Publication
Article
Peer Reviewed
Pharmacy Practice in Focus: Health Systems
A pharmacist-led transitions of care program reduced chronic obstructive pulmonary disease readmissions by implementing guideline-based inhaler prescribing and addressing medication adherence barriers, decreasing 30-day readmission rates.
Background
Chronic obstructive pulmonary disease (COPD) remains one of the leading causes of death worldwide and represents a significant financial burden to both individual patients and the health care system at large.
Objective
The goal of the COPD-focused transitions of care (TOC) program implemented in the Baptist Memorial Hospital-Memphis inpatient hospital pharmacy department was to reduce 30-day hospital readmission rates for patients with COPD.
Intervention
A pharmacist-led, multidisciplinary TOC service was implemented at our institution to increase guideline-based inhaler prescribing and remove medication adherence barriers to improve care and reduce hospital readmissions in our patient population with COPD.
Outcomes
The 30-day readmission rate for patients admitted with a principal diagnosis of COPD decreased from 25% at baseline to an average of 16.2% after service implementation.
Conclusion
After implementation of a pharmacist-led multidisciplinary COPD TOC service, prescribing practices improved and 30-day readmissions were reduced. This paper describes the process of service implementation and insights gained.
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Chronic obstructive pulmonary disease (COPD) remains one of the leading causes of death, contributing to 3.3 million deaths worldwide in 2019. COPD presents a significant economic burden to both individual patients and the health care system at large.1
In 2014, the Centers for Medicare & Medicaid Services (CMS) added COPD to its hospital readmission reduction program, under which hospitals are financially penalized for excessive 30-day readmissions.2-4 In addition to the financial incentive to reduce readmissions for COPD, the desire to provide a high standard of care for patients at our institution led to the creation of a task force to address this issue.
A significant risk factor for COPD hospitalization is a prior exacerbation requiring hospitalization, especially within the previous year. Other risk factors include severe baseline airflow limitation and dyspnea.5,6 Additionally, cigarette smoking contributes significantly to morbidity and mortality in patients with COPD.7,8
Inhaled bronchodilators have long been a mainstay of COPD therapy to reduce dyspnea and improve symptom burden as well as prevent exacerbations.9 Further, it is well established that adherence to inhaled COPD therapies is low. A qualitative analysis of barriers to disease self-management identified gaps in understanding medication regimens and their importance in navigating the burden of medication costs.10
Pharmacists play an important role in the care of patients with COPD and have proved theirbenefit in improving medication adherence, inhaler technique, and success of smoking cessation efforts.11,12 Clinical pharmacists are also uniquely positioned to both provide clinical recommendations and assist in navigating medication acquisition.
For these reasons, our inpatient hospital pharmacy department implemented a COPD-focused transitions of care (TOC) program with the goals of improving care and decreasing 30-day readmissions. We developed a pharmacist-led service where pharmacists aid in optimizing inhaler regimens; assist with medication affordability and access; and provide smoking cessation counseling, inhaler device teaching, and patient education on symptom self-management. This article will review the process of service implementation, outcomes, and insights gained during the process.
Baptist Memorial Hospital-Memphis is a large tertiary care community hospital and level 2 trauma center in the metropolitan area of Memphis, Tennessee, in the United States. The facility averages 2300 admissions per month and houses 22 rounding hospitalist teams on a daily basis. Though it is not primarily an academic medical center, there are programs for learners from multiple disciplines and academic rounding teams for several specialties.
The pharmacy department is arranged in a decentralized model with clinical pharmacists stationed in patient care areas and present on academic teaching teams. Clinical pharmacy services are also available to providers via a consult service, which includes but is not limited to pharmacokinetic monitoring, anticoagulation management, and medication reconciliation. There is also an onsite retail pharmacy that provides medications for both hospital staff and patients. Before implementing the TOC service, treatment of COPD exacerbations and discharge prescriptions were at the discretion of the treating hospitalist and pulmonologist when consulted.
