At Allegheny General Hospital in Pittsburgh, Pennsylvania, we created an end-to-end solution for patients with chronic obstructive pulmonary disease (COPD) that led to improved care, decreased readmissions, and a reduced total cost of care.
Health systems can start this process by investing in respiratory therapists and navigators who are focused on the care and management of COPD patients.
It is imperative to perform pulmonary function testing or spirometry to obtain an accurate diagnosis and to assess the comprehensive symptomatic impact of COPD with use of the COPD assessment test (CAT questionnaire) or a measure of breathlessness using the modified Medical Research Council (mMRC) dyspnea scale. We prefer the former.
It is also important to risk-stratify patients, because doing so helps to identify patients who are at greatest risk and thus need greater attention. This patient population tends to comprise the highest users of health care resources, which leads to increased total cost of care.
In this era of value-based care, health systems can improve clinical outcomes in this patient population and demonstrate value as they collaborate with payers on value-based payment models.
COPD, a condition that is characterized by persistent respiratory symptoms and airflow limitation caused by a mixture of airway disease and parenchymal destruction, is a leading cause of chronic morbidity and mortality worldwide. Although COPD is both preventable and treatable, it remains the fourth-leading cause of death in the world and is anticipated to become the third-leading cause by 2020. Mortality is estimated at 6% globally, and COPD is the second-leading cause of disability and mortality in the U.S. in terms of disability-adjusted life years (DALYs).
Economically, the estimated direct and indirect costs in the U.S. are $52.4 billion, with COPD exacerbations — especially those that lead to hospital admission — accounting for the greatest proportion of total COPD burden on the health care system. There is a direct relationship between COPD severity and the cost of care, with the cost distribution varying as the disease progresses. COPD is a serious public health challenge, and the burden is projected to increase considerably over the next 30 years because of ongoing risk factor exposures and an increasing aging population.
Through initial funding from the Highmark Clinical Transformation Office, two pulmonary and critical care physicians at Allegheny General Hospital (AGH) in Pittsburgh, Pennsylvania, sought to transform care, improve outcomes, and reduce total costs. AGH is insurance-agnostic institution that serves as the main hub of an eight-hospital system that includes a Level-1 trauma center and >576 licensed beds, with approximately 24,000 inpatient admissions and 55,000 emergency room visits annually.
Because the hospital is part of an integrated delivery and finance system with a large insurer as the finance system, claims data were available for patients whom this specific insurance covered. As part of the strategic initiative for improving care for our patients with COPD, we developed an end-to-end solution in which patients with COPD were risk-stratified and placed on a care path that included inpatient coordination and outpatient navigation.
The Execution Team
Our team initially comprised two pulmonary/critical care physicians, one inpatient navigator (a respiratory therapist with >30 years of experience), and two outpatient nurse navigators. As the physicians — with the help of the respiratory therapist — began to understand the gaps in care that occurred shortly after discharge, they began to develop the model of care coordination for this specific patient population. Through ongoing trial and error, the team slowly began to train outpatient navigators and subsequently other physicians.
As the program began to scale, three additional physicians were included to meet volume requirements. Additionally, as time progressed, the team expanded to include a behavioral health specialist, a pharmacist, a social worker, a nutritionist, and a case worker to help fill in gaps of care for these chronic patients. These resources were shared with other teams focusing on other chronic disease states, including diabetes and heart failure, which will not be discussed here.
The Care Pathway
Starting in March 2016, patients who were either admitted or referred to AGH with COPD could enter the care pathway in one of three ways: (1) referral by a respiratory therapist as an inpatient, (2) referral by a physician as an outpatient, or (3) self-referral to pulmonology. All patients, regardless of their insurance, were evaluated either after admission to the hospital or as an outpatient. There were no insurance-based incentives for either the provider or the payer.
Patients with a diagnosis of COPD who were admitted to our quaternary hospital were automatically evaluated by the inpatient respiratory therapist navigator, who searched the electronic medical record for lung function studies or computed tomography (CT) scans verifying the presence of emphysema. If, after review of the inpatient medical record, the patient was deemed not appropriate, they were excluded from the care path. If there was uncertainty regarding the diagnosis, the patient was placed on the care path and then was sent to the pulmonologist for confirmation. Lung function testing was not performed if the patient had been recently discharged with an acute exacerbation of COPD from the hospital as testing is inaccurate during the acute phase of illness; in such cases, testing was performed within 6 to 12 weeks after discharge.
