Approaching COPD health outcomes analytics

As for 2014, COPD was the third leading cause of death in the US. To change these statistics to the better, providers, insurers and policymakers aim at improving COPD patients' health outcomes.

But what exactly should they improve? Seems like everyone has their own opinion on the measures caregivers should target in their medical data analytics in order to fight with the mortality, morbidity and complication risks efficiently. Especially, while specific COPD challenges impeding the process of defining, measuring and analyzing patients’ health outcomes.

COPD challenges hindering health outcomes analytics

It is incurable

All COPD treatment measures are aimed to relieve patient symptoms (a chronic cough, shortness of breath, abnormal sputum and more) and slow down the disease progression. Therefore, caregivers can’t use any outcome measures related to a complete recovery.

Differences in initial health statuses

It is harder to define the right measures for evaluating the health outcomes since patients with COPD differ in their general states. For example, when an individual has chronic bronchitis, he or she may need to lose weight. On the other hand, patients with emphysema can be recommended to gain weight and muscle mass. The goals and targets of pulmonary rehabilitation for such patients will definitely differ, and their outcomes too.

Slow pulmonary rehabilitation progress

As the functional improvement of lung capacity doesn’t necessarily lead to objective pulmonary function improvement, it is useless to analyze short-time outcome data (apart from acute complications).

Patients with COPD can develop heavy complications, such as:

• lung infections (e.g. pneumonia)
• osteoporosis, especially when a patient takes oral corticosteroids
• heart failure
• pneumothorax and more

However, these complications can take significant time to develop, or develop ‘silently’ – for instance, osteoporosis usually progresses without any symptoms until a fracture occurs / vertebrae collapse. Accordingly, this lag between care delivery and the following patient’s health outcomes improvement makes data analytics even more challenging.

CMS approach to defining the must-have measures for COPD

In its ‘Roadmap for Quality Measurement in the Traditional Medicare Fee-for-Service Program’, CMS emphasizes that moving to a more value-based care environment means rethinking the quality measures and shifting the focus from process measures (which can be easiest to produce or assess) to evidence-based ones, including outcomes, resource use and transitions of care.

CMS also considers COPD a “priority area for outcomes measure development because it is a common, debilitating condition associated with considerable morbidity and mortality”.

While this statement explicitly shows the importance of defining relevant measures to improve COPD patients’ health outcomes, CMS offers providers to use two complementary measures:

• Hospital 30-day, all-cause, risk-standardized readmission rate following hospitalization (target outcome: readmission rate)
• Hospital 30-day, all-cause, risk-standardized mortality rate following hospitalization (target outcome: 30-day all-cause mortality rate)

Outtake

In this ‘Roadmap for Quality Measurement’, CMS also states that outcomes measures look at the morbidity and mortality arising from a disease, which can be a possible reason for such a scarce set of measures. While this pair can be useful for general reporting to CMS, it’s still not the coverage level we would expect for the ‘priority area’.

For example, what about more patient-oriented measures that address preventable complications, pulmonary rehabilitation and treatment progress? Let’s review other sources to see if the answer is there.

Where to look for more guidance: AHQR, NQF

AHRQ

Currently, there are 3 COPD-related measures on AHRQ’s National Quality Measures Clearinghouse (NQMC) web portal:

• Hospital 30-day, all-cause, risk-standardized mortality rate following acute exacerbation (target outcome: mortality rate)

• Proportion of patients admitted for acute exacerbation of COPD who die within 30 days of admission (target outcome: mortality rate)
• Percentage of patients who quit smoking (100% quit-rate goal) (target outcome: smoking cessation)

Outtake

The first two measures resemble those provided by CMS, and we again doubt that the presented set can offer extensive coverage to COPD health outcomes.

Since AHRQ itself identifies COPD as an ambulatory-care-sensitive condition (ACSC), it’s anticipated to address the outpatients’ challenges and their outcomes. COPD patients have to deal with dyspnea, weight problems, certain activity limitations, bad sleep, possible social isolation, anxiety and depression.

Therefore, the sets of measures targeting admissions, readmissions and mortality only seem insufficient, even with the additional smoke-quitting measure.

NQF

The National Quality Forum’s website offers 6 measures that help to evaluate COPD outcomes, yet two of them are these mortality and readmission measures provided by CMS. So let’s not repeat ourselves and head on to distinct criteria:

• Admission rate of patients with COPD or asthma, ages 40 years and older (target outcome: admission rate)
• Functional capacity in patients before and after pulmonary rehabilitation (target outcomes: functional status, exercise capacity)
• Health-related quality of life in COPD patients before and after pulmonary rehabilitation (target outcome: life quality)
• Comfortable dying: pain brought to a comfortable level within 48 hours of initial assessment (target outcome: pain control)

Outtake

While considering such habitual measures as admission, readmission and mortality, this set also focuses 2 ambulatory measures – life quality and functional capacity. We also want to highlight the importance of the pain control measure, which is created for hospices. It is a somewhat a borderline measure between mortality and life quality, as it targets the dying patient’s comfort. It is an essential health outcome for hospices, allowing them to improve palliative care delivery.

Overall, while it may not be the sufficient coverage level, the measures above present both inpatient and ambulatory care delivery. This is definitely a step further from CMS and AHRQ criteria sets, as providers now can define the areas for improvement in ambulatory conditions, such as applying more efforts to pulmonary rehabilitation.

A look around: UK, NICE

The UK National Institute for Health and Care Excellence (NICE) provides caregivers with healthcare improvement guidance on a national level by developing care quality standards, measures and indicators. Additionally, providers can access guidelines on diagnosis and management, interventional procedure guidance and technology appraisal guidance.

The quality standards part is where the measures belong. Here providers can find the sets of certain quality statements, where each statement is a separate measure. From 7 statements available for COPD, 6 focus multiple patient health outcomes:

• Inhaler technique (target outcomes: exacerbation rates, hospital admission)
• Assessment for long‑term oxygen therapy (target outcomes: admission for acute exacerbation, life quality)
• Pulmonary rehabilitation after an acute exacerbation (target outcomes: admission for acute exacerbation, life quality, exercise capacity)
• Pulmonary rehabilitation for stable COPD and exercise limitation (target outcomes: admission for acute exacerbation, life quality, exercise capacity, GP attendances)
• Emergency oxygen during an exacerbation (target outcomes: frequency of non‑invasive ventilation due to oxygen toxicity, morbidity rates)
• Non‑invasive ventilation (target outcomes: mortality rates)

Outtake

Most part of NICE’s measures targets multiple outcomes, and patient’s life quality is the focus. Both ambulatory and inpatient measures present as well. In our opinion, this approach allows more systematic COPD health outcomes coverage. It not only considers morbidity and mortality but also takes patient health status apart from hospitalization (pulmonary rehabilitation).

NICE also explains the reasons behind certain statements, their practical and research value, as well as solid connection to patient health outcomes.

Final outtake on COPD health outcomes measures

Here we are with different opinions in place. CMS aligns their measures with their own definitions, AHRQ supports them and NQF creates a wider set considering the experience of two previous stewards. UK’s NICE goes the different way with their practice.

Who’s right? Of course, we can’t say that any of the sources is wrong in their approach to measuring COPD health outcomes.

However, the full COPD patient experience with their condition, first of all, includes ambulatory setting and, to the lesser extent, an inpatient one. In this case, to accurately address high mortality and morbidity in COPD patients, the ambulatory part should be considered too. Simple as it is, health outcomes improvement starts from relevant care delivery and timely treatment plan updates. And the better the spirometry and oximetry results are, the higher the life quality is. Consequently, the survival rate increases and mortality rate drops.