COPD in Primary Care Amy Shaheen, MD, MSc

Learning Objectives Learn structural changes needed provide high quality care COPD in primary care settings Learn what can/could be targeted in primary care to prevent admissions and readmissions

Quick Facts Over 10,000 patients in COPD registry at UNCHC Over half have had an admission in the last one year 3rd most common reason for admission and readmission at UNC Our readmission rates have hovered around 30% Serve a large indigent and rural population Interventions that prevent admissions also prevent readmissions

What is Possible in Primary Care? Prevention Tobacco Cessation Appropriate pharmacotherapy Diagnosis Spirometry Education Inhaler education Anticipatory Guidance Outreach Identifying admissions real time and scheduling follow up How do you identify who needs what?

Structural Changes-Registry Built a registry in the EMR High sensitivity to identify patients Remove patients only after normal spirometry and central review Using this can identify admissions, poorly controlled patients, patients out of care, visit dates, medications and class, action plan, oxygen status, pulmonary rehab participation, antibiotic or steroid use in the last year. Visit Based Reminders for Spirometry, Rescue inhalers, Annual Inhaler education, Symptom Assessment, and Stepped Care for therapy

Practice changes Spirometry Device Nurse/MA training (via Clinical implementation coaches) Physician training (via LMS) Knowledge Gap VBR help providers learn best practices Teaching alone does not help Stepped care VBR must be supported with care management (medication access) Pulmonary availability must support good primary care

Practice Changes Train the teachers (MAs, Nurses) Demo inhalers Documentation Symptom assessment consensus Teach stepped care algorithm Provide easy access to formularies

Audit and Feedback Institutional Goal Setting

Some promising early data…

Anticipatory Guidance Use system form or standard text for Action Plans Reach agreement on antibiotic and steroid use

Care management Use registries to Identify admissions real time Readmission prevention/hospital follow up clinic-Staffed by pharmacist and hospitalist Seen within 7 days MUST address socioeconomic and educational barriers to pharmacotherapy Suggest using a check list to be comprehensive during visit

Summary and suggestions: Step wise implementation in one practice and then spread (5 in out pilot) Start with high sensitivity (i.e. diagnoses, problem list, inhalers, smoker with inhalers, etc) Use Office based spirometry with supportive training to exclude patients Implement symptom assessment with VBR (don’t need to be computerized to start) Use symptoms to guide therapy using VBR Build momentum, data, and then use to get institutional buy-in Set practice and organizational goals Create Toolkits for use in your organization-See handouts Measure, measure, measure