COPD Performance Improvement Teleconference Lara Zisblatt, MA Assistant Director Continuing Medical Education Boston University School of Medicine Boston, Massachusetts

1

Participants in the Program ™ 227 people registered ™ 61 finished baseline chart review ™ 35 submitted their Action Plans ™ 6 completed the program

2

Outcomes Measure Initial Spirometry Repeat Spirometry Queried about Smoking Smoking Intervention Oxygen Saturation Assessed Inhaled Bronchodilators Prescribed Influenza Vaccination

% Improvement 42% 129% 12.5% 8.5% 8.5% 3.1% 11.8%

3

Chart Review Challenge • Biggest Challenge = Time • Ways to overcome this barrier: • Lowered the requirement from 10 charts to 5 charts for review • Ask support staff to review patients seen in past month with any ICD 9 code for COPD and pull charts or review EMR • Complete the chart review with another member of your team • Make a plan to complete this chart review • Schedule 2 one-hour sessions over the next week using administrative time or your lunch hour 4

Performance Improvement • Enrolling in this PI program is the 1st step in improving care for your patients • Key component to improvement is chart review • Simple way to look at baseline measures of your practice • The very act of reviewing charts can be illuminating

5

COPD Project ™ Make a commitment to yourself and to your patients to work toward improving care! ™ Complete the chart review as soon as possible as your first step toward improvement ™ If you are having trouble completing the chart reviews, please let us know. We can help! ™ Janet Schuldiner, PA, is our program coach. She will be calling you to offer help ™ If you have any questions, please e-mail us at [email protected] or call us at 617.638.4605 6

Pulmonary Rehabilitation in COPD Claire Murphy, NP-C Instructor of Medicine Pulmonary Nurse Practitioner Boston University School of Medicine 7

Faculty Disclosure Information Claire Murphy, NP-C, has no financial relationship with the grantor and/or any commercial interest

8

Learning Objectives ™ Identify criteria for patient referral to pulmonary rehabilitation ™ Describe how pulmonary rehabilitation optimizes body systems to ease extrapulmonary manifestations of COPD

™ Explain how pulmonary rehabilitation affects patient outcomes in 3 definitive areas

9

COPD Overview ™ Did you know: – There are approximately 12 million people diagnosed with COPD, and ANOTHER 12 million may have COPD but remain undiagnosed – COPD is the 4th leading cause of death, projected to slide into 3rd place by 2020 – There is a 5.1% increase in mortality for COPD (20042005), while the mortality for HD and CA declines – Cigarette smoking is the most common risk factor

COPD = chronic obstructive pulmonary disease; HD = heart disease; CA = cancer.

10

But first… ™ Remember that 58-year-old female you inherited, whose medical record you reviewed during COPD Virtual Communities of Practice, and you: – Accurately diagnosed COPD through spirometry – Obtained a smoking-cessation referral – Started her on appropriate inhaled medications, ie: • Long-acting bronchodilator (beta2-agonist, anticholinergics, ICS, etc)

– Brought her immunizations up to date (influenza, pneumococcal) – But…something’s missing ICS = inhaled corticosteroid.

11

On her most recent visit… ™ She tells you she is still experiencing dyspnea on exertion ™ She is no longer going out to the shopping mall as much, because she gets tired more quickly…she must just be getting old ™ Her weight has increased ~20 lb since she really avoids walking along the beach…her legs hurt too much ™ She can tell you the Monday-Friday lineup of the new TV shows on cable, since that is her only source of entertainment these days

12

On physical examination… ™ Spirometry shows a moderate obstructive pattern ™ Auscultation of breath sounds reveals mild, prolonged end-expiratory breath sounds decreased in the bases ™ EKG obtained in office R/R/R ™ ? Maybe a stress test might not be a bad idea to rule out cardiac ischemia….. ™ What about pulmonary rehab??? 13

Know that…. ™Although the lung function is most severely impacted: – Skeletal muscle (esp. those of the lower extremities) = increase in lactic acid production = decrease in exercise tolerance – Dyspnea from hyperinflation of the lungs as a result of increased ventilatory demand with little time for expiration – Increased anxiety and depression Nici L, et al. Am J Respir Crit Care Med. 2006;173:1390-1413. Casaburi R, et al. Am Rev Respir Dis. 1991;143:9-18.

