Bob Kronemyer

home

authors

bob-kronemyer

Because most patients with undiagnosed chronic obstructive pulmonary disease (COPD) adjust their lifestyle to address their symptoms, diagnosis occurs much later in disease progression, resulting in escalating costs for treating exacerbations through hospitalizations and emergency department visits.

) asked Christopher Blanchette, PhD, MBA, an associate professor of public health sciences at the University of North Carolina at Charlotte, to articulate the challenges that COPD patients face and how COPD expenditures might be reined in.

MHE: How do COPD patients mask their symptoms?

 They might take the elevator instead of the stairs or they might stop being as active as they used to be; hence, they end up being diagnosed at stage 3 instead of stage 1.

It is important that these patients receive an earlier diagnosis by better screening patients who are current or former smokers and have the symptoms of wheezing, coughing, and/or sputum production.

MHE: What is the roll of controller therapy in reducing COPD costs?

Extremely important. Once a definite COPD diagnosis has been made, the patient should be immediately placed on a type of controller therapy. But adherence to the medication is key.

Controllers all have different breathing systems. However, sometimes the patient does not use the correct system or the device does not work for them. Therefore, the patient does not receive the benefits of the drug, so they end up in the emergency room or hospital.

Patients also need to be shown how to use an inhaler and providers should ensure that patients can use the device before being discharged. Additionally, if the drug tastes bad or makes the patient’s mouth dry, the patient may discontinue use completely.

The reality is that 20% of COPD patients are responsible for 80% of the cost, which now stands at roughly $50 billion a year in the U.S. Just between 2003 to 2010 alone, costs increased from $32 billion to $39 billion. The disease is still out of control.

MHE: Isn’t that due largely due to increased prevalence, though?

Yes, but COPD is a dormant disease. For example, smokers end up with COPD 20 to 30 years after starting smoking, despite the fact that the rates of smoking have decreased over the past 10 to 15 years.

The sheer volume of older adults is also contributing to rising COPD costs.

Next: What can healthcare organizations do to reduce COPD expenditures?

MHE: What can healthcare organizations do to reduce COPD expenditures?

 More white glove services like care managers and more coordinated care are needed because the cost is not limited to COPD. For instance, congestive heart failure is a comorbid disease that occurs in most COPD patients.

You also want to make sure patients are using their medications appropriately.

Using predictive analytics to identify high-cost COPD patients is helpful as well, plus employing care managers to follow-up with patients to make sure they are seen at the clinic.

Encouraging patients to embrace new inhaler and nebulizer technology can also reduce cost by the provider team being sent information remotely about user compliance.

MHE: Going forward, do you anticipate that COPD costs will diminish?

 Unfortunately, costs are expected to continue to rise sharply, unless we take drastic measures.

I recently conducted a study that showed there has been no change in curbing these costs over the last 30 years. Therefore, healthcare systems need to invest in measures, not only for the patient but also for the healthcare systems themselves and their own cost sharing to help manage these patients.

While in the past, most healthcare institutions have employed a fee-for-service model, now more healthcare systems are taking on more risk-sharing agreements with a focus on population health and an emphasis on reducing long-term costs, which has really been the problem for COPD patients.

Up until now, there has not been an incentive in place to reduce costs. But with new payment models, there are more incentives for healthcare systems to keep people out of the hospital and the emergency room. Controller therapy and ensuring patient compliance are crucial.

Articles

Healthcare organizations should focus on these things to improve health management of COPD patients and reduce costs.

What Healthcare Executives Can Do to Curtail Rising COPD Costs

Chronic obstructive pulmonary disease (COPD) affects women differently than men. Here are some of the biggest variations: 

1. Women have a more adverse response to smoking 

Many studies suggest that women are more prone to the adverse effects of cigarette smoking, which is a major contributor to COPD.

Ohar“Hence, women often develop COPD at a younger age or with less smoking history,” says Jill Ohar, MD, a professor of medicine at Wake Forest University in Winston-Salem, North Carolina.

Similarly, women who start smoking in childhood experience a much greater decline in lung function than their male counterparts who started at similar ages.

“It has been conjectured that women have increased vulnerability to lung function because of the difference in the geometry of the airways between the two sexes,” Ohar says. “But I do not think anyone knows for sure.”

