9/30/2018 1 9/30/2018 Business Opportunities for Improving - - PDF document

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Terry L. Seaton, PharmD, FCCP, BCPS Professor, St. Louis College of Pharmacy Lisa Umfleet, RPh, BCGP, CDE Owner, Parkland Health Mart Pharmacy NCPA 2018 Annual Convention

Business Opportunities for Improving Population Health: COPD Patient Care

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

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Learning Objectives

• Summarize clinical interventions that improve patient-centered
• utcomes 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

• ptimize 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

CDC—BRFSS > 11 million diagnosed

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Making a Case for COPD as a Target Condition

• 3rd 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

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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 FEV1 (% Predicted) 1 Mild ≥ 80% 2 Moderate 50-80 3 Severe 30-50 4 Very Severe <30

GOLD Guidelines 2018

COPD Diagnosis Requires FEV1/FVC Ratio of < 0.7

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Modified Medical Research Council (mMRC) Dyspnea Scale COPD Assessment Test (CAT)

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Assess Number of COPD Exacerbations (Past Year)

Increased Risk for Future Exacerbation

• ≥ 2 moderate/severe*, OR
• 1 leading to hospital admission

CDC—Division of Population Health

*Exacerbation Definitions Mild = SABD only Moderate = SABD + systemic antibiotic or corticosteroid Severe = ED visit OR hospitalization

Combined COPD Assessment BY GROUP

GOLD Guidelines 2018

C D A B

mMRC 0-1 CAT < 10 mMRC ≥ 2 CAT ≥ 10 ≥ 2 OR ≥ 1 Hosp 0-1 OR No Hosp Exacerbations Symptoms

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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

GOLD Guidelines 2018

Group C

LAMA LABA + LAMA (Preferred) LABA + ICS

Group D

LAMA or LABA + LAMA or LABA + ICS LABA + LAMA + ICS rolflumilast if FEV1 < 50%, or macrolide if former smoker

Group A

bronchodilator continue, stop, or try alternative class

Group B

LABA or LAMA LABA + LAMA

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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 FEV1/FVC ratio < 0.7

• Patients were highly symptomatic
• mMRC score ≥ 2 = 61%
• CAT score ≥ 10 = 90%
• Significant exacerbations in past year = 57%

JAPhA (Submitted)

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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)

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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?

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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

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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

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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

• f times.”

Mark Twain

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Smoking Cessation

• Become the expert
• It takes average of 9-12 attempted quits
• Encouraging approach… 1st 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

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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

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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?

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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

Questions?