November01,2013_SectorConfidential1

COPD:HomeNIV…..Istherebenefits?

October13thMoncton,NB

ConflictofInterestDisclosures

Type of Potential Conflict Employee ofPhilipsRespironics Inc.

Grant/Research SupportConsultant

Speakers’ BureausFinancial support

Other

2.Iwishtodisclosethefollowingpotentialconflictsofinterest,OR

3.Thematerialpresentedinthislecturehasnorelationshipwithanyofthesepotentialconflicts,OR

4.Thistalkpresentsmaterialthatisrelatedtooneormoreofthesepotentialconflicts,andthefollowingobjectivereferencesareprovidedassupportforthislecture:1.2.3.

1.Idonothaveanypotentialconflictsofinteresttodisclose,OR

X

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COPD – fast facts

• leading cause of death

• Million afflicted

• Million diagnosed

• 3rd

• 3

• 1.5

3

4

ManagingCOPDpatientsisamajorissue

SOURCE:CanadianThoracicSociety

GrowingCOPDpopulation Increasingeconomicburden

COPDreadmissionsareplacingincreaseddemandsonhealthsystems,governmentsand

payersthroughouttheworld.

3millionMorethan

afflictedinCanada

50%afflictedUpto

Remainundiagnosed

WhyfocusonCOPD?Onlychronicdiseasewheremortalitystillrising

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Change in COPD Mortality compared with

other major causes from 1970-2002

COPD Heart disease Cancer Stroke Accidents DiabetesDeath rate (% change) 102.8% -52.1% -2.7% -63.1% -41.0% 3.2%

-80.0%

-60.0%

-40.0%

-20.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0% Death rate (% change)

U.S.LeadingCausesofDeath;JAMA,September14,2005– Vol.294,No.106

Canada:COPDPrevalence,Aged65+,2010

1:4 Canadians >35 years will develop COPD Hospitalizationratesare60%higherinruralareas

NewBrunswick:Top10mostfrequenthospitaladmissions(2011-12)

• NewBrunswick:HospitalreadmissionsforCOPDpatients

•within30days6%•within90days13%•within180days23%• Source:CIHIPortal- NBfacilities(AcuteCare)for2009/10.

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EconomicCOPDimpactinAlberta.KeyPoints

1

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CurrentCOPDpatientreadmittance scenario

23% of patients readmitted within 30-180 days² @ $7,400 per patient average readmission¹

¹Toyetal.TheeconomicimpactofexacerbationsofCOPDandexacerbationdefinition.Areview.COPD 2010:7:214-228²NationalQualityForum#1891,October26,2012

MarketDynamics

Changingpayer

modelsandlandscape

• Keepingpatientsoutofthehospitalisnowafinancialpriority

Hospitalswillbepenalized3%

• UnplannedadmissionsforCOPDwithin30daysofdischarge

Planningforpost-discharge

• Involvesstrongpartnershipwithallpost-acutecareproviders

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COPDisnotglamour!

DrJohnHaggie,ministerofhealth,NL

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ClinicalEvidence

16PhilipsConfidentialInformation

COPD stagesSeverity classified by spirometry

Stage 1

Stage 2

Stage 3

Stage 4

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COPD stages

MILD

FEV1 / FVC < 70%

FEV1 ≥ 80% predicted

With or without symptoms

Stage 180% normal lung function

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A guide for Health Care Professionals Updated 2010. See also www.goldcopd.org18

COPD stages

MODERATE

FEV1 / FVC < 70%

50% ≤ FEV1 < 80%

predicted

Stage 250 – 80% normal lung function

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A guide for Health Care Professionals Updated 2010. See also www.goldcopd.org19

COPD stages

SEVERE

FEV1 / FVC < 70%

30% ≤ FEV1 < 50%

predicted

Stage 330 – 50% normal lung function

Modified from GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A guide for Health Care Professionals Updated 2010. See also www.goldcopd.org20

COPD stagesSeverity classified by spirometry

VERY SEVERE

FEV1 / FVC <70%

FEV1 <30% predicted

Stage 4Less than 30% normal lung function

Modified from GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A guide for Health Care Professionals Updated 2010. See also www.goldcopd.org21

22PhilipsConfidentialInformation

COPDSimplyput;itsanAIROUTproblem.CO2hastobeclearedtomanagept.ventilation.

