Download HQO`s Episode of Care for Chronic Obstructive

HQO’s Episode of Care for
Chronic Obstructive
Pulmonary Disease
Dr. Chaim Bell, MD PhD FRCPC
Ontario Hospital Association Webcast
October 23, 2013
Objectives
1. Describe the rationale and methodology for HQO’s
episode of care approach as it applies to identifying
cohorts, grouping patients, considering complexity and
defining the scope of the episode of care
2. Review the previous recommendations of the Congestive
Heart Failure Acute Episode of Care panel in these areas
3. Discuss and seek feedback from this Panel on the
approach to be applied for the Congestive Heart Failure
Community-based Episode of Care
Recap: why do we need to stratify the post-acute heart
failure population?
• A core deliverable requested by the Ministry for each QBP topic area is
a recommended approach to stratifying the clinical population
• Purpose is to break down heterogenous populations into subgroups
that are more clinically and resource homogenous, in order to:
1. Define best practices relevant to specific patient trajectories and
sub-trajectories (pathway and triage tool)
2. Appropriately fund cases with different needs at different rates
• Often (but not always), clinically meaningful approaches to stratifying
patients also result in meaningful groupings from a cost perspective
• HQO’s Episode of Care method draws from clinical expert panel input
to define patient characteristics to model for their association with
variation in cost, length of stay and other key outcomes
• Output of this analysis: a set of patient groups (e.g. high and low risk)
and patient complexity factors identified for risk adjustment within the
groups (e.g. age, comorbidity)
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The major components of our
approach
Define inclusion / exclusion criteria for the
patient cohort to be studied
Case Mix
Set the scope and parameters of the episode
of care for analysis
Recommend an approach to stratifying
patients within the cohort
Best
Practice
Develop evidence-based care pathway(s) for
the cohort and subgroups
Develop indicators for measuring adherence
to the care pathway and resulting outcomes
Defining the inclusion / exclusion criteria for the
COPD cohort
Inclusion / exclusion criteria:
1. Diagnoses: Most responsible diagnosis In the Range of J41-J44,
excluding “J43.1” “J43.2” “J43.0”
2. Age: Age greater than or equal to 35 at time of admission
3. Intervention: Is not assigned to an intervention based HIG cell based on
the current methodology. (i.e. MCC_partition variable is not “I”)
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Review: Defining the COPD patient grouping approach
Three major patient groups:
1) Mild exacerbation
Treated in ED or outpatient; not admitted
ED, Urgent Care Centre or outpatient visit recorded without a subsequent hospital
admission
2) Moderate exacerbation
Admitted to inpatient care; not ventilated
Inpatient acute discharge without a procedure code for noninvasive positive pressure
ventilation or invasive mechanical ventilation, and without an ICU stay recorded
3) Severe exacerbation
Admitted to inpatient, ventilated (NPPV or IMV) and/or admitted to ICU
Inpatient acute discharge with procedure code for noninvasive positive pressure ventilation
and/or invasive mechanical ventilation and/or with ICU stay recorded
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Identifying markers for complexity in COPD
patient population
Factors that contribute to COPD patient complexity:
COPD severity markers
• O2 dependence
• Respiratory failure
• Recent (e.g. within 30 days) discharge
from ED / hospital
• Frequency of acute exacerbations over
previous 6 – 12 months
• Oral steroid use / dependence
• Lung function (FEV1 / FVC)
• Failed response to outpatient therapy
• Functional ability / dyspnea (MRC grade)
Housing / supports / frailty markers
• Homeless
• Lack of support (CCAC,
isolation/transportation)
• Continuing care / nursing home resident
• Access to primary care
• Functional status (e.g. walking aids)
• Drug plan
• Access to pulmonary rehab
Significant comorbidities
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Bronchiectasis
Pneumonia
Coinfections (pseudomonas, mycobacterium, urosepsis)
Mental health (anxiety, depression, dementia, delirium)
Congestive heart failure
Arrhythmia (including atrial fibrillation)
Diabetes
Tobacco dependence
Benzodiazepine dependence / chronic use
Immunosuppressant disease
Lung cancer
Renal failure
Osteoporosis
BMI (overweight or underweight)
Chronic pain
Sleep apnea
Myocardial infarction
Neuromuscular disorder
GERD
Muscoskeletal disorders
Asthma
Interstitial lung disease
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The COPD Episode of Care Model
Mild
Level of care
Discharge planning
& full clinical
assessment
Recovers
Usual medical
care (in ED /
outpatient)
Assess recovery
N = 19,337
Pr = 0.447
Legend
Home
Go to usual
medical care
(inpatient)
Treatment fails
Care module
Assessment node
Moderate
Level of care
Episode endpoint
Patient presents with
suspected exacerbation
of COPD
N = 43,215
Pr = 1.0
Usual medical
care (inpatient)
Assess
level of care
required
NPPV
Usual medical
care (inpatient)
IMV
Discharge planning
& full clinical
assessment
Assess recovery
Treatment fails
