JAMDA 18 (2017) 553.e17e553.

e22

JAMDA
journal homepage: www.jamda.com

Clinical Experience

Chronic Obstructive Pulmonary Disease in Post-acute/Long-term

Care Settings: Seizing Opportunities to Individualize Treatment and
Device Selection
Meenakshi Patel MD, CMD a, Karl Steinberg MD, CMD, HMDC b, *,
Manuel Suarez-Barcelo MD, CMD c, Dana Saffel PharmD d,
Rick Foley PharmD e, Chad Worz PharmD f
a
Wright State University, Boonshoft School of Medicine, Dayton, OH
b
California State University Institute for Palliative Care, San Marcos, CA
c
Mount Sinai Medical Center, Miami Beach, FL and Vitas Hospice, Miami, FL
d
PharmaCare Strategies, Inc., Santa Rosa Beach, FL
e
Omnicare (CVS Health), Sorrento, FL
f
University of Cincinnati, College of Pharmacy, Cincinnati, OH

a b s t r a c t

Keywords: Introduction: The burden of chronic obstructive pulmonary disease (COPD) in post-acute/long-term
COPD care (PA/LTC) settings is high, and many patients do not receive guideline-recommended care.
guidelines Methods: An interprofessional expert panel of PA/LTC professionals convened to discuss the unmet
assessment
medical needs in patients with COPD in PA/LTC settings, and to make recommendations for the
device
assessment of COPD patients to individualize the selection of maintenance treatment.
algorithm
nebulization Results: Unmet needs observed in patients with COPD are described in addition to new tools for assessing
individual patient abilities and appropriate device selection for maintenance treatment.
Conclusion: COPD management in PA/LTC settings needs to be reevaluated and updated to help reduce
exacerbations, hospitalizations, and readmissions.
2017 Published by Elsevier Inc. on behalf of AMDA e The Society for Post-Acute and Long-Term Care
Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Chronic obstructive pulmonary disease (COPD)-related exacerba-
tions, hospitalizations, and mortality are a troubling health care
burden in the United States.1,2 COPD is often underdiagnosed and
undertreated,3e6 and medication adherence is poor.7 Physical and
cognitive functions required to effectively self-administer medications
decline with age,8e11 and this is particularly evident in COPD patients
in post-acute/long-term care (PA/LTC) settings, who have a high
prevalence of dementia. Importantly, the assessment of physical and
Funding for the live roundtable meeting held in March 2016 in Boston, Massa-
chusetts, and medical writing support was provided by Sunovion Pharmaceuticals.
The sponsor had no role in the development or nal approval of this manuscript.
The authors disclose receiving an honorarium for their attendance at the
roundtable meeting from Sunovion Pharmaceuticals. Additional disclosures include
K.S.dspeaker for Boehringer Ingelheim; and M.P.dadvisor for Mylan. M.S.B., D.S.,
R.F., and C.W. report no other relevant conicts of interest, nancial or other. The
authors were not remunerated for the development of this manuscript and retained
full control of its content and nal approval.
* Address correspondence to Karl Steinberg, MD, CMD, HMDC, California State
University Institute for Palliative Care, San Marcos, CA 92056.
E-mail address: karlsteinberg@MAIL.com (K. Steinberg).
cognitive functioning to individualize treatment of COPD is not
routinely performed in practice.12
Two studies highlight the burden of COPD in LTC settings.13,14 The
rst was a retrospective analysis of a large data source of 126,121
residents in skilled nursing facilities (data from October 2009 through
September 2010). This rst study found that nearly 1 in 5 of the more
than 27,000 patients with a diagnosis of COPD received no respiratory
medications.13 The second analyzed 8094 residents in assisted living
and other regulated adult care facilities from the 2010 National Survey
of Residential Care Facilities. The second study found that COPD was
associated with an increase in emergency department visits, hospital
stays, and comorbidities.14
This article summarizes an expert consensus on current unmet
medical needs in patients with COPD in PA/LTC settings, particularly
the needs for individualized treatment and the reduction of hospital
readmissions. The authors agreed that a paradigm shift is necessary to
prevent negative outcomes in PA/LTC settings. Recommendations are
made to align current practice with emerging value-based, person-
centered, accountable care models.