PathologicallinksfromDiseasetoSigns

Emphysema

ChronicBronchitis

Infection

Deteriorationofthe

Parenchyma

InflammationoftheBronchioli

Mucous

EFL

DynamicHyperinflation

↑WOB

↑PaCO2

↓PaO2

Va/Qmismatc

hAlveolarDeadspac

e

AlveolarDestruction

ReadmissionRiskfactors

• Previoushospitaladmission(ICU/ventilation)• HigherlevelsofPaCO2

• Dyspnea• Long-termoxygentherapy• Noroutinephysicalactivity• Poormedicationcompliance• Nosupport/caregiver

EconomicCOPDimpactinAlberta.KeyPoints

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CarbonDioxideisariskfactorforreadmission

1.KesslerR,FallerM,Fourgaut G,Mennecier B,Weitzenblum E.1999.Predictivefactorsofhospitalizationforacuteexacerbationinaseriesof64patientswithchronicobstructivepulmonarydisease.AmericanJournalofRespiratory&CriticalCareMedicine,159:158–642. Bahadori,K,Fitzgerald,M.RiskfactorsofhospitalizationandreadmissionofpatientswithCOPDexacerbation– systematicreview,InternationalJournalofCOPD

2007:2(3)241–2513. Ligtowler JVetal.Non-invasivepositivepressureventilationtotreatrespiratoryfailureresultingfromexacerbationsofCOPD;CochraneSystematicReview.BMJ.

2003.Jan25:326(7382):185.4. Duiverman ML,Wempe JB,etal.Two-yearhome-basednocturnalnoninvasiveventilationaddedtorehabilitationinchronicobstructivepulmonarydiseasepatients:

arandomizedcontrolledtrial.Respir Res.2011Aug23;12:112.5. DeBackerL,Vos W,etal.Theeffectsoflong-termnoninvasiveventilationinhypercapnic COPDpatients:arandomized

controlledpilotstudy.Int JChron ObstructPulmon Dis.2011;6:615-24.

• ElevatedPCO2 isariskfactorforhospitaladmissionforaCOPDpatient.1• 52%ofthestudiesreportedPaCO2asariskfactorforreadmission.2

• NIVhasbeenshowntobethemosteffectivetreatmentoptionforreducingPaCO2 inhypercapnic COPDpatients.3

• ClinicalstudiesonNIVinhypercapnic COPDshowimprovedbloodgasesandlowerhospitalizationratescomparedtopatientsnottreatedwithNIVathome.4,5

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2

WhydoCOPDpatientsexacerbate?

ØTheyfailinadherenceofsteroidalsØTheyfailinmednebadherenceofbronchodilators

ØTheiractivitylevelsdecreaseorstopØTheyfailtomakefollowupphysicianappointments.

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Ifweknowthecausesoftheseexacerbations,whyare

readmissionratesashighas23%?• WHATISMISSING?NIV?

• WhywouldwewanttotreatthesepatientsanydifferentlyinthehomethanwedowhentheyarriveintheER??

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• NIVhasshowntobethemosteffectiveinreducingCO2 instablehypercapnicCOPDpatients.3

• Wheninitiatedearlythiscanhelpreducehospitaladmissionratesandthecostofhealthcare,whileimprovingthequalityoflife.3

TreatingCOPDinthehome

³(Ligtowler JV,Wedzicah JA,ElliottMW,RamFs.Non-invasiveventilationpositivepressureventilationtotreatrespiratoryfailureresultingfromexacerbationsofCOPD.CochraneSystematicReview.BMJ2003Jan25:326(7382):185

2

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Hot-HMVERS2016abstract

• Multi-centre,RCTfundedbyPhilipsRespironicsandResMed– 116patients

§ SevereCOPD§ Recentlifethreateningexacerbation§ PaCO2>7kPA

– Interveneintherecoveryphase– Followupat6weeks,3monthsand1year

• Titrationstrategy– Highpressurestocorrectnocturnalhypoventilation

§ MeanIPAP=24§ Meanrate=14§ MeanEPAP=4

– O2startedatdaytimerate

• Results– Prolongedadmissionfreesurvivalform1.4to4.3months(p=0.007)

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1.CoughlinS.,LiangWE,Parthasarathy S.RetrospectiveAssessmentofHomeVentilationtoReduceRehospitalization inChronicObstructivePulmonaryDisease.JClin SleepMed.2015Jun15;11(6):663-70.

MultifacetedCOPDprogramshowntoimprovecare

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AVAPS-AE:ClinicalEvidence

• Retrospective Cohort Study• Single centre in the US• n = 397• COPD patients with ≥ 2 hospitalisations in

prev. year with AE-COPD• Multifaceted quality improvement (QI)

intervention • nocturnal NIV with AVAPS-AE• RT-led respiratory care• Medication reconciliation by a

pharmacist• Appropriate oxygen therapy initiation• Patient education

CONCLUSION- Reduction in hospitalisations

(decrease from 100% to 2.2%)

RetrospectiveAssessmentofHomeVentilationtoReduceRehospitalizationinCOPDCoughlinetal.JCSMVol 11. No. 6, 2015

TalkingPoints:MethodsUsed• Consecutivepatientswhohadbeenhospitalizedtwiceina

singleyearwithanacuteCOPDexacerbationwerescreenedforeligibilityandadmittedif:– COPDGOLDstages2,3or4– (b)BodeIndexScoregreaterthanorequalto5;– (c)oneofthefollowing:

• PaO2lessthanorequalto60mmHgor• PacO2greaterthanorequalto52mmHgor• FEV1lessthanorequalto40%

