Breathing Easier: Evidence Based Process Improvement in Chronic Obstructive Pulmonary Disease
- April 2015 – First evidence based guidelines dedicated to the prevention of acute exacerbations of chronic obstructive pulmonary disease (COPD) released by the American College of Chest Physicians (CHEST)¹
- July 2016 – Institute for Safe Medication Practices (ISMP) issues a safety alert regarding inhalers; up to 94% of patients use their inhalers incorrectly, resulting in decreased or no drug delivery. Inhalers are a critical component in COPD prevention²
1 Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest. 2015;147(4):894–942.
2 Correct use of inhalers: help patients breathe easier. ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
The Hospital will decrease readmissions of COPD patients by at least 30%. The baseline readmission rate is 17.2% for August through October of 2015 with a goal of less than 12% by November of 2016. This will be accomplished by creating an inter-professional partnership with Respiratory Therapy (RT), Pharmacy, Comprehensive Care Management (CCM), and Physicians to ensure patients have the correct inhalers in hand and education on proper use prior to discharge.
COPD readmissions have considerable financial consequences:
- Cost of COPD visits exceeds reimbursement (-4% contribution margin)*
- Centers for Medicare & Medicaid Services (CMS) penalty under the Hospital Readmission Reduction Program (HRRP)**
This program prevented 20 COPD*** readmissions over one year, resulting in:
+ $70,349 Savings where cost exceeds reimbursement
+ $76,369 Savings from CMS readmission penalty avoidance
– ($13,509) Cost of program****
= $133,209 Annual Savings to the Hospital
No significant financial risk identified; program did not increase staffing and can be stopped at any time without financial repercussions
*Source: Performance Manager
**Hospital’s readmission penalty is $4,964 per readmitted Medicare patient (FY16 penalty amount and volumes)
***Based on 17.2% baseline rate, the expected readmissions from 166 CMS index cases would be 29 in 10 months. Actual COPD readmissions were 12. Expected 29 – 12 actual = 17 prevented readmissions/10 months = 20 prevented readmissions annualized
****When inhalers are dispensed, nebulized medications are discontinued. Therefore cost of program equals the cost of inhalers ($32,204) minus the savings realized in discontinued nebulized treatments ($18,695) = $13,509. Savings on nebulized treatments assuming 6 doses saved per patient.
Patient and Family Centeredness Implications
- The COPD inter-professional team collaborates using a common focus to provide customized evidence based inpatient care that supports the patient after discharge. As early as day two of the patient hospital stay, the patient is transitioned to their customized inhaler regimen based on CHEST guidelines. Customized patient education begins concurrently. At discharge, the patient is armed with optimal inhalers and is empowered with education
- For patients with financial liability, the average out of pocket cost of a COPD readmission is $1,041; by decreasing COPD readmissions the Hospital’s COPD team decreases the financial burden of COPD for the patients.
- “I had no idea I could prevent my own exacerbations!”
- “Mom is doing wonderful, road a bike for 10 minutes at the Pulmonologist’s office. It is because of your respiratory therapist recommending a different medication for her COPD that is long acting. She even wants to go shopping!”
Process Measure (Rapid Cycle Improvement Efforts)
- Increase the number of COPD patients receiving evidence based interventions by the COPD inter-professional team
- Percent of COPD patients readmitted with COPD
- Hospital Consumer Assessment of Healthcare Providers and Systems Score (HCAHPS) – Patients who rate the hospital a 9 or 10
- Length of stay
Rapid Cycle Improvement: Cycle 1
(November 2015 – February 2016)
COPD readmissions were reviewed in the fall of 2016. Root cause analysis revealed optimization of inhalers, patient education, smoking cessation, medication cost, and discharge medication list as opportunities for improvement (OFIs).
PLAN: Single pharmacist intervention. At discharge provide evidence based inhaler recommendations to provider Monday-Friday (8:00 am to 4:30 pm).
DO: Capture prescribing trends and compare to 2015 CHEST guidelines and identify opportunities for improvement.
CHECK: Confirmed the Hospital COPD patients discharged on optimal inhalers per 2015 CHEST guidelines had decreased readmissions.
ACT: Developed an inter-disciplinary workflow with RT to address opportunities identified and to increase the number of COPD patients captured by the evidence based interventions.
Rapid Cycle Improvement: Cycle 2
(May 2016 – July 2016)
The foundation of the inter-professional collaboration was developed. A file with patient names and COPD enhanced services was shared between RT and Pharmacy. By July, it was apparent that the process required more structure. Root cause analysis identified workflow variance, barriers to disease management, and improved team workflow documentation as process OFIs
PLAN: Maximize inter-professional skill set to impact root causes.
DO: Capture COPD admits and distribute list to RT. Pharmacy and RT document status of COPD services on shared file list; Monday-Friday .
CHECK: Confirmed increased communication between Pharmacy and RT regarding COPD patient services. Confirmed COPD patients receiving enhanced COPD related inter-professional services.
ACT: Expand team to include CCM, begin standardized COPD workflow documentation in EHR, daily assignment of a COPD RT, and standardize workflow tools.
Rapid Cycle Improvement: Cycle 3
(August 2016- February 2017)
The designation of a COPD RT and addition of CCM to the intervention provided the additional structure required. Outpatient pharmacy inhaler pricing was discontinued per ISMP recommendations. CCM patient assessment provided information to the team regarding disease management barriers, including financial barriers for medications. The online tool http://use-inhalers.com/ was approved by the Hospital Education Council to support inhaler technique education. Pharmacy provided pharmacology education to RT team regarding inhalers.
PLAN: Standardize intervention education tools and documentation in EHR regarding COPD workflow and expand team.
DO: Implement usage of http://use-inhalers.com/ and pharmacy education to RT regarding pharmacology of inhalers; incorporate CCM assessment into intervention; expand service to 24/7.
CHECK: Confirmed routine use of EHR for COPD intervention documentation and follow readmission trend.
ACT: Operationalize updated inter-professional COPD workflow between Pharmacy, RT, CCM, and Providers.
- COPD patients readmitting with COPD decreased by 58.1% by November 2016, exceeding the goal of a 30% decrease.
- Decreasing COPD readmissions is in alignment with health system goals.
Baseline Readmissions = August 2015 – October 2015
Intervention Readmissions = May 2016 – February 2017
Process and outcome improvement have been sustained 13 months and includes data captured through February 2017.
- In an effort to optimize workflow and support longevity, the team is aiming to establish facility guidelines around transitioning the patient to optimal inhalers before discharge. This will “hardwire” the intervention.
- The prioritization matrix identified the lack of pulmonary rehab as a focus for intervention. It was beyond the scope of this project, but remains a topic of interest in enhancing the care of COPD patients.
In between PDCA 1 and PDCA 2, there were 2 months (planning period) with no COPD intervention which resulted in a readmission spike to 19.2%. This reiterated the need for a continuous COPD partnership focusing on patient service.