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TRANSCRIPT
10/22/2019
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THE ROLE OF THE AMBULATORY CARE PHARMACIST IN THE
MANAGEMENT OF COPDRachael Hiday, PharmD, MBA, BCPS, [email protected]
DISCLOSURE
I have no relevant financial relationships to disclose.
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EDUCATIONAL NEED ANDPRACTICE GAP
• COPD is the 3rd leading cause of death in the US
• $50 billion was spent in 2010 - 70% attributed to exacerbations
• Each COPD admission/readmission costs approximately $8400-$11,100
EDUCATIONAL NEED
• Lack of education on disease state and inhaler technique
• Time constraints during provider visits post-hospitalization
• Pharmacists have key role in prevention of exacerbations/admissions
PRACTICE GAP
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD – 2016. GOLD website. goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Published 2016. Accessed December 27, 2016
LEARNING OBJECTIVES
Describe the components of effective collaborative drug therapy management (CDTM) for COPD
Demonstrate how to perform a pharmacist-led COPD visit
Explain different programs available to enhance access to medications for COPD
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EXPECTED OUTCOMES
After this presentation, the pharmacist will be able to: Develop a pharmacist-led practice model to
successfully manage patients with COPD
Demonstrate how to perform an initial and follow up pharmacist-led COPD visit
Identify available patient-specific resources to decrease or eliminate affordability barriers in managing COPD
Indiana University Health
AMBULATORY CARE PHARMACY
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INDIANA UNIVERSITY HEALTH
Academic Health Center comprised of three major hospitals in downtown Indianapolis 16 PGY1 pharmacy residents
11 PGY2 pharmacy residency programs
Indiana University Health Physicians (IUHP) 50 primary care practices surrounding Indianapolis
metro area
23 ambulatory care pharmacists embedded in primary care practices
AMBULATORY CLINICAL PHARMACY SERVICES
OutcomesQuality metrics, readmissions, medication interventions
16 unique CDTM protocolsPatients referred by providers or through population health
19,203 patient visits in 2018Patients managed by a pharmacist in a primary care setting
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COPD MANAGEMENT
REQUIREMENTS FOR REFERRAL
Recent exacerbation requiring a hospital admission or emergency department visit Automatic referral to the clinical pharmacist
Providers can refer patients to pharmacy services for any of the following: COPD disease-state education
Medication management
Affordability concerns regardless of exacerbation history
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OFFICE-BASED SPIROMETRY
All patients with diagnosis of COPD must have documentation of pulmonary function testing (PFT)
If no record or history of PFTs in medical record perform office-based spirometry
OFFICE-BASED SPIROMETRY
Pharmacists are trained and certified to perform office-based spirometry American Association for Respiratory Care (AARC)
Pharmaceutical manufacturers will coordinate set up and pay for course (Boehringer Ingelheim)
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INITIAL VISIT - ASSESSMENT
MEDICATION HISTORY
• All current and prior medication trials
• Assess adherence
• Assess inhaler technique
SPIROMETRY
• Ensure appropriate diagnosis
• Document severity and classification
• May be repeated annually or if significant change in symptoms
IMMUNIZATION STATUS
• PPSV23
• PCV13
• Influenza vaccine
SYMPTOM ASSESSMENT
• CAT (assess symptoms)
• mMRC (assess breathlessness)
TOBACCO USE
• Current and prior use
• Previous quit attempts
• Previous quit methods
• Emphasize smoking cessation
INITIAL VISIT - PLAN
DISEASE STATE EDUCATION
• Understanding the disease process
• Symptoms
• Risk factors
GOALS OF TREATMENT
• Set realistic expectations
• COPD action plan
THERAPY SELECTION
• Appropriate drug
• Appropriate device
• Appropriate technique
• Formulary status
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INHALER TECHNIQUE
COPD ACTION PLAN
GREEN ZONE ACTIONS
• Usual activity and exercise level• Usual amounts of cough and phlegm• Sleep well at night• Appetite is good
• Take daily medications• Use O2 as prescribed• Continue regular exercise/diet plan• Avoid cigarette smoke and inhaled irritants
YELLOW ZONE ACTIONS
• More breathless than usual• Less energy for daily activities• Increased cough and/or thicker phlegm• Using rescue inhaler/nebs more frequently• Poor sleep• Poor appetite
• Continue daily medications• Use rescue inhaler ever 4 hours• Start oral corticosteroids• Use O2 as prescribed• Use pursed lip breathing• Call provider immediately if symptoms do not
improve
RED ZONE ACTIONS
• Severe shortness of breath at rest• Unable to perform any activity or sleep due to
shortness of breath• Fever, shaking, or chills• Confusion• Coughing up blood
• Call 911 immediately
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FOLLOW UP VISITS
Patients are seen every 2-12 months based on severity of symptoms
Updated medication history obtained
Assess inhaler technique, compliance, adverse effects, and effectiveness
History of COPD exacerbations, hospitalizations, or ED visits since previous visit
Assess frequency/severity of symptoms of COPD Review or perform spirometry, at least annually, if there is substantial increase in
symptoms or suspected complications
Assess classification of COPD CAT and/or mMRC
FOLLOW UP VISITS
Initiate, discontinue and/or adjust COPD medications based on protocol
Educate on inhaler technique/compliance if new medication started
Update COPD action plan
Order/administer immunizations based on CDC recommendations
Provide any necessary patient education materials
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SMOKING CESSATION
ASSESS HISTORY
DISCUSS BARRIERS AND TRIGGERS
SELECT TREATMENT AGENTS
SET QUIT DATE
PROVIDE SUPPORT AND FOLLOW UP
SMOKING CESSATION
Maintain close follow up Patient encouraged to come for appointment even if
initial quit date did not result in cessation!