14

Pulmonary rehab will… ™ Not directly improve lung function, but rather will minimize its DYSFUNCTION through: – Moderating lactic acid levels through exercise – Exercise combined with decreased levels of lactic acid will improve ventilatory demand, thus … – Resulting in a slowing of expiratory rate with diminishing dyspnea and... – Antidepressant effect of exercise combined with social interaction

Casaburi R, et al. Exercise training in chronic obstructive lung disease. In: Casaburi R, Petty TL, eds. Principles and Practice of Pulmonary Rehabilitation. Philadelphia, PA: WB Saunders; 1993, pp 203-204.

15

Exercise Training Targets in Pulmonary Rehab Program for COPD Patients

Casaburi R, ZuWallack R. N Engl J Med. 2009;360:1329-1335.

16

And there is always… ™The promotion of self-management interventions as the patient becomes the manager of his/her disease – Generates positive behaviors – Increases adherence – Early recognition of worsening symptoms – Cost-effective

Bourbeau J, et al. Arch Intern Med. 2003;163:585-591. Bourbeau J, et al. Chest. 2006;130:1704-1711.

17

The evidence supports that… ™ Exercise capacity increases ™ Severity of dyspnea decreases ™ Quality of life improves

18

The evidence supports that… (cont’d) ™ Lacasse et al in a recent meta-analysis of 31 randomized clinical trials reports: – In 11 trials (n=618), improvement was demonstrated in 4 domains by CRDQ • Dyspnea • Fatigue • Emotional function • Mastery of disease

– Results support 1.5 - 2.1 x the minimum of clinical difference in treatment vs. control group CRDQ = Chronic Respiratory Disease Questionnaire. Lacasse Y, et al. Cochrane Database Syst Rev. 2006 Oct 18;4 CD003793.

19

The evidence supports that… (cont’d) ™ In 16 trials (n=669) ™ Demonstrated improvement of functional exercise capacity through 6-min walk test was 48 m ™ Anticipated result: 50 m

Lacasse Y, et al. Cochrane Database Syst Rev. 2006 Oct 18;4 CD003793.

20

Efficacy of Pulmonary Rehabilitation Dyspnea (CRDQ Score)

Walking Distance (m)

20

250

16

200

12

150

8

100

4

50

0

0

Placebo

Rehabilitation Baseline

CRDQ = Chronic Respiratory Disease Questionnaire. Griffiths TL, et al. Lancet. 2000;355:362-368.

6 wk

Control

Rehabilitation

1 yr

21

Components of a Pulmonary Rehabilitation Program ™ Interdisciplinary team ™ Exercise training ™ Strength training ™ Nutrition ™ Occupational therapy ™ Education/Self-management ™ Psychological counseling – Assess for depression Ries AL, et al. Chest. 2007;131:4S-42S.

22

So…who do YOU want to send to rehab? ™ Symptomatic patients with an FEV1 ≤65% ™ And even patients with lesser disease with poor exercise tolerance ™ Resting (and exercise testing with) hypoxemia ≤90% ™ Patients WITH SOME MOTIVATION ™ Obstructive diseases – Typically Stage 3/Stage 4 GOLD – COPD/Per Asthma/Bronchiectasis/cystic fibrosis

™ Restrictive diseases – ILD (pulmonary fibrosis, sarcoidosis, scleroderma, chest wall diseases)

™ Neuromuscular ™ Lung cancer, pre- and post-transplant FEV1 = forced expiratory volume in 1 second; GOLD = Global Initiative for Chronic Obstructive lung Disease; ILD = interstitial lung disease.

23

Pulmonary Rehab…Yet Another Example of a Performance Improvement Goal ™ Increase number of appropriate patients receiving pulmonary rehabilitation – Obstacles: time, lack of referral sites, process – Interventions • Think about it!! • Develop a process for referral • Institute home program for home-bound patients • Use flowsheet to track appropriate referrals • Use check-off box in EMR

EMR = electronic medical records.