http://dx.doi.org/10.1016/j.jamda.2017.03.020
1525-8610/ 2017 Published by Elsevier Inc. on behalf of AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
553.e18 M. Patel et al. / JAMDA 18 (2017) 553.e17e553.e22
Methods
An interdisciplinary roundtable meeting was convened with a
panel of expert PA/LTC professionals to discuss the unmet medical
needs in patients with COPD and recommendations for the assess-
ment of COPD patients to individualize the selection of maintenance
treatment. Select literature was retrieved by keyword search in
PubMed and summarized to support unmet medical needs identied
by the panel. Clinical experience and available COPD clinical practice
guidelines were used to support the authors recommendations.
Results
Unmet Medical Needs for COPD Patients in PA/LTC Settings
Unmet needs identied by the authors are summarized in
Appendix 1. Two major unmet needs were given focus: (1) the
underuse of long-acting bronchodilator maintenance therapy,
including individualized device selection, and (2) to decrease hospi-
talizations and readmissions from exacerbations of COPD. To address
these needs, the authors asked the following questions: What evi-
dence can we use to support changes in care that may address these
needs? When in a COPD patients journey should changes in care be
made? How can we implement changes in practice to address these
needs?
Long-Acting Bronchodilator Maintenance Therapy for COPD
The rst issue is the underutilization of long-acting bronchodilator
maintenance therapy. A 2012 study found that more than 69% of high-
complexity COPD patients (those with more severe disease and co-
morbid conditions) in a Medicare population failed to receive main-
tenance medication despite Global Initiative for Chronic Obstructive
Lung Disease (GOLD) recommendations.5,15 In real-world practice,
many health care providers do not use guidelines to inform decision
making. In addition to physician-related factors, other concerns may
play into the failure of patients to receive these medications for
maintenance therapy, including psychosocial and socioeconomic
factors.
Long-acting bronchodilators are strongly recommended as daily
maintenance therapy for COPD symptoms; however, choosing a spe-
cic therapy and delivery device can be challenging.16e18 Short-acting
bronchodilators are generally effective for 4 to 6 hours and are often
used on an as-needed basis to improve breathing quality following an
escalation of symptoms or for an exacerbation. They are not recom-
mended as daily around-the-clock maintenance therapy.17 Currently,
there are several long-acting bronchodilators approved for use in the
United States as monotherapy or in combination with other agents.
These include the long-acting b2-adrenergic receptor agonists (LABAs)
formoterol [dry powder inhaler (DPI) and by nebulizer], salmeterol
(DPI), arformoterol (by nebulizer), indacaterol (DPI), and olodaterol
(soft mist inhaler). LABAs are effective at reducing exacerbations,
improving exercise performance, and enhancing the benets obtained
from a structured exercise rehabilitation program.19e21 LABAs also
may improve health-related quality of life in patients with COPD.22
There are also the long-acting muscarinic (anticholinergic) antago-
nists (LAMAs) tiotropium bromide (DPI and soft mist inhaler), aclidi-
nium bromide (DPI), and glycopyrronium bromide (DPI). Clinical
studies have shown these inhaled therapies to be both effective and
well-tolerated when used alone. However, the LABA/LAMA combina-
tions (glycopyrronium/indacaterol or aclidinium/formoterol) have
been shown to provide an even greater bronchodilatory effect, most
likely because of the additive impact of their actions on two different
pathways, compared with either agent alone or the combination of a
LABA with an inhaled corticosteroid (eg, salmeterol/uticasone).23,24
LABA/LAMA combinations have similar efcacy and safety by indi-
rect comparison. Direct head-to-head comparison data are not avail-
able to denitively show which may be the most effective for patients
with COPD.25
Hospitalizations From Exacerbations of COPD
The second issue is the need to reduce hospitalizations from ex-
acerbations of COPD. Although there are limited prospective data on
this issue, some evidence has shown that long-acting bronchodilator
therapy alone or in combination with an inhaled corticosteroid steroid
can prevent these events.
In a 2013 post hoc study of pooled data from 6 randomized,
double-blind, placebo-controlled trials (6 to
12 months duration) of
handheld tiotropium in patients with COPD, time to rst exacerbation
or hospitalization and exacerbation rates were analyzed at 6 months
and 1 year.26 In total, 4355 patients were analyzed at 6 months and
2455 at 1 year (tiotropium 1317, placebo 1138). Tiotropium delayed
time to rst hospitalized exacerbation at 6 months and 1 year (P < .001
vs placebo).
In a 2011 retrospective observational cohort study of commercially
insured patients receiving maintenance treatment with handheld
uticasone propionate/salmeterol or tiotropium bromide, the risk of
COPD exacerbation (moderate, severe, and any), COPD-related health
care utilization, and COPD-related costs (overall and by service
setting) was assessed over 12 months after the initiation of treat-
ment.27 Treatment with the LABA/inhaled corticosteroid combination
was associated with a 14% reduction in risk of COPD-related hospi-
talization (P .0406) and lower health care utilization and medical
costs (P < .0001) over a 12-month follow-up period.27
In a 2013 assessment of 3017 patients with COPD who were
enrolled in Medicare from 2006 to 2008 and had no COPD therapy for
at least 6 months prior, initiating long-acting b2-agonist therapy
increased the time to all-cause hospitalization and reduced the risk of
hospitalization versus initiating short-acting b2-agonist (SABA) ther-
apy (P < .05).28 In a 2013 retrospective study comparing 812 nebulized
LABA patients and 1651 nebulized SABA patients who were discharged
from their initial COPD hospital admission, all-cause 30-day read-
mission rates were 8.7% for nebulized LABA patients and 11.9% for
nebulized SABA patients (31% reduction; P .017).29 In a 2016 retro-
spective study of 417 COPD patients using nebulized LABA therapy,
PharMetrics Plus health plan claims data were used to compare ex-
acerbations, health services utilization, and costs.30 In this study, use
of nebulized arformoterol was associated with fewer exacerbations,
lower inpatient costs, lower risk for exacerbations, and lower COPD-
related costs (primarily related to hospital readmissions) than in pa-
tients using nebulized formoterol, suggesting that medication choice
even within the same class may affect outcomes and costs.30
The authors acknowledged that the prevention of hospitalizations
cannot be accomplished with prescribed agents alone, and a
comprehensive COPD action plan is needed to help patients stay out of
the hospital to the extent possible.
Opportunities to Individualize Treatment for Patients With
COPD in PA/LTC Settings
Disease severity should be assessed by objective measures when
feasible, including pulmonary function testing (spirometry), strati-
cation of risk for exacerbations, and subjective measures, such as
patient-reported breathlessness and symptoms that impact functional
ability.31 Treatment should be guided by the results of the following
assessments.
1. How severe is the patients COPD? (using pulmonary function
tests when available)
 M. Patel et al. / JAMDA 18 (2017) 553.e17e553.e22 553.e19