Prior to establishment of the TOC service, we first evaluated baseline prescribing habits for COPD and existing order sets built into the electronic health record. Providers at our institution were noted to prescribe oral steroids at doses exceeding the recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) for the treatment of an acute exacerbation of COPD. Initial analysis also demonstrated patients were frequently discharged from their COPD-related hospitalization without appropriate maintenance inhaler therapies. Issues with discharge regimens included a total lack of maintenance inhaled therapy, inappropriate regimens or doses, and duplications in therapy. The baseline 30-day readmission rate for patients with an admission principal diagnosis of COPD exacerbation was 25%.
The first step in service implementation was patient identification. To identify the patients who would most benefit from pharmacy intervention, information technology was consulted and a list of hospital diagnosis-related groups (DRGs) was created to pinpoint patients admitted with a primary diagnosis of COPD exacerbation. Physicians were also given the option to consult pharmacy for COPD TOC services in any patient with COPD regardless of the main reason for hospital admission. Because one of the largest risk factors for hospitalization for COPD is a prior hospitalization, our goal was to intervene during patients’ index hospitalization.
Patients were excluded from TOC services if they were discharged to hospice care, a long-term care facility, a skilled nursing facility, or a correctional facility; this allowed the team to focus on patients going home to self-manage symptoms. Additionally, patients admitted to the intensive care unit (ICU) or who required ventilator support did not receive TOC services until after transitioning out of the ICU.
In response to oral steroid overprescribing, admission order sets were updated to promote oral prednisone 40 mg daily for 5 days in accordance with GOLD guidelines, with an alternative option for critically ill patients to receive intravenous methylprednisolone 40 mg every 8 hours for up to 72 hours before de-escalation to oral prednisone to complete 5 days of therapy.13,14
As part of the pharmacy-led TOC program, a pharmacist dedicated to the program reviews the DRG and consult lists daily to identify patients in real time in order to initiate interventions early in the hospital stay. The pharmacist then interviews the patient to assess barriers to medication therapy, including prohibitive costs or lack of disease state understanding. The pharmacist reviews the patient’s maintenance regimen and collaborates with the provider to implement any changes based on the most updated GOLD guidelines. Steroid deescalation or initiation of inhaled therapies for acute management is recommended when necessary.
To assist in cost savings, a protocol was approved by our pharmacy and therapeutics committee that allows pharmacists to automatically substitute discharge maintenance inhaled therapies within the same therapeutic class to alternatives preferred by the patient’s insurance plan, along with providing refills to last up to 1 year. Inhaled regimens are also optimized utilizing co-pay assistance and patient assistance programs as needed. If a patient is discharged on nebulized medications, the pharmacist works with case managers to ensure the patient has a working nebulizer device at home or that they receive one prior to discharge. These steps ensure the best chance of medication access and therapy adherence for patients after hospital discharge.
To provide the most comprehensive care for patients, pharmacists collaborated with respiratory therapists and physicians to devise a protocol for smoking cessation counseling and aid for interested patients. Motivational interviewing is used to encourage smoking cessation and to provide options for assisting patients who are active smokers prior to their hospital admission. All patients interested in smoking cessation are seen by respiratory therapy for counseling on cessation tools and methods, and pharmacists are consulted to make recommendations on and assist with access to medications for smoking cessation if agreed to by the patient. Respiratory therapists may bill for their time for smoking cessation counseling, which generates revenue for their department and the hospital. This collaboration provides more comprehensive education for the patient and provides a financial benefit to the hospital.
Once the finalized maintenance regimen is decided on in conjunction with the providers, the pharmacist utilizes demo inhalers to provide education on proper inhaler technique. If the patient cannot correctly use their device, inhaler changes are discussed with the prescriber to ensure proper medication delivery. Patients also receive counseling on a COPD action plan and are provided educational materials to guide them through their maintenance regimen, symptom self-management, and when to contact a physician or seek emergency help.