• Patientsreceived:– Medicationreconciliationbyapharmacist,– The(continued)provisionofoxygen,– AVAPS-AEinitiationbyarespiratorytherapist– Ongoingrespiratorytherapist-ledcare

AVAPS-AE isaauto-titrationmodeofnoninvasiveventilationdesignedtobettertreatrespiratoryfailurepatients(OHS,COPDandNMD)inthehospitalandhomecareenvironments

AVAPS-AE

• ProvenperformanceofAVAPS– Maintainstargetedtidalvolume

• AutoEPAP– Maintains patentupperairwayatcomfortablepressureutilizingPRIclinicallyproven

proactivealgorithm

• Autobackuprate– Preventsbreathstacking

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AutoBackupRate

• AutobackupratecombinedwiththetidalvolumeassuranceofAVAPSprovidesaminimumlevelofventilation

• Comfortableassistancewhenneeded

• Nomanualadjustments

• Allowsthepatienttofullyexhalebeforethenexttimedbreathisdeliveredtopreventbreathstacking.

Spontaneousratecalculatedandback-upratesetto12

IncompleteExhalation CompleteExhalation

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Proventoreducereadmissions

*AllreceivingNIVandmeetingprogrameligibilityrequirements.Allsubjectswereadmittedatleasttwiceintheprior12monthsbeforeenrollment.1.CoughlinS.,LiangWE,Parthasarathy S.RetrospectiveAssessment ofHomeVentilationtoReduceRehospitalization inChronicObstructivePulmonaryDisease.JClin SleepMed.2015Jun15;11(6):663-70.

88%reductionInareviewof398COPDpatients*

inhospitalreadmissions1

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Proventoreducecosts

*AllreceivingNIVandmeetingprogrameligibilityrequirements.Allsubjectswereadmittedatleasttwiceintheprior12monthsbeforeenrollment.1.CoughlinS.,LiangWE,Parthasarathy S.RetrospectiveAssessment ofHomeVentilationtoReduceRehospitalization inChronicObstructivePulmonaryDisease.JClin SleepMed.2015Jun15;11(6):663-70.

719fewerInareviewof398COPDpatients*

hospitalreadmissionsintheyearfollowingenrollment

$8millionSavingapproximately

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Dyspnea:keyconcernforCOPDpatients

InaCDCstudy,62%ofCOPDpatientssaidshortnessofbreathaffectedtheirqualityoflife1.

1.BehavioralRiskFactorSurveillanceSystem,UnitedStates,2011.Availableathttp://www.cdc.gov/brfss/annual_data/2011/pdf/codebook11_llcp.pdf

Solutionsexist;patientswantmore

Dailymedications

Rescueinhalers

Pursedlipbreathing

Anxietymanagementtechniques

Inspiratorymuscletraining

Pulmonaryrehabilitation

Dyspnea:keyconcernforCOPDpatients

InaPhilipsfocusgroup,55%ofCOPDpatientsindicatedthatshortnessofbreathwastheirbiggestconcern2.

2.InternalPhilipsRespironicsfocusgroupheld4/4/12with25COPDpatients

KeeppatientsoutofthecycleYourpatientfeels

breathless

Sheavoidsactivitiesthatmakeherbreathless

Hermusclesbecomeweakerandlessefficient

Shegetsmorebreathlesswhenshehastobeactive Shedoesfeweractivities

NIVstudiedwithCOPDpatientsNIValonewasmorebeneficialthansupplementaloxygenaloneinimprovingexercisetoleranceandqualityoflifeinsevereCOPDpatients3.

COPDpatientsusingNIVwhilewalkinghadlessdyspneaandwalkedfarther4.

COPDpatientswhousedNIVduringexercisetrainingshowedimprovementsinshuttlewalktestsandChronicRespiratoryDiseaseQuestionnaire5.

3.Borghi-Silvaetal.AdjunctstoPhysicalTrainingofPatientswithSevereCOPD:OxygenorNoninvasiveVentilation.RespiratoryCare2010,Jul:55(7),885-894.

4.Dreher,M.etal.NoninvasiveVentilationduringWalkinginPatientswithSevereCOPD:ARandomizedCrossoverTrial.ERJ,2007;29:930– 936.

5.Garrod etal.RandomizedControlledTrialofDomiciliaryNoninvasivePositivePressureVentilationandPhysicalTraininginSevereChronicObstructivePulmonaryDisease.AmJRespirCrit CareMed2000;162:1335-1341.

NIVhelpsCOPDpatientsrecover

Bi-levelof18/8demonstratedstatisticallysignificantreductioninrecoverytimecomparedtobaseline6

6.MahadevanA.etal.TheImpactofPEP,CPAPandBilevel inpost-exerciserecoveryfromdyspneainCOPDPatients.ERJSeptember1,2012vol.40no.Suppl 56P3532.

Exercise Recovery

KW10/20/15MCI4107017