Patients who were admitted to the hospital and were found to be appropriate for the care pathway were followed throughout their stay by the inpatient coordinator, who provided educational information on the disease state, smoking cessation, inhaler technique, and self-management. Perhaps most importantly, the navigator created rapport with the patient and explained the entire care plan in depth. Once discharged, the inpatients followed the same care path as the outpatients (Fig. 1).
Two outpatient nurse navigators assumed care after discharge. The nurses performed telephonic outreach to the patients and performed ongoing clinical assessments through use of a questionnaire and social assessments for pathway determination. When appropriate, the patients were then placed on evidence-based clinical protocols and were tracked longitudinally. Patients were risk-stratified according to the number of recent exacerbations within the last 12 months, symptoms, and lung function (Fig. 2).
The outpatient navigators staged and risk-stratified all patients on the care path according to the 2016 Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations, thereby yielding appropriate diagnosis, treatment, and follow-up (Fig. 3). Following these guidelines, the navigators evaluated the number of exacerbations, emergency room visits, or hospitalizations in the last 12 months; the Medical Research Council dyspnea score; and the results of the COPD assessment test. The scores were tallied, and patients were appropriately staged and categorized from level A (lowest risk) through D (greatest risk) (Fig. 3). Over the years, as the GOLD recommendations have been updated, we also have updated our pathway accordingly.
Patients in COPD Stages A and B received follow-up from the nurse navigator every 3 months or as needed, those in Stage C received follow-up monthly or as needed, and those in Stage D received follow-up weekly or as needed. Although the frequency of touch points by the nurse navigators varied based on the stage of the disease, the touch points for all patients included disease education, counselling on smoking cessation, and addressing behavioral health concerns. A follow-up visit with a pulmonologist was scheduled for all inpatients within 72 hours after discharge. Furthermore, patients in Stages A and B were scheduled for follow-up with a pulmonologist yearly and every 6 months, respectively; patients in Stages C and D were scheduled for follow-up with a pulmonologist every 1 to 3 months. Pulmonary function tests were routinely performed, and an educational care plan was reviewed regularly with all patients. The average outpatient nurse navigator:patient ratio was 1:150.
If a patient left the system without a planned return date, moved out of the area, or chose not to participate in our care pathway, they were removed. If the patient had previously seen a pulmonologist that was outside of our system, the patient was given the choice to return to that pulmonologist and was not required to stay within our system.
Because Allegheny Health Network is a payer-agnostic system, claims data were not available for all patients. We utilized claims data from Highmark-insured patients to perform most of our analytics around the total cost of care.
Data were analyzed with use of a propensity score–matched difference-in-difference analysis. The propensity score was adjusted for the following metrics: COPD severity (as determined by Optum), the number of COPD exacerbations, the cost of COPD in the year prior to the launch of the care path, the duration of enrollment with Highmark Insurance, participation in Highmark drug plans, age, sex, and Charlson Comorbidity Index (to measure overall patient complexity). After matching each variable, the matching algorithm was tested to make sure that no significant differences existed between pathway members and the control group. Once matched, patients were observed over the same pre-program and post-program time frame so that there was equal exposure to incur COPD claims and to account for any seasonality.
When reviewing cost, we considered any claim in which COPD was listed as a primary diagnosis, admitting diagnosis, or within the first five secondary diagnoses; claims can have up to 26 diagnoses, but very often only a handful are populated. The cost data were analyzed with use of per-member-per-month (PMPM) costs (to adjust for variations in time in the program) and a mixed model. This mixed model assessed the interaction between the pathway indicator variable and the pre-post pathway variable, which was the variable of interest. The interaction variable accounts for any trends in the control population and essentially differentiates those trends from the pre-post trend in the patients on the care path.
All analyses were done with use of SAS Enterprise Guide software (version 7.1).
As of April 2018, a total of 792 patients had been placed on the care path. Claims data were available for 143 of these patients with appropriate matched controls. We used a pre-post analysis to evaluate the financial data.
The breakdown of the total cost of care is shown in Figure 4. Claims data initially were available for 110 patients who were on the path for an average of 4.7 months. A total cost savings of $711 PMPM was achieved, with the largest decrease in spending being observed in the area of inpatient admissions ($857; p = 0.02).