24

It’s Not Just About the Exercise ™ Understanding COPD and coping strategies ™ Bronchial hygiene ™ Breathing from the abdomen ™ Strategies to stop the panic when you feel you can’t breathe ™ In-home breathing exercises ™ Using pulmonary rehab equipment to increase and bump up functional capacity ™ Availability of community resources – Support groups 25

For That Home-Bound Patient, How About Some Home…Work? ™ Start with some easy coughing to clear your lungs of mucus ™ Now let’s practice relaxing and deep breathing for a few minutes • Continue deep breathing for a few minutes • Try to keep breathing out twice as long as you breathe in • Count as you breathe • Breathe in: 1-2. Breathe out: 1-2-3-4 • No breath holding

American Lung Association, May 1999.

26

Some Advice for the Patient ™ Stretching and Reaching Movements Help You Warm Up and Get Ready to Exercise.

™ Trunk Turning Sit in a straight-back chair with your shoulders relaxed, and breathe in ™ As you breathe out slowly, turn your trunk to the left, and reach your arms over your left shoulder, as if you were reaching behind you ™ Bounce your arms a few times. Rest, and repeat on the other side

American Lung Association, May 1999.

27

Some Advice for the Patient (cont’d) ™ Start with a warm-up period, including stretching and reaching exercises ™ If you feel tired or short of breath at any time while exercising, stop, take a break, and relax a few minutes; then start again ™ Remember, being short of breath isn’t bad ─ it means your lungs are working harder than usual ™ Always end your exercise with a cool-down period American Lung Association, May 1999.

28

Some Advice for the Patient (cont’d) ™ Having a little trouble starting and keeping to that exercise plan? ™ Try to pick an exercise or activity that you enjoy ™ Not to worry...you most likely are already doing exercise like walking, dancing, or gardening ™ Anything that keeps you up and about and active counts! American Lung Association, May 1999. 29

The Role of Immunizations in Preventing COPD Exacerbations William C. Kohlhepp, DHSc, PA-C Associate Professor of Physician Assistant Education Quinnepiac University 30

Faculty Disclosure Information William C. Kohlhepp, DHSc, PA-C, has no financial relationship with the grantor and/or any commercial interest. Mr. Kohlhepp owns stock in Pfizer Inc.

31

Learning Objectives ™ Identify the ways that COPD exacerbations affect the health status of patients ™ Describe the role of viruses and bacteria as COPD exacerbation triggers ™ Explain the benefits of vaccinations against influenza and pneumococcal pneumonia in preventing COPD exacerbations ™ Describe the barriers that prevent susceptible patients from receiving needed vaccines ™ Identify strategies for improving our ability to successfully vaccinate patients with COPD 32

Vaccinations ™ All patients with COPD should receive a pneumococcal vaccine if aged ≥65 yr ™ All patients with COPD should receive an annual influenza vaccination

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2008. http://www.goldcopd.org

33

Role of Influenza and Pneumococcus Virus in Exacerbations ™ Bacteria and viruses are thought to cause a substantial portion of COPD exacerbations ™ Viral infection is thought to cause one-third of exacerbations – Significant causative virus is influenza

™ Impairment of host defense by influenza leads to colonization with bacteria

Wongsurakiat P, et al. Chest. 2004 Jun;125(6):1971-1972.

34

Benefits of Vaccination ™ Approach using prophylaxis is less effective due to growing pneumococcal resistance ™ Influenza vaccine to chronic lung disease – 52% reduction in hospitalizations – 70% mortality reduction – RCTs in COPD patients demonstrate that influenza vaccine is highly effective in prevention of acute respiratory infections related to influenza virus

™ Pneumococcal (pneumonia) vaccine – Conflicting evidence RCTs = randomized clinical trials. Niewoehner DE. Am J Med. 2006;119(10 Suppl 1):38-45.