Subsequent follow up monthly for 4-6 months (coordinate with COPD visits)
Keep the visit positive Much higher success rates if focus is not about the
negative effects of smoking but rather the positive effects that will occur once patient quits
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SMOKING CESSATION
12 MONTH SUCCESS RATE
NATIONAL AVERAGE
4.7%
IUH AVERAGE
42%
MEDICATION ACCESS
COPAY CARDS
PATIENT ASSISTANCE PROGRAMS
LOW-INCOME SUBSIDY
GOOD RX (WALGREENS)
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COPAY CARDS
Available on manufacturer website
Eligibility Requirements: Must have non-government funded prescription
insurance
Must not be eligible for Medicare
Monthly limit for savings Not good for patients with high-deductible plans
PATIENT ASSISTANCE PROGRAMS
COMPANY DRUGS ELIGIBILITYREQUIREMENTS
OTHER REQUIREMENTS
GLAXOSMITHKLINE (GSK)
Advair Diskus/HFA®
Anoro Ellipta®
Arnuity Ellipta®
Breo Ellipta®
Flovent Diskus®
/Flovent HFA®
Incruse Ellipta®
Trelegy Ellipta®
Ventolin HFA®
< 250% FPL US address
Uninsured
Medicare Part D must have spent $600 in prescriptions during
calendar year
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PATIENT ASSISTANCE PROGRAMS
COMPANY DRUGS ELIGIBILITYREQUIREMENTS
OTHER REQUIREMENTS
ASTRA ZENECA (AZ)
Bevespi®
PulmicortFlexhaler®
Symbicort®
< 250% FPL US citizen
Uninsured
Medicare Part D must have spent 3% of
annual income on prescriptions during
calendar year AND not eligible for LIS
PATIENT ASSISTANCE PROGRAMS
COMPANY DRUGS ELIGIBILITYREQUIREMENTS
OTHER REQUIREMENTS
BOEHRINGERINGELHEIM
CombiventRespimat®
Spiriva Respimat®
Stiolto Respimat®
Uninsured< 300% FPL
Medicare Part D< 250% FPL
US address
Uninsured
Medicare Part D must not be eligible for
LIS
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LOW INCOME SUBSIDY
• Higher income level than Medicaid• Annual income for couple = $24,690• Annual income for individual = $18,210
LIMITED INCOME
• No Medicare Part D premium, deductible, or coverage gap
• Brand copay = $8.50• Generic copay = $3.40
REDUCED DRUG COSTS
• Social Security website – apply online• Apply in person at Social Security office• Call Social Security to apply over the
phone
APPLICATION
GOOD RX
Free discount prescription program Accessible via smartphone app or via website
Walgreen Pharmacy Fluticasone/salmeterol HFA (generic Airduo) - $51.14
Albuterol HFA (generic Proair) - $22.54
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OUTCOMES TRACKING
QUALITYMETRICS
NUMBER OF VISITS
DRUG INTERVENTIONS
COST SAVINGSSUBSEQUENT
EXACERBATIONSSMOKING
CESSATION
THE ROLE OF THE AMBULATORY CARE PHARMACIST IN THE
MANAGEMENT OF COPDRachael Hiday, PharmD, MBA, BCPS, [email protected]