Home
Go to IMV
Recovers
Decision on
ventilation
modality or
palliative care
Go to ventilation
(NPPV or IMV)
Treatment fails
Recovers
N = 773
P = .018
N = 1,824
P = .042
Home
Assess recovery
N = 22,054
Pr = 0.511
Severe
Level of care
Discharge planning
& full clinical
assessment
Recovers
Wean
from IMV
Assess recovery
N = 1051Treatment fails End of life care
Pr = .024
Usual medical
care (inpatient)
Death
Discharge planning
& full clinical
assessment
Home
Diagnosis of COPD
•
Consider clinical diagnosis of COPD in any patient who has
dyspnea, chronic cough or sputum production, and/or a history
of exposure to risk factors for the disease
•
Spirometry is required to make clinical diagnosis: postbronchodilator FEV1/FVC <0.70 confirms COPD
•
Spirometry need not be performed during the initial phase of
an exacerbation when the patient is unstable, but should be
performed once the patient has stabilized
•
Spirometry should only be performed if the patient has no
recent, reliable, objective documentation of COPD by
spirometry
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Patient presents to hospital with suspected
COPD exacerbation
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Vital signs and physical exam
Check patient history
Document and reconcile medications currently used
Chest X-ray
Baseline bloodwork
ECG
Check arterial blood gases, where appropriate
If suspected pneumonia or sepsis – draw blood cultures
Cardiac markers, if appropriate
Patient wishes: goals of care and/or limitations of treatment
Spirometry
Other diagnostic interventions as appropriate to identify / rule
out other suspected diagnoses or co-morbidities
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Decision to admit
•
Decision to admit relies largely on clinical judgment and
availability of local resources – see NICE / GOLD criteria below
Factors to consider when deciding where to
manage exacerbations
(Take into account the person’s preference)
NICE
Decision
Guidelines
for
Hospital
Admission
(2011)
Treat at
home?
Treat in
hospital?
Able to cope at home
Yes
No
Breathlessness
Mild
Severe
General condition
Good
Poor/deteriorati
ng
Level of activity
Good
Poor/confined
to bed
Cyanosis
No
Yes
Worsening peripheral
oedema
No
Yes
Level of
consciousness
Normal
Impaired
Already
receiving LTOT
No
Yes
Social circumstances
Good
Living
alone/not
coping
Acute confusion
No
Yes
Rapid rate of onset
No
Yes
Significant
comorbidity
(particularly cardiac
disease and insulindependent diabetes)
No
Yes
SaO2 < 90%
No
Yes
Changes on chest Xray
No
Present
Arterial pH level
≥ 7.35
< 7.35
Arterial PaO2
≥ 7 kPa
< 7 kPa
GOLD Indications for Hospital
Assessment or Admission
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Usual medical care (1 of 2)
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Short-acting bronchodilators (Beta-2 agonists recommended)
– If patient is already on long-acting anticholinergics, continue to
administer in combination with Beta-2 agonists
– Metered dose inhalers with spacers are the preferred delivery
vehicle; nebulizers should be considered second line treatment
due to infection risk
Corticosteroids are effective except for only very mild exacerbations,
or if contraindicated
– 30 – 50 mg / day Prednisone or equivalent – 10-14 days
– Manage corticosteroid-induced side effects
Theophylline is not recommended, unless already receiving
If necessary, deliver oxygen to maintain 90% oxygen saturation
Where appropriate, initiate bronchopulmonary (lung) hygiene physical
therapy to clear mucus and secretion from the airway
If patient is admitted, use early ambulation therapy
Begin discharge planning, including referral to pulmonary rehab
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Usual medical care (2 of 2)
•
Use antibiotics for indications of infection (e.g. purulent or high
volume sputum)
‒ Refer to institution-specific antimicrobial stewardship policies
‒ Oral antibiotics are preferred
‒ Intravenous antibiotics should be considered a 2nd line therapy
used only when oral antibiotics are contraindicated (e.g. GI issues)
‒ See CTS guidelines below (2007)
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Decision on ventilation
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If possible, seek patient preferences for ventilation therapy
before proceeding to ventilation interventions
If ventilation is not desired, proceed to palliative care
NPPV should be considered as first line treatment for patients
with acute respiratory failure and pH < 7.35
NPPV should be trialed before proceeding to invasive
ventilation for all patients with indications for ventilation,
including severe patients (pH < 7.20), unless contraindications
are present
Where patients have expressed preferences against intubation,
NPPV can still be considered but ensure that therapy does not
progress to IV in the case of failure to respond to NPPV
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Noninvasive ventilation
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Ensure continuous monitoring of patients receiving NPPV
Specialized respiratory teams and/or units are likely to be
more effective in delivering NPPV
Invasive ventilation
•
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Use NPPV to help wean patients from IV when they fail
