AECOPD patients in both outpatient clinic and inpatient care. In the outpatient clinic, the therapist may be responsible for classifying the severity of the COPD (questionnaires and spirometry), preparing a care plan, educating the patient and caregiver about the disease, pharmacotherapy, device use, smoking cessation, rehabilitation, and follow-up. In the hospitalized AECOPD patient, the therapist may be responsible for all bronchodilator therapy and, closer to discharge, all the aforementioned roles. The responsibilities for the hospital-based RT will by necessity expand to fill these roles.
As discussed in Part One, COPD stage-appropriate pharmacotherapy, smoking cessation, pneumococcal and influenza vaccination, proper use of drug delivery devices, pulmonary rehabilitation, and patient education help to prevent AECOPD. During the office visit, the severity of the COPD should be determined. This is followed by patient education about the disease and its course and how to use the prescribed inhalers.
A COPD action plan may be a useful tool for the patient. In it, the pharmacotherapy is presented in simple terms:
- What medications to take, and when;
- The need to get vaccinated;
- Arrangements for pulmonary rehabilitation;
- Contact information for a smoking cessation counselor;
- Signs of an impending exacerbation and the primary provider’s contact information.
This information should be provided to all COPD patients upon conclusion of an office visit and at discharge. A follow-up visit should be scheduled to determine adherence and the effectiveness of the plan; this may be assessed by spirometry, a review of signs and symptoms, and the CAT test or mMRC scale. The pharmacotherapy and delivery devices are reviewed and any additions or changes are made. The patient’s ability to obtain the medications is reviewed, with assistance provided as needed with an application for patient assistance if necessary. Teaching self-management skills has been shown to result in fewer exacerbation-related hospitalizations, exacerbation-related emergency department visits, and unscheduled primary care visits.6,7
Current Problems with Exacerbation and Readmission
The attention of respiratory therapists has been called to the readmission rate for patients with chronic obstructive pulmonary disease (COPD). Thirty-day readmissions for COPD have been determined to be 23% in the Medicare population.8 While this data is remarkable, the impact of this fact will be felt by hospitals, as Medicare, under the Affordable Care Act, will begin to penalize hospitals for higher than expected readmission rates for AECOPD as of October 1, 2014.
These penalties have begun at 1% of Medicare payments in FY 2013 (for heart attack, heart failure, and pneumonia) and will increase to 3% by FY 2015. These 30-day readmission rates will be compared to the expected rates of readmissions, using risk adjustment for age, gender, medical diagnosis, and selected medical history. Medicare is most interested in unplanned readmissions for which the reason for readmission is related to the reason for initial admission. So, if the therapist is caring for a patient with AECOPD who goes home, and is then readmitted within 30 days for a new or continued AECOPD, this is the type of readmission for which Medicare will be tracking and penalizing.
The Affordable Care Act9 specifies that certain readmissions will be excluded from a hospital’s readmission rates, including readmissions that are unrelated to the prior discharge. These include planned readmissions or transfer to another applicable hospital.10
The American Hospital Association (AHA) contends that readmission rates may not be well suited as measures of quality.10 They contend that other factors may intervene: some readmissions are beyond the hospital’s control; there are patient characteristics and patterns that cloud the picture; and some readmissions could not have been anticipated. These contentions have yet to be resolved.
There are several patient characteristics and health conditions that play an important role in readmissions. These are low income, lack of social support, comorbid conditions, and underlying disabilities. As the number of comorbid conditions a patient has increases, so does the likelihood of readmission. Demographic factors such as race and ethnicity (African-American), language barrier, income, socioeconomic status, income from Supplemental Security Income, and public insurance coverage contribute to an increase in readmission rate.
How Can Hospitals Reduce Readmissions?
The AHA points out that hospitals must focus on avoidable hospitalizations.10 It cited programs that:
- Enhance discharge planning;
- Partner with post-acute care providers;
- Staff disease-specific units with nurses who have advanced training;
- Use nursing personnel to provide disease-specific patient education;
- Schedule primary care provider follow-up visits at discharge;
- Develop a high-risk readmission tool;
- Use social workers to make follow-up telephone calls;
- Link patients to community services; and
- Appoint a discharge advocate to assist the patient to understand diagnosis.
Patients, their caregivers, and providers need to be able to recognize the signs and symptoms of AECOPD. Evidence-based guidelines (GOLD 2013) exist to assist with pharmacologic and nonpharmacologic care planning in AECOPD. The healthcare team is encouraged to know and follow these guidelines. Preventing AECOPD is a multidisciplinary and multitiered effort. Not only do proper pharmacological therapies need to be prescribed, but the additional use of pulmonary rehabilitation and smoking cessation education for patients can improve exacerbation management.
The challenge to respiratory therapists and respiratory care departments is to determine what additional services should be provided by RTs and how they can be provided in a cost-effective manner to decrease the rate of and readmission for AECOPD. RT
Timothy Op’t Holt, EdD, RRT, AE-C, FAARC, is a professor in the department of cardiorespiratory care at the University of South Alabama. He will be contributing a subsequent article on AECOPD. For further information, contact firstname.lastname@example.org.
- The tobacco use and dependence clinical practice guideline panel, staff, and consortium representatives. A clinical practice guideline for treating tobacco use and dependence. JAMA 2000;28:3244-3254.
- GOLD 2013, http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf: 27-28. Accessed June 14, 2013.
- Gardner DD. Patient education and health promotion. In: Kacmarek RM, Stoller JK, Heuer AJ. Egan’s Fundamentals of Respiratory Care, 10th ed. Elesvier, St. Louis, 2013: 1269-1282.
- Heuer AJ. Cardiopulmonary rehabilitation. In: In: Kacmarek RM, Stoller JK, Heuer AJ. Egan’s Fundamentals of Respiratory Care, 10th ed. Elesvier, St. Louis, 2013:1283-1304.
- GOLD 2013, http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf: 34-36. Accessed June 14, 2013.
- Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med 2003;163:585-591.
- Effing T, Monninkhof EM, van der Palk PD, et. al. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007:CD002990.
- Jenks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare Fee-for –Service Program. NEJM 2009;360:1418-1428.
- The Affordable Care Act is the combination of the Patient Protection and Affordable Care Act (PPACA), P.L. 111-148, enacted on March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 (HCERA), P.L. 111-152, encated on March 30, 2010. See section 3025.
- American Hospital Association. Examining the drivers of readmissions and reducing unnecessary readmissions for better patient care. Trendwatch; September 2011:1-11.