Making matters worse, women tend to find it harder to quit smoking than men, Ohar says. “They perceive more barriers than men.”

2. Women experience more decline as they age

Postmenopausal women also experience a more rapid loss of lung function. “Some studies propose that hormonal replacement may actually mollify the rate of decline in lung function in women with COPD, although controversy remains,” Ohar notes.

3. Women may face more adverse effects from inhalers

An important cause of severe obstruction in the setting of a modest smoking history is asthma and COPD coexistent in the same individual.

For inhalers, there is probably a sex difference, in that the dry powders “require a fair amount of inspiratory strength to nebulize the dry powders from the pellet up to a respirable particle size,” says Ohar, noting that about one-third of COPD patients, mostly women, have a suboptimal inspiratory flow rate.

Women are also more frequently hospitalized for COPD than men and die more rapidly, even though the percentage of women and men who have the disease is similar, says Ohar.

5. Men are diagnosed with COPD faster than women

Clinicians, especially older clinicians, are more likely to attribute coughing, sputum and shortness of breath to COPD in a man versus asthma in a woman. “Although unfounded, this notion still exists,” Ohar conveys. “But it lingers because women used to not smoke in the numbers that men did.”

Ohar says there is about a 20-year lag between starting smoking and the early stage of COPD. “About 90% of people smoking today started at age 20 or below,” she says. “Thus, in nearly all instances, you are not going to find COPD in a patient under the age of 40.”

Much of current COPD demographics are reflective of smoking habits 20 to 30 years ago, according to Ohar. “So now you are starting to see COPD in equal numbers among men and women,” she says.

Women also do not complain as frequently about coughing and sputum as men do, “probably because women tend to swallow sputum,” Ohar says. “But women complain more of shortness of breath and fatigue. So how women perceive their symptoms seems to be different than for men.”

Chronic obstructive pulmonary disease (COPD) affects women differently than men. Here are some of the biggest variations.

Five COPD Gender Differences Healthcare Executives Should Watch

There are a host of causes for a patient with chronic obstructive pulmonary disease (COPD) to be hospitalized, ranging from pneumonia to infection.

The most common reason is a COPD exacerbation, which is defined as “a change in breathing symptoms beyond the normal day-to-day variation,” says M. Bradley Drummond, MD, an associate professor of pulmonary and critical care medicine at the University of North Carolina in Chapel Hill, NC.

Typically, this change in breathing is accompanied by a necessary switch in medications, such as additional inhalers or an initiation of an antibiotic or a steroid. “Sometimes, there is a combination of all three,” says Drummond.

Nearly two-thirds of COPD hospitalizations are associated with a COPD exacerbation, according to Drummond, with an infection being the most prevalent instigator. “Normally, these are viral infections, but they might also be related to bacterial infections,” he says.

Furthermore, some exacerbations can be triggered by inhaling irritants like air pollution, allergens, and dust, which may cause worsening respiratory symptoms.

But there are a substantial number of hospitalized exacerbations that cannot be identified by cause, including an undetectable infection or some other etiology that cannot be teased out.

This second most common cause of COPD hospitalization is at times difficult to separate from an exacerbation. “Because people with COPD have underlying abnormal inflammation in their lungs or have an abnormal lung structure, typically related to smoking, they are more susceptible to both bacterial and viral infections,” says Drummond, director of the Obstructive Lung Diseases Clinic at UNC Health Care. “These infections often settle in and progress to a full-blown pneumonia, characterized by fevers, increasing sputum production, and more shortness of breath.”

Drummond estimates that one in five COPD hospitalizations is due to a pneumonia, typically detected in the emergency room via chest X-ray imaging or CAT scan. “Pneumonia can also have the signs and symptoms of an exacerbation,” he says. “Thus, these two conditions might coexist during a hospitalization.”

However, not all COPD patients with pneumonia necessarily lead to hospital admission.

This is the third most likely cause of hospitalization, specifically heart-related illnesses, with congestive heart failure (CHF) the most prevalent, followed by coronary artery disease and stress on the heart related to impaired blood flow.

“We know that patients with COPD often have other comorbidities frequently related to their prior or current smoking use,” Drummond notes. “These patients can also have swelling of the legs or difficulty lying flat at night due to breathing problems.”

