The American Thoracic Society Conference Coverage

AJPB® Translating Evidence-Based Research Into Value-Based Decisions®, July/August 2013, Volume 5, Issue 4

The ATS 2013 conference focused on pulmonary care, critical care, sleep medicine, and more.

The American Thoracic Society (ATS) held its 2013 International Conference May 17-22 in Philadelphia, PA, focusing on subjects that included pulmonary care, critical care, sleep medicine, and more. According to ATS, the conference showed attendees the connections between basic, translational, and clinical research.

Hospital Readmissions: Challenges in Pulmonary Medicine Practice—Part 1

David H. Au, MD, MS, kicked off the Hospital Readmissions session at the American Thoracic Society 2013 conference with his presentation on “Defi ning the Role of the Practitioner, Scientist and Policymaker.” In the presentation, Dr Au said that it is important for all stakeholders in the healthcare industry to focus on hospital readmission rates. About 20% of admitted hospital patients are readmitted within 30 days, which the Medicare Payment Advisory Committee suggests costs an average of $12 billion. These costs and readmissions must be considered, especially since the advisory committee found that 13.3% of readmissions are usually preventable.

Although hospital readmissions are easy to measure, they are difficult to improve. Dr Au said it is important for policy makers, scientists, and practitioners to reconceptualize the issue of readmission, and therefore, how it is measured. Reduction in such rates comes from a focus on good health and quality of life. This is a societal issue, not just an isolated problem of the hospitals. If healthcare professionals wish to reduce readmissions, they must support constructs for overall health in the outpatient and home environment. They should also consider the importance of greater community engagement.

Dr Jerry Krishnan, with his presentation on “Transitions of Care: Identifying the Key Stakeholders in the Readmissions Process,” said that such significant engagement comes through identifying key stakeholders. Some programs like Boost, a national initiative led by the Society of Hospital Medicine, and Project Red, based out of Boston University Medical Center, have been successful in assisting patients as they transition from hospital to home, reducing their readmission risks. The reason these programs work is that the caregivers provide a social support circle for the patient.

Dr Krishnan finds there are various proactive procedures that stakeholders can implement at patient admission, near patient discharge, and at patient discharge to reduce likelihood of readmission. However, the most critical decisions involve overall support and ensuring patient understanding. The key takeaway is that all stakeholders, from nurses and physicians to case managers and family, are involved in the discharge process and patient engagement. This will guarantee a smoother transition for the patient from the hospital to outpatient care.

Dr J. Daryl Thorton also noted the complexities of improving hospital readmission rates. His presentation on “COPD, Asthma, and Pneumonia: Revisiting Predictors of Readmission in Respiratory Patients” showed there must be a consideration for factors that go beyond the care received at the index hospitalization, including the fact that some rehospitalization is not disease specific. Dr Thorton says to improve readmission rates, “A better understanding of the factors occurring outside of the hospital (ie, income inequality) are needed to make a meaningful impact.” Some programs, like the Hospital Readmissions Reduction Program (HRRP), which began in October 2012, fine hospitals for excessive readmission rates. These fi nes are intended to incentivize providers to be more cautious upon initial admission and with follow-up procedures.

In examining hospital readmissions, 2 things are apparent: they are frequent, and they are costly. It will be critical to garner the support of all healthcare stakeholders in the admission and discharge processes to ensure improved patient transition from the hospital to outpatient environments. Communication goes beyond simply telling; it must be a dialogue between patient and provider with all independent risk factors considered.

When Conventional Drugs Aren’t Enough: Enhancing the Immune System in Pulmonary Infections

Dr Keertan Dheda’s presentation at the American Thoracic Society 2013 International Conference, “XDR TB: What Else Can We Do?” focused on the growing epidemic of drug-resistant tuberculosis (DR TB). Dr Dheda said there are about 25,000 XDR TB global cases annually, and that DR TB can be “very expensive to treat and manage.” Despite several drug regimen variations, there is evidence that truly effective DR TB treatments may take decades to be formulated. Dr Dheda further commented that poor adherence to drug regimens can partly predict resistance in TB patients. Future studies may have to contemplate treatment alternatives. “The immunology of DR-TB is poorly studied,” Dr Dheda said, “and given success in other chronic diseases and the lack of effective drugs, immunomodulatory strategies deserve further investigation.”

