By Robert Messenger, RRT, CPFT, FAARC

Image of RT with patient.The Patient Protection and Affordable Care Act (PPACA) has caused unprecedented controversy and extreme polarization of opinions. However, the one thing that everyone seems to be able to agree on is that our nation’s health care system has been on a path to fiscal disaster. National health care spending has been increasing at a rate more than twice the growth of our gross domestic product (GDP). Fortunately, for the last several years, the growth in health care spending has dropped to a level matching the growth in GDP. But we have a long way to go. Left unchecked, health care expenditures will swell as a large percentage of the American population, the Baby Boomer generation, enters into retirement and onto the Medicare rolls. If we want a sustainable system, we must develop multiple strategies to improve efficiency and rein in costs, all without sacrificing quality. One such strategy is to reduce readmissions.

Readmissions have been targeted both because they are expensive and because they are perceived as an indicator of poor outcome or, in other words, poor quality of care. In an analysis of all Medicare claims in 2003 and 2004, one study1 identified that 19.6% of patients (almost 1 out of 5) are readmitted within 30 days of discharge with an annual cost to taxpayers of $15 billion to $17 billion per year.1,2

In response to this problem, Medicare has focused its attention, and thus the attention of hospitals, on seven diagnoses. Three of these—chronic heart failure (CHF), acute myocardial infarction (AMI), and pneumonia—are subject to reviews and penalties, beginning in 2012. The remaining four—chronic obstructive pulmonary disease (COPD), angioplasty, coronary artery bypass grafting (CABG), and vascular diseases—will be subject to penalties in 2015.

Collectively, these seven diagnoses account for almost 30% of readmissions nationwide and are being used by Medicare as a sort of focused audit of quality. Hospitals are being held accountable for the readmissions within 30 days of patients who were originally hospitalized (the so-called “index hospitalization”) with any of these diagnoses. The readmission diagnosis does not need to be the same as that of the index hospitalization, nor does the patient need to be admitted to the same hospital.

Hospitals that fail to achieve a predetermined, risk-adjusted readmission rate are penalized on all Medicare admissions the following year. The penalty came into effect last October 1, the beginning of fiscal year 2013, and is capped at 1% of reimbursement. It is measured on the basis of initial discharges occurring between July 1, 2008 and June 30, 2011. The penalty will rise to a maximum of 2% in FY 2014, then a maximum of 3% in FY 2015. Currently, 44.5%3 of the 4,9854 hospitals in the United States are being penalized for excessive readmissions, with 307 receiving the maximum penalty.

The COPD Education Gap
By John Bethune

Educating patients is a significant challenge in reducing readmissions for COPD cases. But according to pulmonologist David Law, MD, that major hurdle is matched by an equally daunting one: educating primary care physicians.

At Saddleback Memorial Medical Center (SMMC) in Laguna Hills, Calif, Law works with a multidisciplinary team led by nurse practitioner Victoria Valensky to run an innovative pulmonary disease management program. Through this program, patients are given intensive post-discharge attention. Moderate- to high-risk patients are monitored by telehealth nurses, but the highest-risk patients are both called and visited in person by Valensky. As Law puts it, what “makes the difference in this program is boots on the ground.”

According to Law, when it comes to COPD, primary care physicians are the weak link in the disease management chain. “There is a huge education gap out there,” he says. It is probably the most challenging of the seven conditions targeted for reductions in readmissions by CMS because primary care physicians have trouble identifying COPD patients and managing them appropriately. To some extent, says Law, when it comes to COPD, primary care physicians are “still in the dark ages.” Some of them, he adds, even resist having their patients take part in a disease management program.

Law says internists tend to underestimate the number of COPD patients they have. He estimates that 10% to 15% of an average primary care physician’s patients have COPD, but “if you ask most of the physicians, they’ll say it’s maybe just 1%.”

