Pharmacists can play an integral role in transitions-of-care for patients with chronic obstructive pulmonary disease (COPD) to prevent hospital readmissions.
COPD affects at least 16 million individuals in the U.S., according to the CDC. This disease causes airflow blockage and breathing-related problems, which can affect daily activities and ultimately lead to hospitalization and death. Hospital and community pharmacists can play an important role in transitions-of-care for patients with COPD through medication management and education
COPD Transitions-of-Care in Health Systems
Melissa Santibañez, PharmD, assistant professor, Department of Clinical and Administrative Sciences at Larkin University College of Pharmacy, Miami, FL says most patients presenting with COPD exacerbations will be admitted to the intensivecare unit (ICU) because they develop acute hypercapnic respiratory failure (high carbon dioxide levels) requiring emergent endotracheal intubation and mechanical ventilation for respiratory support.
All COPD patients—regardless of their staging along the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria—should be on maintenance long-acting bronchodilator inhaler therapy, using either a long-acting muscarinic antagonist (LAMA) or long-acting beta-agonist (LABA), and also on short-acting bronchodilator rescue inhaler therapy, using a short-acting beta-agonist (SABA) if and when needed.
Use of an inhaled corticosteroid at different intensities of dosing is also possible as an adjunct to LAMA/LABA maintenance with SABA rescue. Evidence suggests that LAMAs may have a greater effect on reducing exacerbation rates than LABA treatment. Systemic corticosteroids are recommended for acute COPD exacerbations, with guidelines supporting prednisone 40-50 mg orally once daily for 5 days.
“I believe that the most consistent contribution that a critical care clinical pharmacist can make to ensure optimal care for the COPD exacerbation patient after transition from the ICU comes from medication reconciliation,” says Santibañez.
She adds that the pharmacist’s role in reviewing the patient’s verified home medication list against the list of inpatient therapies initiated during the exacerbation period and recommending changes to the chronic COPD management plan.
“I especially caution patients and caregivers against continuing systemic corticosteroid therapy after the exacerbation (unless if indicated for another reason), and I verify that they know what their chronic and rescue medications are at the current moment,” says Santibañez. Critical care pharmacists can facilitate the final discharge medication counseling by handing off any pertinent medication-related concerns post-exacerbation to their pharmacist colleagues on the corresponding floor/ward service or on the transition of care side.
“My number 1 clinical pearl that I emphasize is that inhalers for COPD are daily medications just like pills for hypertension,” says Paul Boylan, PharmD, BCPS, assistant professor, Department of Clinical and Administrative Sciences, Larkin University College of Pharmacy, Miami, FL.
Boylan says that if patients need to use rescue inhalers 2 or more times per week, then it may be a sign that their COPDisuncontrolledandtheyneedto see a provider. “During my postgraduate training, my mentors emphasized the importance of ‘discharge begins on admission,’” says Boylan.
His goal is to see his COPD patients every day while they are admitted so they can establish a rapport before discharge. Boylan and his students make post-discharge appointments for patients with their primary care providers or special- ists. They also follow-up with a 15- to 20-minute telehealth phone call to assess patients’ symptoms and see if they picked up their prescriptions from the community pharmacy. Boylan adds that it is important to update the home medication list in the electronic medi- cal record to ensure it reflects all of the current treatments in case the patient is readmitted to the hospital.
Community Pharmacists and COPD Transitions-of-Care
It is important for community pharmacists to ensure that COPD patients are up-to-date on their immunizations, especially the influenza and pneumococcal vaccines to prevent serious illness (eg, lower respiratory tract infections) and death.
Counseling on smoking cessation that includes the 5 A’s (Ask, Advise, Assess, Assist, and Arrange), should be incorporated into patient education. When patients pick up their prescriptions, pharmacists should assess their inhaler technique.
According to a study published in Federal Practitioner, a COPD care service consisting of a clinical pharmacist and nurse improved access to follow-up care and patient education at the time of transition from hospital to home. The study identified patients recently hospitalized for COPD, and clinic follow-up was coordinated by a clinical pharmacist and nurse within 30 days of hospital or emergency room discharge. Disease monitoring as well as patient-self monitoring of COPD was improved through this interprofessional approach to patient care. Pharmacists can play an integral role in the community setting by collaborating with the entire healthcare team to ensure that COPD patients are appropriately managed when transitioning from the hospital to the community setting.
Ahzam Afzal, PharmD is founder and managing partner at Frontizo, located in Bingham Farms, MI. Frontizo is a chronic care management company that services patients in 18 different states and is covered for all Medicare and Medi- care advantage plans as well as through most commercial and private payers. The program services patients nationally across physician practices, hospitals, accountable care organizations, and independent physician associations and has reduced COPD exacerbations by following-up with each patient monthly to determine whether there are any signs/ symptoms of exacerbations.