9/30/2018 1
9/30/2018 Business Opportunities for Improving Population Health: COPD Patient Care NCPA 2018 Annual Convention Terry L. Seaton, PharmD, FCCP, BCPS Professor, St. Louis College of Pharmacy Lisa Umfleet, RPh, BCGP, CDE Owner, Parkland Health Mart Pharmacy Disclosures Terry Seaton and Lisa Umfleet declare no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria 2
9/30/2018 Learning Objectives • Summarize clinical interventions that improve patient-centered outcomes and lower the overall cost of care in patients with COPD. • Describe opportunities for interdisciplinary collaboration that activate patients and engage clinicians, academicians, and industry sponsors to optimize the quality of care for patients with COPD. • Explain business opportunities that support sustainable models of care for patients with COPD by pharmacists in community pharmacies. Making a Case for COPD as Target Condition > 11 million diagnosed CDC—BRFSS 3
9/30/2018 Making a Case for COPD as a Target Condition • 3 rd leading cause of death in US in 2016 • Annual direct medical costs = $32 billion in 2014 – projected to be $49 billion in 2020 • High symptom burden leads to poor health-related quality of life • Patient adherence < 50% • Poor inhaler technique in 80-90% of patients • Clinical inertia in up to 50% of patients CDC—Division of Population Health 2018 Clinical Practice Guidelines: COPD 4
9/30/2018 COPD vs. Asthma Characteristic COPD Asthma Allergy Rare Common Age > 45 years Any Course Progressive Variable Smoking Usually Sometimes Airway Reactivity Minimal Yes Response to Drugs Limited Significant Classifying COPD Severity GOLD Grade Description FEV 1 (% Predicted) 1 Mild ≥ 80% 2 Moderate 50-80 3 Severe 30-50 4 Very Severe <30 COPD Diagnosis Requires FEV 1 /FVC Ratio of < 0.7 GOLD Guidelines 2018 5
9/30/2018 Modified Medical Research Council (mMRC) Dyspnea Scale COPD Assessment Test (CAT) 6
9/30/2018 Assess Number of COPD Exacerbations (Past Year) Increased Risk for Future Exacerbation • ≥ 2 moderate/severe*, OR • 1 leading to hospital admission *Exacerbation Definitions Mild = SABD only Moderate = SABD + systemic antibiotic or corticosteroid Severe = ED visit OR hospitalization CDC—Division of Population Health Combined COPD Assessment BY GROUP Exacerbations C D ≥ 2 OR ≥ 1 Hosp 0-1 OR A B No Hosp mMRC 0-1 mMRC ≥ 2 CAT < 10 CAT ≥ 10 Symptoms GOLD Guidelines 2018 7
9/30/2018 Active Learning Opportunity Clinical Case Scenario A 67-year-old male visits his community pharmacy and requests a refill of his albuterol MDI. His FEV1 is 62% predicted and his CAT score is 18. He was hospitalized for a COPD exacerbation once, 6 months ago. What is his GOLD combined assessment? A. grade 1, group B B. grade 2, group B C. grade 2, group D D. grade 3, group C Pharmacologic Treatment of COPD Group C Group D LAMA LAMA or LABA + LAMA or LABA + ICS LABA + LAMA (Preferred) LABA + LAMA + ICS LABA + ICS rolflumilast if FEV1 < 50%, or macrolide if former smoker Group A Group B bronchodilator LABA or LAMA continue, stop, or try alternative class LABA + LAMA GOLD Guidelines 2018 8
9/30/2018 Study: COPD Symptoms and Medication Adherence in Missouri Community Pharmacies Methods • Cross-sectional design • 35 community pharmacies (rural and urban) • N = 682 patients • Data sources: • Questionnaire from patient • Pulmonary function results from physician • Medication fill records from community pharmacy JAPhA (Submitted) Study: COPD Symptoms and Medication Adherence in Missouri Community Pharmacies Results • 251 patients (37%) had spirometry data available and 52% of those patients had FEV 1 /FVC ratio < 0.7 • Patients were highly symptomatic mMRC score ≥ 2 = 61% CAT score ≥ 10 = 90% • Significant exacerbations in past year = 57% JAPhA (Submitted) 9
9/30/2018 Study: COPD Symptoms and Medication Adherence in Missouri Community Pharmacies Results • GOLD group breakdown (ALL patients, based on CAT) A = 6% B = 37% C = 4% D = 53% JAPhA (Submitted) Study: COPD Symptoms and Medication Adherence in Missouri Community Pharmacies Results PDC for maintenance COPD medications (past 12 months) • Mean = 0.54 (with PFT-confirmed COPD) • 0 - <0.2 = 23% • 0.2 - <0.4 = 16% • 0.4 - <0.6 = 14% • 0.6 - <0.8 = 14% • ≥ 0.8 = 33% JAPhA (Submitted) 10
9/30/2018 COPD-Related Quality Measures • 30-day hospital readmission • MIPS (one of two tracks under MACRA) beginning in 2020 • COPD: Prescribing long-acting inhaled bronchodilator therapy • COPD: Performing spirometry evaluation • Preventive care and screening: Tobacco use and cessation • Tobacco use and help with quitting among adolescents JAPhA (Submitted) Active Learning Opportunity Think-Pair-Share – Audience Question In your pharmacy today, how are you responsible for contributing to population health quality measures? 11
9/30/2018 Mission Possible The mission of Parkland Health Mart is to improve the health of our patients and positively impact the communities we serve. Culture of Care - Whatever it Takes 12
9/30/2018 Clinical Partnerships • Physicians and Clinics, including FQHCs • Hospitals • Cardiac Rehab Facility • LTC Facilities • Home Health Agencies • Schools/Colleges of Pharmacy • Community Health Advocate groups • Division of Aging, Department of Health & Human Services • Health Departments Our Community Local Health Departments receive grant funding • Iron County Health Department Adult Smokers in the county up to 40% • St. Francois County Health Department Community Health Ranking–101 of 114 counties 13
9/30/2018 Managing the COPD Patient • Medication Management • Inhaler/Nebulizer Technique Education • PA Management • Adherence Monitoring • Disease State Education • Immunization Screening • Oxygen • Smoking Cessation Persistence… “Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.” Mark Twain 14
9/30/2018 Smoking Cessation • Become the expert • It takes average of 9-12 attempted quits • Encouraging approach… 1 st attempt at success, not failure • Use evidence-based data to set yourself up for success • Understanding tobacco dependence • Physiological = Addiction to nicotine • Behavioral = Behavioral change program Opportunity • Transitions of Care • Chronic Care Management • Collaborative Practice Agreement • CMR/MTM • Shared Risk Model • P4P Pay for Performance • CPESN and beyond 15
9/30/2018 Revenue-Generating Potential for Pharmacists Kliethermes MA. Pharmacy Times 2017 (July);23:57-68 Revenue-Generating Potential for Pharmacists Kliethermes MA. Pharmacy Times 2017 (July);23:57-68 16
9/30/2018 Revenue-Generating Potential for Pharmacists Kliethermes MA. Pharmacy Times 2017 (July);23:57-68 Active Learning Opportunity Think-Pair-Share – Audience Question In your pharmacy today, what opportunities do you have to collaborate with others to improve the care of patients with COPD in a manner that can have a successful business plan? 17
9/30/2018 Questions? Lisa Umfleet, RPh BCGP CDE Parkland Health Mart Pharmacy lumfleet@parklandrx.com Terry Seaton, PharmD, FCCP, BCPS St. Louis College of Pharmacy tseaton@stlcop.edu 18
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