Inpaent Index hospitaliza on or Care Transion Planning

readmission for COPD Conduct goals of care conversa on
exacerba on and schedule follow-up within
Hospital discharge first 30 days

PA/LTC Pa ent discharged with a Coordinate care for pulmonary

prescrip on for long-ac ng rehabilita on and oxygen therapy
bronchodilator therapy?
Reconcile COPD
medica ons/vaccina ons (e.g.
influenza, pneumococcus)
Yes No
Ensure pa ent is counseled on
Is the pa ent able to use Evaluate need for long-ac ng smoking cessa on
their device eec vely? bronchodilator therapy
Develop and implement plan to
No Reeducate to improve
Yes prevent hospital readmission
adherence/eec ve use

Is the pa ent adherent

with their medica on? Consider nebulizer vs
Have physical, cogni ve, Yes handheld device
No and disease assessments
Yes Perform recommended Consider nebulizer
been done? No
assessments* vs handheld device

Fig. 1. Treatment Evaluation Algorithm for Patients Following Hospitalization for an Exacerbation. *Recommended assessments. Physical assessments: neuromuscular evaluation
for conditions limiting inspiratory force, identication of arthritis or other condition limiting ability to use a handheld device; cognitive assessment: Brief Interview for Mental
Status (BIMS); respiratory assessments: recent change in dyspnea, cough, mucus production, or SABA use, recent exacerbation or upper respiratory infection, and check inspiratory
force/ow.

