Screening Women for COPD
Stephanie Koch, BS, RRT
Editor’s Note: The following article comes from the Winter edition of the AARC’s Long-Term Care Section Bulletin.
The 2014 guidelines from the Global Initiative on Chronic Obstructive Lung Disease (GOLD) provide a comprehensive look at how to diagnose, manage, and prevent COPD. GOLD also mentions that some studies are showing that women are more susceptible to the effects of tobacco smoke than men.
In 2004, the U.S. Surgeon General reported, “Women smokers are nearly 13 times more likely to die from COPD compared to women who had never smoked.” On average, hospitals reported a 42% increase in female deaths caused by COPD between 1980 and 2000. According to an American Lung Association report on women and COPD, women have surpassed men in the number of COPD hospitalizations, with 52.7% of the 715,000 hospital discharges for COPD in 2010 occurring among women.
So why the shift? Many believe it’s caused by the change in cigarette smoking in women. In the 1960s, women were focused on political and social freedoms. Tobacco companies captured this idea and positioned cigarettes as symbols of liberation, independence, self-confidence, beauty, and adventure. You might recall some of the branding, such as, “You’ve come a long way baby!” Companies even changed the names of their cigarettes to entice women: Virginia Slims, Eve, and Satin are prime examples.
Another factor influencing the increase of COPD in women is occupational exposure. Women began working in jobs that were historically held by men, including those where exposures to dust and chemicals play a major role in the development of COPD. Then there’s the secondhand smoke exposure, as well as the everyday exposure to air pollution.
Physiologically, women have smaller airways than men, which results in a higher exposure to inhaled irritants. Women have a peak FEV1 at about 13 years of age and reach plateau by 16. Men reach their peak FEV1 at 16 years of age and plateau by 18. Cigarette brand preferences and differing inhalation particles between cigarette brands also influence gender-related risk of COPD. COPD has been shown to develop differently in men and women as well. CT scans show women have less evidence of emphysema and a greater significance of bronchitis or thicker airway walls and a smaller airway lumen.
Today, smokers are shifting from cigarettes to e-cigarettes, changing the levels of air pollution affecting the environment and adding different chemicals to the mix, such as those used in nail salons. I wonder what changes we’ll see in 20 years? This is an important question to ask, given that we provide screening for COPD. We cannot forget that this disease isn’t gender specific and affects women too.
New Value in Managing COPD
Richard M. Ford, BS, RRT, FAARC, Director of Pulmonary Services, UC San Diego Health System, San Diego, CA
Editor’s Note: The following article comes from the Winter edition of the AARC’s Management Section Bulletin.
In the January 1971 edition of Respiratory Therapy News, Dr. D.S. Tysinger wrote an article titled “Lessons Learned in Twenty Years’ Experience in Treating the Chronic Lung Patient.” His message was one of opportunity for improvement. He declared that patients with chronic lung disease are likely to get improper, ineffective, and in some cases, detrimental and even lethal treatment, specifically in the home environment.
Ironically, while the field of respiratory care has experienced tremendous advancement in understanding the diagnosis and treatment of COPD since 1971, we can still agree that today such patients are still at risk. Luckily, there are new opportunities to improve outcomes.
Readmissions reduction
With the significant and unsustainable cost of health care in the U.S., the Affordable Care Act (ACA) emerged. The Readmissions Reduction Program within the ACA provides for significant penalties for readmission of COPD patients to acute care hospitals. COPD was included in the program as of October 2014, with penalties for readmissions for pneumonia, myocardial infarction, heart failure, and COPD amounting to as much as 3% of total Medicare annual payments.
While COPD was just included last year and will impact penalties applied in 2015, there are concerns over the program. Some have expressed that the program may actually place patients at increased risk, in that centers that are in underserved communities and already struggling may incur further financial losses that will hinder their ability to serve such communities.
For example, the program does not take into account the socio-economic, literacy level, or homeless population of a community, despite the fact that these factors greatly impact the ability of caregivers to influence care once a patient is discharged. There are also planned readmissions for necessary follow-up care to consider, and mechanisms are being refined to ensure readmissions under these conditions are exempt.
Doing the right thing
Lastly, there are also centers, such as UCSD, in which there is a profit in COPD admissions/readmissions. In the case of UCSD, the total gain of taking care of patients readmitted for COPD is estimated to be greater than the penalty that would be incurred by avoiding these 30-day readmissions. But regardless of the financial incentives, improving the care and outcomes for these patients is the right thing to do.
To that end, we have programs in place at UCSD that provide for a positive margin in the care of such patients. The initiatives already in place include:
- Evidence-based COPD and treatment-based protocols
- Presence of therapists in clinics
- COPD order set reflective of best practice
- Pulmonary rehabilitation program
- Hospitalist program
- Therapist-provided patient education
- Partnerships with durable medical equipment providers
- Transitional care nurses
- Effective aerosol medication substitution policies/protocols
With these programs in place, the cost of treating COPD patients produced a positive gain over a length of stay of 4.5 days. These programs have also impacted the 30-day readmission rate. In 2013 the readmission rate had increased to 27%, and over the 2014 period it dropped to 17.6%. We also recognized we could have a greater impact on the cost of inpatient care, the continuity of care, and the transition to home if we could allocate additional resources to coordinate the care of these patients.
The addition of “COPD coordinators” (six individuals amounting to one FTE) was approved and will be implemented this year to assist with sustaining existing programs and increasing physician compliance with the COPD order set. These coordinators will also provide additional focus on patient/family education; medication management; development of a personalized COPD Action Plan; and referrals to PFT, pulmonary rehab, and smoking cessation; as well as personalized telephone follow-up once the patient has been discharged.
Opportunity is great
Regardless of the financial incentives, we must ensure compliance with the recommendations contained in the GOLD guidelines and make sure COPD patients not only receive the most effective and efficient care possible while in the hospital but also have access to the services they need to stay healthy post discharge. Never has there been a greater opportunity for the RT.
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Attention all budding authors: Got an interesting story? Have an abstract you would like to share? Want to tell a funny story about your program? (Names changed to protect the innocent and HIPAA laws, of course.) Email your contributions toGerilynn Connors or Pamela Neuenfeldt by the deadlines stated below.
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