Admitted patients with evidence of fluid accumulation will be administered diuretics to try to remove some of the fluid through the kidney. Likewise, a cardiac catherization may be required to determine the status of the blood vessels feeding the heart.

The fourth most common reason for COPD hospitalization is general respiratory failure; in other words, someone coming into the emergency department struggling with shortness of breath. “This may be caused by exacerbations or pneumonia or CHF,” Drummond says. “The patient has been trying to manage his condition at home for such a long time that he has essentially tired out from his breathing.”

Rounding out the top five reasons for hospitalization is an overwhelming infection. “An infection in the lung may have moved into the bloodstream,” Drummond explains. “Similarly, there may be an infection somewhere else in the body, such as the kidneys or urinary track, which has spread to the bloodstream.”

Because COPD is a lung disease, these patients are unable to compensate for those infections as effectively as the non-COPD population.

“If the infection is identified early, patients will often be started on antibiotics, which can frequently stave off the infection from progressing,” Drummond states.

The average length of hospitalization for a COPD-related complication can vary, but typically is around five to six days.

Top Five Reasons for COPD Hospitalizations

Reducing readmissions for chronic obstructive pulmonary disease (COPD) is an ongoing challenge for healthcare systems.

One success story is the University of Cincinnati Medical Center. Before starting its new COPD care program, its readmission rate for COPD within a 30-day period after discharge was about 23%. Now it is about 14%.

) asked Jonathan Ko, BS, RRT-NPS, AE-C, clinical manager for respiratory care at the hospital, to elaborate.

MHE: What inspired your institution to implement a customized COPD care bundle?

 We wanted to ensure that we were following best practice methods for patient care to prevent readmissions. We sought to keep patients out of the hospital as much as we could.

Being an intercity hospital and a safety-net hospital, we are tasked with a large indigent patient population. Our challenge was to balance the cost of the prescription drugs that patients need to routinely take with finding a provider that they could visit instead of using the emergency room, which they often do because of lack of insurance.

MHE: What have you achieved since starting the care bundle program about two years ago?  

 Before starting, our readmission rate for COPD within a 30-day period after discharge was about 23%. But now we have roughly a 14% all-cause readmission rate [for these patients].

We began by asking patients what their needs were. Also, once a physician makes a definitive diagnosis of COPD, a series of steps are triggered. For example, the respiratory department shares tailored inhaler education with the staff, based on what the patient is going home on, because we know that hospital formulary drugs sometimes differ from what insurance will pay upon patient discharge.

Further, patients are provided a visual sheet and a handout about inhalers, as well as a live demonstration with demo inhalers, before discharge.

In addition, patients are oriented as to which drugs to use when they are having an emergency versus which drugs to use on a daily basis. Counseling patients on the side effects and complications of the drugs they take home is covered too.

MHE: Any other discharge instructions?  

 We have a standardized discharge instruction, also generated by the respiratory department. The trifold handout consists of three sections. The first section is a checkbox of what patients should request or anticipate receiving before discharge, including a follow-up appointment with their primary care physician and ensuring patients have medication prescriptions.

The second section lists signs and symptoms that patients should look for following discharge if they have trouble breathing or need to see a doctor. For trouble breathing, steps are listed, like taking their rescue inhaler, along with oral steroids like prednisone if you have them.

The third section of the trifold is left blank so patients can write a list of their discharge inhalers. 

MHE: Is social work part of the bundle program as well?

 Yes. Besides the social and financial aspects of discharge, however, our social workers ensure that patients make a follow-up appointment with a primary care doctor within seven days of discharge if possible. But if the patient does not have access to a doctor, we schedule an appointment with one of our hospital primary care physicians.

Another component of our bundle is pharmacy, both inpatient and outpatient pharmacy, to identify insurance-compatible inhaler brands. Our pharmacy also fills a 30-stay supply of medicine for the inhalers that are taken home.

We plateaued in our reduction in COPD readmissions about six months ago. And going forward, we do not expect a variability in this reduction.

Nonetheless, the bundle program has been slightly challenging to institute because there are so many moving parts. We have taken a more holistic approach consisting of a large, multidisciplinary team, whereby we have essentially put aside our differences and have agreed on the evidence out there for reducing readmissions.  

Reducing readmissions for chronic obstructive pulmonary disease (COPD) is an ongoing challenge for healthcare systems. Here’s how one is successful.