This initial analysis led to a larger dichotomized analysis comparing patients who were on the path for <1 year or ≥1 year in an effort to parse out the time effect of the program. Figure 5 demonstrates the cost breakdown for 143 patients who were on the path for a longer duration (average, 6.3 months). Although the difference was not statistically significant, there was a trend toward total cost savings ($305 PMPM; p = 0.06). Inpatient spending decreased by $506; however, both outpatient spending and pharmacy spending increased, as expected.
Figure 6 depicts a longitudinal analysis of 59 patients who were on the care path for an average of 20 months, with an estimated total cost savings of $90 to $100 PMPM. Inpatient spending continued to decrease, whereas outpatient spending, durable medical equipment, and pharmacy services continued to increase.
We contend that the total cost of care began to plateau over a longer duration of time because the patients were better cared for in the outpatient realm, which led to reduced admissions overall. Thus, the narrowing of total cost savings that was observed as the duration of follow-up increased was an expected finding. Although there were spikes in spending, a comprehensive review of the medical records demonstrated that six patients — all of whom had conditions that were not associated with COPD (e.g., heart surgery, abdominal aortic aneurysm repair, lung surgery for cancer resection, etc.) — accounted for 30% of the total spending.
Figure 7 demonstrates the reduction in readmissions of COPD patients who were on the care path as compared with patients who were not on the path, as well as those who were managed at seven other hospitals in our system. Hospital readmission rates at our hospital were reduced from 16.2% prior to introduction of the care path to 6.8% for those on the care path. System-wide readmissions stayed relatively constant over 4 years (from 2014 to 2018) at approximately 14%.
At AGH, the inpatient navigator was hired in 2014, and all patients admitted with COPD were evaluated. Patients who chose to be enrolled on the care path showed a consistent decline in readmissions from 2014 to 2018. For AGH patients not on the care pathway, there was an initial decline in readmissions that we believe was due to the effectiveness of the inpatient navigator; however, over the course of the following years, there was an increase in readmissions that we believe was the result of lack of outpatient navigation. As we continually improved our processes and patient care efforts on the inpatient navigation, a decline again was noted in 2018.
The cost of the program at our hospital consisted of the salaries of three staff members (one respiratory therapist and two nurse navigators), and these expenses did not have a negative impact on PMPM savings.
Additional metrics are shown in Table 1. Of note, baseline data showed that 34%, 18%, and 5% of COPD patients had post-discharge outpatient pulmonary visits, pulmonary function testing, and pulmonary rehabilitation referrals, respectively. Patients who were placed on the care path showed improvement in all metrics to 96%, 94%, and 81% respectively. The average Press Ganey patient satisfaction score was 4.8 of 5 (data not shown).
We encountered multiple challenges during this process. First, a significant amount of time and effort was necessary to change physician practices, and initial physician buy-in was difficult. Stakeholder notification, executive support from leadership, and ongoing education and reassurance to the physicians about the purpose, benefits, and results of the program helped to overcome this specific challenge.
Second, the creation of a navigator role for a respiratory therapist was a major obstacle in that this role was foreign to many physicians, social workers, and care managers at the time of initial implementation. A third challenge was that our specific patient population was elderly and was not as comfortable with modern technology; based on estimates provided by our outpatient nurse navigators, we determined that only 30% of this population had smartphones, which led to difficulty when we attempted to utilize technology (e.g., email, text messages, etc.) for outreach.
Allegheny Health Network is an integrated delivery and financial system with eight hospitals, and this care pathway was started at our flagship quaternary care hospital. Our primary goal is to scale the program to all other hospitals, with continuous improvement of our processes to improve the care of patients with COPD, and, ultimately, other chronic disorders. To that end, we recently added palliative care support to our pathway, which has been a true value-added benefit for our patients, and we are continuously looking for a digital solution to reduce the manual requirements of our model.
Another goal is to better utilize advanced practice providers to help reduce the burden on the physicians who are seeing patients in the outpatient setting. As we continually improve, we will track staff satisfaction scores and look for ways to reach a larger population of patients, even outside of our current system.
Other Contributors: Joseph Gordon, RT, Allegheny Health Network; Kevin Nauer, RN, Allegheny Health Network; Mary Altenbaugh, RN, Allegheny Health Network; Michael Fisher, BS, Highmark Health; Yan Tan, MBA, Highmark Health; and Carrie Pappal, RN, Allegheny Health Network.