Dr Kevin Fennelly, MD, MPH, followed Dr Dheda as he discussed prevention as the key in controlling TB transmission. His presentation, “Preventing Transmission: Attacking TB Outside the Host,” asserted that prevention starts by focusing on the TB-infected patient. Because TB is spread by aerosols, and not sputum, healthcare providers should be especially vigilant in removing the infected patient from the environment to prevent exposing uninfected people. In some cases, patients who wore a surgical mask decreased TB transmission by 56%; Dr Fennelly suggests these data may provide evidence for more efficient prevention in transmission of TB to caregivers.

While technology varies on TB patient care internationally, sometimes there are traditional treatments that work despite cost restrictions. For instance, Ugandan clinics often use open ventilation in large patient rooms because they do not have the resources for individual isolation rooms. Often individual isolation is more common in American hospitals.

Dr Fennelly further suggested that it is environmental controls that will greatly help prevention of spreading the disease. At the patient level, they should be given cough monitors, be put on therapy as quickly as possible, and separated from other susceptible patients. For treatment options, he suggests there should be studies around aerosol collection and inhaled antibiotics. At the environmental level, it is critical to optimize dilution ventilation, keep patients outdoors when possible, and minimize crowding if separate rooms are not available. For example, Dr Fennelly noted one study in Milan showed that the clinic was able to control outbreaks just by moving patients to isolation. Finally, at the healthcare worker level, education is key. Dr Fennelly felt it was important to teach those care providers with immunosuppressant diseases, like diabetes or HIV, to keep away from infected TB patients. In addition, it is worthwhile for healthcare providers to consider more simple factors in treatment, such as a patient’s nutrition and sleep pattern.

Overall, issues related to preventing transmission of tuberculosis, as well as the treatment of afflicted patients, will be a continuing field of study. While some drug regimens contribute to effective TB management, sometimes the more traditional methods like ventilation or surgical mask use can be just as beneficial to transmission control.

Hospital Readmissions: Challenges in Pulmonary Medicine Practice—Part 2

The panel at the American Thoracic Society 2013 International Conference continued discussions that suggested high rates of hospital readmissions may be an indicator of poor initial treatment, or failure to coordinate care. Further, these rates, which varied dramatically from hospital to hospital, were often excessively expensive. Dr Colin Cooke, MD, MSc, in his presentation, “Will the Affordable Care Act Alter the Readmission Landscape?” says that the Affordable Care Act (ACA) will provide various means for improving readmission rates. In fact, Dr Cooke says the ACA offers “a unique opportunity to improve the quality of inpatient care and simultaneously reduce costs.”

Bundled payments are one path toward readmission reduction, according to Dr Cooke. Unlike the traditional fee-for-service model, bundled payments focus on the overall care for a specific condition. In fact, the Bundled Payment for Care Improvement Initiative reimburses healthcare providers (from hospitals to outpatient care providers) based on the projected costs for episodes of care. Currently there are 48 clinical diagnoses eligible for bundling, including chronic obstructive pulmonary disease, asthma, and pneumonia. Dr Cooke notes that hospitals are able to share in savings if episode costs are below targets, and are penalized if they are above targets. In addition to bundled payments, Accountable Care Organizations (ACOs) will equally focus on incentivized payment models. In general, it reduce readmissions.

As bundled payments drive providers to work together, so may other collaborative efforts. Dr David Weidig, MD, said there are key interventions that can work together to successfully decrease hospital readmissions. For instance, BOOST (Better Outcomes by Optimizing Safe Transitions) at Society of Hospital Medicine is just 1 example of an intervention intended to reduce 30-day rehospitalization risk. BOOST includes several tools for addressing readmission risk including the “8Ps Assessment”: problem medications, psychological, principal diagnosis, polypharmacy, poor health literacy, patient support, prior non-elective hospitalization in the last 6 months, and palliative care. There is also a General Assessment of Preparedness (GAP), which evaluates patients’ status upon admission and prior to discharge.

According to Dr Weidig, “Incorporating assessment, intervention, and education into daily work flow” of a healthcare team is crucial to reducing rehospitalization risk. There should also be patient satisfaction training for physicians, including education about Teachback in patient understanding of transition care. Teachback ensures efficient physician-patient communication, because it requires the patient to explain what has been said to them. Additionally, even something as simple as a 48-hour post-discharge call from the physician has proved to contribute to reducing readmission rates.