How a customized COPD care bundle is reducing readmissions

Given the significant financial penalties associated with Medicare and 30-day COPD readmissions, “hospitals must continue to implement strategies aimed at reducing them,” says Sharon Cornelison, RCP, RRT-NPS, a pulmonary transitional care specialist at Wake Forest Baptist Health in Winston-Salem, North Carolina.

Yet many providers are overlooking important steps that can help guide proper COPD treatment and therefore, reduce admissions and readmissions.

The good news is that prudent, effective, and value-based care for chronic obstructive pulmonary disease (COPD) can be easily incorporated into a managed healthcare setting, says Jill Ohar, MD, a professor of medicine at Wake Forest University in Winston-Salem.

Here are four reasons many COPD patients aren’t receiving appropriate treatment:

1. Failure to perform pulmonary function testing

“First, you need to confirm a diagnosis, based on pulmonary function testing,” she says. “Simple spirometry costs only about $25 and is covered by insurance. It is really the only way to make a definite diagnosis of COPD.”

Nonetheless, Ohar points out that many labeled COPD patients, even those hospitalized, “have no objective documentation of the presence of COPD or the severity of the disease from pulmonary function testing.”

Ohar says this revelation is “absurd, because a diagnosis is the only way to know what therapies to use. Decisions are predicated on severity of lung disease and pulmonary function testing.”

2. Not incorporating pulmonary rehabilitation

Ohar says it is also important to incorporate pulmonary rehabilitation into patient care, not only post-hospitalization but probably at the time of diagnosis as well. “Most patients already have fairly significant severe deconditioning by the time they are diagnosed,” she states.

In fact, one study found that lung function was reduced to slightly more than half of normal at the time of first diagnosis of COPD. “You can only imagine the number of people who have altered their lifestyle to accommodate a growing disability for several years, if not decades," Ohar says.

Therefore, after diagnosis, instituting appropriate therapy of bronchodilators and pulmonary rehab is cost-effective.

Cornelison says pulmonary rehabilitation, “is a comprehensive physical conditioning, education, and disease management program.”

Such a program not only improves the patient’s quality of life through medically-directed exercise and social interaction with other lung disease patients, “it teaches important skills such as managing oxygen therapy devices, identifying early signs/symptoms of a COPD flare, stress/anxiety management, tobacco cessation, breathing techniques, and respiratory medications/correct inhaler techniques,” she says. .

Unfortunately, Cornelison observes, many clinicians remain unaware or unconvinced as to how this intervention can benefit the lives of their COPD patients. “However, this line of thinking must be changed in today’s healthcare climate,” she states.

Cornelison says the keys to improving patient access to this beneficial therapy include educating providers about pulmonary rehab, ensuring everyone has access to an accredited program from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), and working with insurers to reduce copays and increase financial affordability so that more patients can participate.

“In our experience here at Wake Forest Baptist Health, our COPD patients who participate in pulmonary rehab tend to be more active partners in their healthcare, more compliant with their treatment plan, have fewer hospital admissions, and generally consume less healthcare resource dollars as compared to patients who do not participate in pulmonary rehab,” Cornelison says.

3. Not educating patients about proper inhaler use

Inhaler instructions are key. “Inhalers are quite expensive,” Ohar says. “If you purchase one over the counter, it can cost more than $300. However, most physicians do not take time to teach patients how to use inhalers. Often, the patients’ use of their device is faulty and thus they receive little or none of the medication that they have paid large amounts of money for.”

Further, it is important that clinicians impart on patients that many COPD therapies not only improve lung function, “but they reduce exacerbations that can be quite costly and can lead to hospitalizations,” Ohar notes.

4. Failure to incorporate smoking cessation education and programs

Smoking cessation will also reduce overall costs. “Why would you pour hundreds of thousands of dollars of medicines in a patient and then still let them smoke, realizing that people who smoke and develop COPD lose lung function five times more rapidly than a normal nonsmoker?” Ohar says. “Enroll your patient is an effective smoking cessation program.”

Many providers are overlooking important steps that can help guide proper COPD treatment and therefore, reduce admissions and readmissions.