One key tool that more primary care physicians should be using is spirometry. Law says that it takes just half an hour to train staff to administer the test, and the equipment does not need to be expensive to provide an effective pulmonary screen. And, he adds, “Medicare reimburses for spirometry, as long as it’s submitted with the appropriate ICD9 code, making it a revenue source.”

Since initiating the program, raising awareness among both patients and physicians has made a big difference for SMMC. The overall 30-day readmission rate for COPD at SMMC has fallen from 16% in 2011 to 12% in 2012. Among the 80 patients who have completed pulmonary rehabilitation and 50 currently in the disease management program, the effect has been even more dramatic, with 30-day readmissions reduced by 50% to 60%.

Of the seven diagnoses included in the readmission program, the most challenging will be COPD. Most COPD is a direct result of cigarette smoking,5 and according to a Centers for Disease Control and Prevention (CDC) report,6 smoking is associated with lower education and income levels. The progressive nature of COPD results in the severest cases—those with the highest probability for readmission—when patients are in their 70s and 80s.7 Additionally, a growing body of evidence suggests that COPD is a major contributor to cognitive dysfunction.8,9 Thus, the penalty assumes that in the brief 4 or 5 days that a COPD patient is hospitalized and recovering from an acute exacerbation, the hospital will be able to overcome all these behavioral, socioeconomic, cognitive, and age-related obstacles and to change the attitude, understanding, and living conditions of these patients. This is, at best, an unrealistic expectation.

What hospitals can hope to accomplish is to establish a strategy of care for each patient based on specific needs. Based on that needs assessment, the hospitals can then identify what can be accomplished in-house and what needs to be referred out to home health agencies and durable medical equipment providers. During the acute stay, efforts should be made to recruit patients to participate in a pulmonary rehabilitation program. Although the effectiveness of these programs in reducing readmissions has yet to be established,10,11 they are at the very least a good vehicle for patient education, smoking cessation, promotion of physical activity, and medication monitoring.

There are other non-disease-specific factors that have been shown to significantly contribute to the potential for readmission.12 These factors also should be explored and, where appropriate, an action plan established. Although not an exhaustive list, the items following are typical of these factors:

  1. Patients who are not seen by their primary care physician within 2 weeks of discharge are 10 times more likely to be readmitted within 30 days.13 Hospitals would be well served to establish a follow-up appointment for the patient rather than to leave that action to the patient to complete. Many hospitals are now making this appointment before discharge as a part of their standard of care. Further, many are calling the patient 24 hours before the appointment as a reminder and to ensure that the patient has a way of getting there.
  2. The patient’s financial status can have a profound impact on the likelihood of readmission. Most COPD patients receive Social Security and live on a fixed income. These patients may not have adequate resources to afford all the medications that are typically prescribed upon discharge. Or, if they spend their limited resources at the pharmacy, they may not be able to afford adequate nutrition. Either or both of these factors can easily contribute to a re-exacerbation and return trip to the hospital. Knowing the presence of these limitations in advance allows for appropriate advance actions. Some hospitals, for example, are taking steps to provide patients with a 30-day supply of medications upon discharge. Food banks and other community resources such as Meals-on-Wheels and senior resource centers also are being called upon to help meet patients’ basic nutritional needs.
  3. Transportation is an often-overlooked factor. Without some way of getting to the pharmacy, grocery store, or physician’s office, patients will have difficulty complying with their care regimen. Income and age are contributing factors that can influence whether someone has a car or can afford to use public transportation. When transportation is in doubt, cab vouchers and senior transport services can be used.

Patient education has been repeatedly shown to improve outcomes and reduce readmissions.14,15 However, effectively educating the COPD patient is fraught with challenges. Patient education should begin in the hospital, but we need to be mindful that, during the acute phase, patient retention may be limited. Various degrees of hospital psychosis and disassociation are often encountered in the elderly. Cognitive impairment is quite common in COPD, with a recent meta-analysis reporting rates of 90% and higher.16 Add to that the deficits in hearing and vision that accompany aging, and effective education becomes a difficult task. But it can be accomplished.