Gulshan Sharma, MD, MPH, says that the hospitalist role will also have an impact on post discharge outcomes. Dr Sharma noted that hospitalists are defi ned as “a new breed of physicians…specialists in inpatient medicine— who will be responsible for managing the care of hospitalized patients in the same way that primary care physicians are responsible for managing the care of outpatients.” Services they provide include care of critical patients and development of hospital practice guidelines. Dr Sharma suggests that hospitalists will play an increasingly important role in value-based purchasing, as well as provide support for innovative care models in patient transition.

Improved engagement of patients in their care plans will ensure better outcomes in reducing rehospitalization. Engagement requires involvement from all players on a healthcare delivery team, and a focus on reducing readmission risk must be built into the daily work processes.

Choosing Wisely: Top Ways to Reduce Low-Value Care in Pulmonary and Critical Care

Scott Halpern, MD, PhD, discussed the Choosing Wisely campaign with his opening presentation on “The History of and Rationale for the Choosing Wisely Campaign.” As most healthcare providers know, healthcare spending per capita in the United States is signifi cantly higher than in most other countries. As well, physician decisions contribute to a large proportion of healthcare costs. This is why the American Board of Internal Medicine (ABIM) Foundation is promoting Choosing Wisely in an effort to encourage discussions between physicians and patients about healthcare costs. Dr Halpern says that at the center of Choose Wisely is physician stewardship, or the idea that physicians are held responsible for providing effective healthcare, and therefore should be at the center of driving cost control.

With the Choosing Wisely campaign, the ABIM Foundation hopes to reduce the overuse of tests and procedures and motivate physicians in helping patients to make better, cost-saving choices. Choosing Wisely was originally conceived by the National Physicians Alliance, alongside various other medical specialty groups, in order to identify tests or procedures they felt should be questioned or discussed.

Each participating specialty group was then asked to focus on a “Top 5” list for condition-specifi c recommendations. For instance, Dr Renda Wiener, MD, MPH, said in her presentation,“Development of the Top 5 List in Pulmonary Medicine,” that some recommendations for “choosing wisely” in pulmonary medicine include: “Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines,” and “Do not perform chest x-rays in patients without pulmonary symptoms as part of routine examinations.” Rob Fowler, MDCM, MS, in his presentation, “Development of the Top 5 List in Critical Care Medicine,” reported similar recommendations for critical care, including: “Don’t continue life support for patients at high risk for death or impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.”

Jeremy Kahn, MD, MS, says Choose Wisely acts not only as a guideline, but an evidence-based tool in physician decision making. Despite traditional methods of setting strategies for evidence-based decision making, often there are barriers for physicians, including their knowledge, environment, or attitude toward adhering to existing guidelines. Dr Kahn says when traditional incentives do not work, we “need to create fi nancial incentives to do the right thing.”

Dr Kahn further commented that the most valuable part of Choosing Wisely is its simplicity. Physicians need to consider the overuse and cost associated with unnecessary tests or procedures. It is up to them to take control of costs, rather than leave them up to policy makers. Choosing Wisely is a mind-set: physicians should be engaged with patients in formulating better recommendations that will drive value-based care.

Dr Richard Channick, MD, Discusses Clinical Trial in Pulmonary Hypertension

Richard Channick, MD, director, Pulmonary Hypertension and Thromboendarterectomy Program, Massachusetts General Hospital, Boston, spoke at the 2013 American Thoracic Society International Conference as part of a session featuring the Clinical Trials in Pulmonary Hypertension. Dr Channick’s presentation, “Macitentan Reduces PAH-Related Hospitalizations: Results from the Randomized Controlled SERAPHIN Trial,” demonstrated the positive outcomes of the macitentan drug for pulmonary arterial hypertension in the SERAPHIN trial. Pulmonary arterial hypertension (PAH), a condition that causes high blood pressure in the arteries of the lungs, can be life threatening and often requires hospitalization. When a patient with PAH is hospitalized, it not only negatively impacts a patient’s quality of life, but causes a burden on the greater healthcare system.The SERPAHIN trial was unique in that it was the first ever to consider morbidity and mortality rates in patients with PAH.

