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Gaps in Care for High-Risk Patients

August 27, 2018

COPD patients with comorbid conditions don’t receive the quality care they deserve, according to Laura Spece, MD, MS, a pulmonary and critical care medicine fellow at the University of Washington. Her new study involved 2,391 patients hospitalized with a COPD exacerbation at 6 Veterans Affairs hospitals between 2005 and 2011. The findings showed increased comorbidities were associated with greater odds of readmission and reduced odds of receiving treatment with steroids and antibiotics. Additionally, patients with comorbid congestive heart failure, coronary artery disease, and chronic kidney disease were less likely to receive corticosteroids and antibiotic treatments than patients without those comorbidities.

Dr. Spece shared her insights about the apparent gap in care of these high-risk patients that increases the likelihood they’ll end up back in the hospital.

How significant of a factor is managing comorbidities in the care of COPD patients?

This is a very complex and highly morbid group of patients. It’s very common for them to present with comorbidities because of shared risk factors such as tobacco abuse. Many patients have COPD and cardiovascular disease, heart failure, diabetes, kidney disease, and liver disease. COPD can also overlap with mental health issues and depression. I'm a pulmonologist and care for a lot of these patients in the clinic and in the hospital setting. I began to notice that there was a lot of diagnostic uncertainty when providers tried to sort out if patients were short of breath because of their lung disease or because of other comorbidities. I also began to realize that that uncertainty was affecting the quality of care the patients received. 

How specifically has the quality of care been impacted?

Over time providers have generally been taught to consider patients in the context of only a single disease, and guidelines and clinical practice have followed suit. But as patients have evolved and are living longer, providers are able to detect and diagnose more comorbidities. We’re beginning to realize that viewing patient care through a single lens isn’t the best approach, but accepted clinical guidelines haven’t yet caught up with that concept. Hopefully, we’ll start moving beyond thinking about COPD patients in terms of a singular disease context and begin to think about the entire care picture, which needs to include considering all of their comorbidities. 

What can be done to fill the gaps in the care these patients receive?

We still have figured that out. All we know is that the more comorbid patients are, the less likely they are to receive high-quality COPD care items. We’re conducting research to figure out why that’s happening. We’re also trying to assess the quality of care delivered to patients who are admitted with COPD and heart failure to determine why they’re not getting their COPD medications. It goes back to the way health care is set up: Patient care is centered on a single diagnosis, even though the second or third diagnosis might be clinically more important. As providers, we’re faced with caring for these incredibly complex patients and it demands coordination of care. That's a huge challenge. Hospitals are also expected to treat a higher volume of patients in a shorter amount of time, so time is always against us. That time pressure trickles down to sub specialists, and COPD is an incredibly complex disease to navigate during hospitalizations. It's not just about prescribing proper medications and ensuring patients use them properly. Proper treatment also requires behavioral modification for tobacco cessation. Providers must counsel patients about stopping smoking and determine if they need new oxygen equipment, and refer them to rehab therapies to regain their strength after an exacerbation.

What can pharmacists do to improve the care of hospitalized COPD patients?

I work as a pulmonary interventionist in an ICU, where a pharmacist rounds with us daily and helps us asses every COPD patient. More medication mistakes are caught and more suggestions are made to fill gaps in care when pharmacists are present. The model makes sense in the ICU settings, where smaller patient populations and longer rounding lends itself to a multidisciplinary approach to patient care, but I’m not sure if that coverage could be rolled out in acute care areas. It would be interesting to roll out a population management model to a pharmacy group, who could help care for all inpatients with COPD. The pharmacists would make sure patients are on a corticosteroid and receiving an antibiotic. They would notice if patients are on chronic azithromycin and make sure it’s not given for COPD exacerbations during hospitalizations. Pharmacists could also review patients’ use of outpatient inhalers and determine if exacerbations indicate they’ve been undertreated and, if so, step them up to a long-acting bronchodilator.

What’s the big-picture importance of preventing COPD patients from ending up back in the hospital, especially now that CMS is penalizing for readmissions?

Making sure patients receive appropriate therapies that are high in quality and high in value is important. Any methods that we can use to standardize care across the COPD patient population would likely result in cost savings and improved outcomes. That being said, specifically in relation to the CMS Hospital Readmissions Reduction Program, I don't necessarily believe that this incredibly complex patient population with COPD can be fixed in the hospital. Placing the burden of reimbursement penalties on hospitals is potentially inappropriate because, again, there are many factors involved in properly caring for these patients. COPD patients with comorbidities require incredible amounts of outpatient coordination and social support. I'm not sure that it's fair to penalize hospitals that deliver quality care, even if it doesn’t necessarily improve outcomes.

Dan Cook

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