35

Inconsistent and Conflicting Evidence on Vaccine Benefit ™ Pneumococcal vaccination studies: – Few small, underpowered studies – Retrospective studies, including other lung diseases – Prospective study demonstrated reduction in CAP

™ Influenza vaccination studies: – Small, randomized, controlled trials – Large retrospective studies, including other lung diseases – Single Cochrane systematic review • Effective and safe CAP = community-acquired pneumonia. Kunisaki KM, et al. Drugs Aging. 2007;24:303-324.

36

2009: Benefit for Influenza Vaccine, Not Pneumococcal Vaccine ™ Study design – Largest study of patients with COPD (N = 177,120) – Retrospective, community-based population study

™ Study results – Influenza vaccine effective at decreasing all-cause mortality – Unable to demonstrate similar benefit with pneumococcal vaccine

Schembri S, et al. Thorax. 2009;64:567-572.

37

Vaccination Rates (%)

Vaccination Rates for Age ≥65: Not Enough 100 90 80 70 60 50 40 30 20 10 0

Healthy People 2010 Target – 90%

69.1%

66.8%

Influenza Vaccine

Pneumococcal Vaccine

BRFSS data, median percentage of adults ≥65 years who had received an influenza vaccine during the prior 12 months or ever received a pneumococcal vaccine, 2006. Behavioral Risk Factor Surveillance System (BRFSS), United States, 2006. MMWR. 2008;57(SS-7).

38

Vaccination Performance Improvement Goals ™ Influenza vaccine prior to every flu season ™ Pneumococcal vaccine for all COPD patients – Intervention: • Use a flowsheet in all charts of COPD patient, which includes vaccinations • Use stickers on charts of COPD patients • Hang a poster in your reception area • Send patients postcard reminders

39

Medicare Beneficiary Study: Why Did You Not Get Vaccinated? ™ Misconceptions about the vaccine – Not clear if it is safe • Can cause influenza • Could have side effects

– Not clear if vaccine is effective in preventing influenza – Lack of clinician recommendation – Lack of knowledge about vaccine – Concerns about cost

MMWR. 1999 October 8;48(39):886-890.

40

Factors Increasing Likelihood of Pneumococcal Vaccine ™ Patients consider themselves at high risk ™ Discomfort or other side effects are limited ™ Recommendation made by a clinician ™ Patient previously heard of vaccine

Siriwardena AN. Postgrad Med J. 1999 Apr;75(882)::208-212.

41

Importance of Other Perspectives in Patient’s Vaccine Decision-Making ™ Sought advice from others: – Practice nurses (37%) – Family and friends (27%) – Practice receptionists (8%)

™ Read brochure (98%)

McDonald P, et al. BMJ. 1997;314:1094-1098.

42

“Health Belief Model” Provides Focus for Vaccine Efforts ™ Patients are more likely to change health behavior if they understand: – Perceived susceptibility • Assessment of their risk of getting the condition

– Perceived severity • Assessment of condition’s seriousness and potential consequences

– Perceived barriers • Assessment of the influences that facilitate or discourage adoption of the promoted behavior

– Perceived benefits • Assessment of the positive consequences of adopting the behavior Strecher VJ, Rosenstock IM. The Health Belief Model. In Health Behavior and Health Education: Theory, Research, and Practice, eds. Glanz K, Lewis FM, Rimer BK. San Francisco: Jossey-Bass; 1997.

43

Vaccination Strategies ™ Opportunistic – Vaccinate at time of routine visit

™ Contact patients at risk – Hand out leaflet with routine prescriptions (enlist pharmacist aid)

™ Run a vaccine campaign

44

Vaccine Campaign: Support Materials ™ Focus on practice clinicians and support staff – Leaflet to brief professionals – Clinical guidelines – Agreed-upon practice guideline – Patient identification forms – Vaccine reminders on appointment lists

™ Focus on patients – Leaflet to brief patients – Patient invitation letter – Poster for year-round display McDonald P, et al. BMJ. 1997;314:1094-1098.

45

Vaccine Campaigns: A Successful Strategy ™ Increase of pneumonia vaccine – From 4% to 33%

™ Increased clinician participation – Ordering vaccine 17% to 96% – Offering vaccine 16% to 81%

McDonald P, et al. BMJ. 1997;314:1094-1098.

46

Discussion/Questions

47