Dr Channick said macitentan is a “novel dual endothelin receptor antagonist with sustained receptor binding” and that SERPAPHIN was the “fi rst event-driven outcomes trial in PAH.” The results showed that macitentan 3 mg significantly reduced: risk of the combined end point of death due to PAH or hospitalization for PAH by 33%, risk of hospitalization for PAH by 39%, and the rate of all PAH-related hospitalizations by 43%. Further outcome results showed macitentan 10 mg significantly reduced:risk of the combined end point of death due to PAH and hospitalization by 50%, risk of hospitalization for PAH by 50%, rate of all PAH-related hospitalizations by 55%, and ate of PAH-related hospital days by 52%. The SERAPHIN trial made it clear that compared with the placebo drug, macitentan signifi cantly improved mortality and morbidity rates due to PAH.

Although macitentan drastically reduced the risk of hospitalization, only macitentan 10 mg reduced the rate of PAH-related hospital days per year. Dr Channick noted that “This reduction in hospitalizations may favorably impact quality of life and cost of care.” By reducing hospitalizations caused by PAH, there is a potential to also positively impact future costs of providing care.

The Affordable Care Act: Implications for Clinical Practice and Research

In “What Does the Affordable Care Act Actually Do?”, presented by Ivor Douglas, MD, associate professor, University of Colorado Denver, chief, pulmonary sciences and critical care medicine director, medical intensive care, Denver Health Medical Center, at the ATS 2013 International Conference, fundamental issues driving the Affordable Care Act (ACA) include access, quality, andcost. Currently, statistics show between 40 and 50 million Americans remain uninsured. Dr Douglas said that it’s not just patients who are frustrated, but the providers and hospitals. With that in mind, healthcare reform is intended to increase access for 310 million people, reduce healthcare costs, and improve quality in various aspects including extending life expectancy, lowering infant mortality rates, and lowering chronic disease by age. The reform is also slated to expand primary care and offer more preventive services.

Dr Douglas said that while various ACA initiatives have been in place since 2010, the bulk of those efforts will be employed within the next 10 years. In fact, he argues, we are on the cusp of a few major components of implementation including state insurance exchanges, essential health benefi ts packages, and the individual mandate to purchase health insurance. Dr Douglas said one the most signifi cant and largest changes, however, will be Medicaid expansion, as it is an important factor for uninsured Americans. In the ACA era, Medicare is projected to cover 50 million people 65 years and older, as well as youngeradults with disabilities.

Dr Colin Cooke from the Michigan Center for Integrative Research in Critical Care followed Dr Douglas in questioning, “Will Covering More People Remedy Disparities in Access and Outcomes of Care?” Of those millions of uninsured Americans, most are in the low to moderate income bracket, which makes them unable to afford insurance while also being ineligible for public programs. A lack of health insurance can mean reduced access to care, greater economic hardship, and negative healthoutcomes. Subsequently, Dr Cooke asked, “Does providing insurance to an uninsured individual improve these outcomes?” One study of a Medicaid program in Oregon definitively answered yes. It showed that when provided insurance, patients were protected from “catastrophic financial loss,” saw an improvement in quality of life as well as peace of mind, and increased their access to benefi cial health services. Nevertheless, Dr Cooke notes while it is likely the ACA will improve health outcomes, longer-term data are needed, and the overall improvement may not be nearly as much as anticipated. After all, insurance is just 1 small factor that contributes to efficient healthcare outcomes.

In “How Will the ACA Impact the Daily Lives of Clinicians in Pulmonary Critical Care, and Sleep Medicine: Lessons From Abroad,” Dr Robert Fowler, Sunnybrook Hospital, University of Toronto, stated that healthcare and critical care in the United States costs $2.7 trillion each year. This is signifi cantly higher than most other countries, as various data show the United States consistently has higher costs for drugs, higher costs for diagnostic imaging, and higher spending in physicians’ incomes. As Dr Cooke discussed the importance of insurance coverage, Dr Fowler agreed that insurance is a crucial factor in healthcare. This is because uninsured patients are much less likely than those with private/ commercial insurance to receive critical care services. However, the uninsured also may be more likely to require critical care because they do not seek professional advice before health situations become serious in nature. Overall, Dr Fowler says greater expenditures do not equate to quality healthcare. Improving access to healthcare for greater coverage will likely be beneficial for health. While many Americans remain uninsured, increasing coverage may not guarantee increased quality of care across the population.