Prescriptions are filled at the hospital’s onsite outpatient pharmacy and delivered to the patient’s bedside prior to discharge when agreed to by the patient. New inhaled therapies are prescribed with a year’s supply per protocol to ensure continuity of medication availability to the patient. A follow-up phone call is provided by the pharmacist 1 week after discharge to assess the patient’s response to medications and to address any additional barriers.
The initial objective of this service was to reduce 30-day hospital readmissions for a high-risk disease state. We assessed our institution’s rate of readmissions for all index patient admissions with COPD as the principal diagnosis according to the Vizient Clinical Data Base. The baseline readmission rate was compared to the average readmission rates from fiscal years with complete data after service implementation, 2020-2023. We excluded patients discharged to a skilled nursing facility, discharged to another inpatient facility, discharged against medical advice, and discharged with hospice care. Statistical analysis was performed using a χ2 test.
The baseline rate of 30-day readmissions was 25% the year immediately prior to service implementation (60 readmissions of assumed 237 index admissions based on average index rate). In fiscal years 2020-2023, the readmission rates were 14.2%, 16.6%, 19.5%, and 14.8%, respectively, with a significantly lower average of 16.2% (153 total readmissions of 946 total index admissions; P = .001).
We initially excluded patients discharging to skilled nursing facilities from receiving TOC services to focus our limited time and resources on the patients we thought in greatest need of medication and disease state education: patients with a discharge disposition of home with self-care or home with home health care. Now that our service has been established and more resources have been dedicated to sustaining it, expanding services to patients discharging to skilled nursing facilities and other inpatient facilities is an area of need.
Additionally, we initially excluded patients admitted to an ICU from receiving TOC services until they transitioned out of the ICU. Due to hospital flow issues in times of high volume, we amended our practice to include patients in an ICU and in TOC services if they did not require ventilator support and were deemed clinically stable.
It is important to note that our TOC service was implemented in 2019 and was affected by the COVID-19 pandemic within the first year of implementation. Due to the high degree of overlap of respiratory symptoms between acute exacerbations of COPD and acute infection with SARS-CoV-2, many patients were treated for both during the course of a hospitalization if they tested positive for the virus. This could have contributed to readmissions for respiratory illnesses as well. We did not exclude patients with SARS-CoV-2 from receiving COPD TOC services or from analysis of service outcomes.
A limitation of our retrospective analysis of readmission rates was that our institution transitioned to the Vizient Clinical Data Base from a different service provider in 2020. Limited data are available for retrospective analysis before then.
Although we have shown an overall decrease in the reported readmission rates for patients with a principal diagnosis of COPD, we have yet to fully evaluate the impact and value of our service. Next steps for evaluation of the impact of our service will be to perform a formal comparison of readmission rates between patients who received TOC services and those prior to service implementation. The impact of pharmacist intervention on medication costs to patients through the process of formulary review and patient assistance modalities could be evaluated with a cost-benefit ratio. Finally, the impact of the TOC service on quality of care provided for patients with COPD could be evaluated through an analysis of Hospital Consumer Assessment of Healthcare Providers and Systems scores prior to and after service implementation.
Allison Brunson, PharmD, BCPS, is a clinical specialist, internal medicine, at Baptist Memorial Hospital-Memphis in Tennessee.
Dawn Waddell, PharmD, BCPS, is clinical pharmacy manager at Baptist Memorial Hospital-Memphis in Tennessee.
COPD is a complex disease state, and management requires a multifaceted approach. Though primarily pharmacy led, implementation of this TOC service required input and buy-in from a multidisciplinary team of health care providers and continues to require cooperation among disciplines for patients to benefit. Through dedication to guideline-based prescribing, ensuring access to medications, and comprehensive education, implementation of this service ultimately led to a decrease in 30-day readmissions for COPD.
The authors have nothing to disclose.