Four reasons COPD patients don’t receive the right treatments

	Pending and recently approved treatment options for patients with chronic obstructive pulmonary disease (COPD) range from biologics to a triple-drug inhaler. Here are four treatment changes to watch:

	“Inflammation is an important component in the pathogenesis of both asthma and COPD,” says Michael Jacobs, PharmD, director of research development in the department of thoracic medicine and surgery at Temple University Lewis Katz School of Medicine. “The cell types involved in this inflammatory process have generally been considered to be different, with asthma being driven by eosinophilic inflammation and COPD being driven by neutrophils.”

	However, it is now recognized that eosinophils can contribute to the daily symptom burden of some patients with COPD.

	“Interleukin-5 (IL-5) is a cytokine that regulates eosinophil growth and recruitment, and plays a key role in many allergic diseases,” Jacobs says. “Hence, it has been considered a potential therapeutic target.”

	Mepolizumab is a monoclonal antibody that has been directed against IL-5. The results of 

two randomized, placebo-controlled trials

 of the antibody for the treatment of COPD unresponsive to triple therapy were recently published in the 

	“These studies demonstrate that mepolizumab given as a 100 mg. subcutaneous injection every four weeks for 52 weeks reduced the frequency of moderate or severe COPD exacerbations: a reduction of 1.40 exacerbations per year compared to a reduction of 1.71 per year with placebo,” Jacobs says.

	Based on these results, GlaxoSmithKline has submitted an application to the FDA for the approval of mepolizumab for the treatment of COPD with elevated eosinophils unresponsive to triple therapy.

	“The proportion of COPD patients who meet these clinical characteristics is unknown at this time,” Jacobs says. “Nonetheless, mepolizumab will provide a valuable treatment option for those patients who otherwise are poorly controlled.”

	“Patients with mild disease and intermittent symptoms of COPD can be adequately managed with short-acting bronchodilators, such as albuterol or ipratropium,” Jacobs says. “However, as symptoms progress and become more chronic, longer-acting agents are recommended.”

	These longer-acting drugs can be in the form of a long-acting beta-2 agonist (LABA), such as formoterol and salmeterol, or a long-acting antimuscarinic (LAMA) like tiotropium and aclidinium. 

	To further intensify therapy, combinations of a LABA and a LAMA are available; for example, Utibron from Sunovion, a combination of indacaterol and glycopyrrolate. “But some patients require the addition of an inhaled corticosteroid (ICS),” Jacobs says.

	In September 2017, the FDA approved the first triple therapy (LABA, LAMA, ICS) in a single inhaler: Trelegy Ellipta from GlaxoSmithKline and Innoviva, containing fluticasone furoate, umeclidinium, and vilanterol, for maintenance of COPD.

	“Because of the known compliance issues with inhalers, the availability of this triple combination should benefit a sizeable population of COPD patients,” Jacobs says. “Still, there are some potential concerns, such as the higher risk of pneumonia, associated with longer-term use of inhaled corticosteroids in the COPD patient population.”

More targeted use of Daliresp (roflumilast)

	The older oral agent roflumilast, which is a potent and selective inhibitor of the enzyme phosphodiesterase-4 in oral form, may soon show an increased demand, according to Fernando Martinez, MD, chief of the division of pulmonary and critical care medicine at Weill Cornell Medical College in New York City. “There is data under review that suggests that the medication is most likely beneficial in a very narrow population of COPD patients: those with chronic bronchitis, severe COPD, and a previous history of exacerbations,” Martinez says.

	Martinez believes COPD patients most likely to benefit from roflumilast will be those with severe airflow obstruction, chronic bronchitis phenotype, and a hospitalization for a COPD exacerbation in the past year.

	This is considered mostly experimental in the U.S. but is broadly used clinically in Europe. “I suspect, though, within the near future, that bronchoscopic approaches will begin to be used clinically in the U.S., albeit in a narrow group of severe COPD patients with favorable emphysema CT appearance,” Martinez says.

	Overall, there is a growing movement to segment therapy for COPD patients to a precision-based therapeutic approach, says Martinez. “This will balance benefit with risk, and aid patients and likely decision making for their clinicians and payers. As such, therapies with limited benefit but higher risk and/or cost may be less likely to be clinically used,” he says.

Bob Kronemyer is a freelance writer based in Elkhart, Indiana, with an emphasis in healthcare and general business.

Pending and recently approved treatment options for patients with chronic obstructive pulmonary disease range from biologics to a triple-drug inhaler.