It is essential that education sessions not end when the patient is discharged. Myriad factors limit patient retention during an acute hospitalization. Critical to successfully improving outcomes and reducing readmissions is to continue the patient education process post-discharge. Pulmonary rehabilitation sessions, home health visits, and respiratory therapists employed by durable medical equipment companies can all continue the effort started in the hospital. Ideally, the messages from all these various sources will be delivered in a similar fashion and contain the same message. Just as in advertising, when the message is repeatedly delivered, it gains strength and relevance.17

The pendulum has swung, and the rules of the health care game have changed. The PPACA has mandated that quality become a central factor during hospitalizations and holds each of us accountable for the care we provide. Readmissions are one prominent yardstick by which the quality of care that hospitals provide will be measured. There are many factors that can influence readmissions, including patient understanding and empowerment. As respiratory care practitioners, we are ideally positioned to educate those in our care, to make significant contributions to reducing readmissions, and, most importantly, to improve the quality of our patients’ lives. RT

 Robert Messenger, RRT, CPFT, FAARC, is Manager, Respiratory Clinical Education, for Invacare Corporation, Elyria, Ohio. For further information, contact [email protected].

References

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations Among Patients In The Medicare Fee-For-Service Program. N Engl J Med. 2009;360(14):1418-28.

2. Medicare Payment Advisory Commission (MedPAC). Report to Congress. June 2005:83-103.

3. Rau J. Hospitals Face Pressure To Avert Readmissions. The New York Times. November 26, 2012.

4. Kaiser Family Foundation. http://www.statehealthfacts.org/comparemaptable.jsp?cat=8&ind=382

5) American Lung Association: http://www.lungusa.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html. Accessed February 4, 2011.

6. Cigarette smoking—United States, 1965-2008. MMWR Morb Mortal Wkly Rep. 2011;60(01):109-113.

7. Ekstrom MP, Wagner P, Strom KE. Trends In Cause-Specific Mortality In Oxygen-Dependent COPD. Am J Respir Crit Care Med. 2011;183(8):1032-6.

8. Hung WW, Wisnivesky JP, Siu AL, Ross JS. Cognitive Decline Among Patients With Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2009;180:134-137.

9. Dodd JW. Cognitive Function In COPD. Eur Respir J. 2010;35:913-22.

10. Puhan MA, Scharpltz M, Troosters T, Steurer J. Respiratory Rehabilitation After Acute Exacerbation Of COPD May Reduce Risk For Readmission And Mortality—A Systematic Review. Respir Res. 2005;6:54.

11. Garcia-Aymerich J, Farrero E, Félez MA, et al. Risk Factors Of Readmission To Hospital For A COPD Exacerbation: A Prospective Study. Thorax. 2003;58:100-05.

12. Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnosis And Timing Of 30-Day Readmissions After Acute Hospitalization For Heart Failure, Acute Myocardial Infarction And Pneumonia. JAMA. 2013;309(4):355-63.

13. Misky G, Wald H, Coleman E. Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010:5(7):392-397.

14. Lawlor M, Kealy S, Agnew M, et al. Early Discharge Care With Ongoing Follow-Up Support May Reduce Hospital Readmissions In COPD. Int J Chron Obstruct Pulmon Dis. 2009;4:55-60.

15. Fromer L. Implementing Chronic Care For COPD: Planned Visits, Care Coordination, And Patient Empowerment For Improved Care. Int J Chron Obstruct Pulmon Dis. 2011;6:605-14.

16. Dodd JW. Cognitive function in COPD. Eur Respir J. 2010;35:913-22.

17. Messenger R, Lewarski J. The Challenge Of Effectively Training COPD Patients. American Association for Respiratory Care (AARC) Times. 2011;35(8):26-28.