spontaneous breathing tests
There may be a volume-outcome relationship at the
hospital level associated with effectiveness of IV
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Clinical assessment of stabilized patient
•
Where a patient has no prior objective documentation of
spirometry assessment, spirometry should be performed
on the stabilized patient before discharge (as time and
patient’s condition allows) or arranged for following
discharge
•
In addition to classification of airflow limitation, patients
should also be assessed for their severity of symptoms
and other risk factors (e.g. co-morbidities), considering
tools such as the MRC dyspnea scale, CAT / BODE /
LACE indices
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Discharge planning (1 of 2)
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Perform full clinical assessment once patient stabilizes
Patients should leave hospital with an individualized discharge plan
(Re-)establish patients on their COPD maintenance bronchodilator
therapy before discharge, including handheld inhalers
Review and reconcile medications before discharge
• Ensure that patients understand their medication therapy,
including when to stop corticosteroids if prescribed
Assess the patient’s inhaler technique before discharge
Consider developing an action plan with patients, including
identified patient responsibilities for their ongoing care and
instructions for seeking help for future acute exacerbations
Patients without up-to-date influenza or pneumococcal vaccinations
should either be vaccinated or referred for vaccination following
discharge, unless there are contraindications present
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Discharge planning (2 of 2)
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COPD patients with functional disabilities should begin a pulmonary
rehabilitation program within 1 month of discharge
Patients who smoke should receive smoking cessation counseling
while in hospital, with goal of referral to longer-term, intensive
smoking cessation counseling in the outpatient setting
Ensure that patient is supported by CCAC with appropriate home
care services in the community after discharge
Where appropriate, arrange for an assessment of the patient’s home
or living situation by an occupational therapist following discharge
Ensure patients have a follow-up appointment with a primary care
provider, respirologist or internist within 2 weeks of discharge
Patients that qualify should be discharged on home oxygen
If the patient does not have a regular primary care provider, ensure
they are connected with one before discharge.
PCP and CCAC receive discharge summary w/in 48 hrs of discharge
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Where did the evidence for these
recommendations come from?
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The OHTAC COPD mega-analysis: A great source of evidence, but
did not cover some key areas of the episode of care
Evidence-based practices for COPD
Community-based
diagnosis and assessment
Long-acting maintenance
bronchodilators
OHTAC mega-analysis
Long-term oxygen
therapy
Community-based
multidisciplinary care
QBF episode of care
Non-invasive Ventilation
Short-acting
bronchodilators
Pulmonary rehabilitation
following acute exacerbation
Corticosteroids
Pulmonary
Vaccinations
rehabilitation for
stable COPD patients
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Antibiotics
In-hospital
diagnostics
We synthesized a variety of different forms of evidence
through an Expert Panel to inform practice recommendations
Recommended practice
Usual
Medical Care
(mild and
moderate
exacerbations)
Ventilation
(severe
exacerbations)
Discharge
planning
(all patients)
Supporting evidence
Administer 30-50 mg prednisone for
7-14 day course of therapy for all
patients unless contraindicated
CTS: 1+ RCTs; good evidence
GOLD: Expert consensus
Theophylline is not recommended,
unless patient is already receiving
GOLD: RCTs, limited body of data
NICE: Expert consensus
Use noninvasive ventilation as first
line therapy for patients with acute
respiratory failure and pH < 7.35
OHTAC: Moderate quality evidence
GOLD: RCTs, rich body of data OHTAC
NICE: Systematic reviews and/or
meta-analyses of RCTs
Expert Panel
Contextualizion
for Ontario
Refer all hospitalized patients to
begin pulmonary rehabilitation within
1 month of discharge
Develop an action plan with patients
before discharge with instructions on
how to manage future exacerbations
OHTAC: Moderate quality evidence
GOLD: RCTs, rich body of data
OHTAC
CTS: 1+ RCTs; good evidence
GOLD: Expert consensus
NICE: Expert consensus
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HQO RAPID
REVIEW PENDING
Scoping
PICO
Study Selection Criteria
Research Question
5 years
Medline, EMBASE, Cochrane, CRD
SR, HTA, MA
Literature Search
Filling the
gaps in the
evidence:
HQO’s
Rapid
Review
methodology
No
Is there a
SR?
Review of primary studies (RCT,
Obs.) adjusting selection criteria
as necessary
YES
Rate SR with AMSTAR
Did SR GRADE outcomes of
interest for RR?
Did SR
use
GRADE ?
YES
YES
No
Summarize
results
No
Obtain primary studies from SR with outcomes of interest
GRADE Outcome(s) Max 2
Report Results
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