2. What symptoms is the patient experiencing?
3. How often does the patient experience symptoms?
4. Do these symptoms limit his or her daily activities?
5. What is the patients exacerbation history and how great is the
patients risk for a future exacerbation?
6. Does the patient or nurse administering treatment demon-
strate compliance with the device chosen to manage COPD?
Tools for Individualized Assessment and Device Selection in Patients
With COPD
The authors also discussed appropriate patient assessment
following hospitalization for an exacerbation, transitional care plan-
ning, and whether therapy has been selected based on individual
patient needs. An algorithm with the authors consensus on these
issues is shown in Figure 1.
In the PA/LTC setting, the authors consensus was that patients are
generally in GOLD categories B, C, and D. For these patients, GOLD
guidelines state that regular treatment with LABA therapy is more
effective and convenient than SABA therapy.15 However, once a LABA
is chosen, the next step is to select the type of device best suited for
the patient depending on each patients individual physical or
cognitive abilities. To determine which delivery method (ie, handheld
patient population. Care transitions can inform health care providers
on both patient history and the selection of treatment. Challenges
associated with successfully transitioning patients from inpatient care
to PA/LTC were identied by the authors (Appendix 2).
The authors noted the need for careful patient observation within
the rst 30 to 90 days following hospital discharge. It is important to
monitor short-acting medication use, symptom control, and activities
of daily living. It is also important to ensure that long-acting medi-
cations are taken regularly and appropriately. In addition to these
measures of daily functioning, patients should have their vital signs
and need for supplemental oxygen monitored regularly. Regular
monitoring is recommended because recovery to baseline lung func-
tion following an exacerbation is often not complete for an extended
Table 1
Device Suitability Tool for Benchmarking Whether Patients With COPD May Require
Nebulized Long-Acting Bronchodilator Therapy
_____ Do you think your patient might be unable to generate sufcient inspi-
ratory force to overcome the resistance of a dry powder inhaler?
_____ Does your patient with COPD have any physical or neuromuscular con-
ditions limiting movement, hand-to-mouth coordination, intraoral coordination
(eg, tongue position)

vs nebulized therapy) is more appropriate for the patient, the authors
developed a checklist to aid decision making (Table 1).
Health care providers should consider how device selection affects
outcomes. Improper inhaler technique can result in decreased drug
delivery and potentially reduced efcacy.12 Medication sometimes
does not reach the target organ for a variety of reasons, including
dexterity, cognitive impairment, visual impairment, and reduced
inspiratory force.8,32e35 It is prudent to individualize delivery options
based on the capabilities of the patient.32 Education of staff on the
selection and appropriate use of these devices is recommended to
ensure medication is optimally delivered.
_____ Can your patient take a deep breath and hold it for a count of 10?
_____ Does your patient have any cognitive decits that might limit his or her
ability to coordinate (hand-breath coordination with exhalation and inhalation
upon device activation) a DPI or pMDI?
_____ Is your patients vision poor and/or hindering his or her ability to read
medication instructions or handheld device labels?*
_____ Is your patient already receiving as-needed or multiple daily short-acting
bronchodilator treatments for daily symptom control?
_____ Is your patient confused about the nature of his or her care environment
or unaware of the type of medications he or she receives?
_____ Is your patients health care literacy level causing confusion about the
need for a new medication to treat his or her COPD?*

Opportunities to Improve Care Transitions pMDI, pressurized metered-dose inhaler.

If you answered yes to any of these questions, it may be appropriate to consider
nebulized LABA therapy.
Care coordination across the inpatient-PA/LTC continuum can help *Consideration for patients in assisted living settings or when they choose to self-
prevent future exacerbations and hospital readmissions in this fragile administer medications in PA/LTC.
553.e20 M. Patel et al. / JAMDA 18 (2017) 553.e17e553.e22
period of time.36 In a study of 101 patients with moderate to severe
COPD studied over 2.5 years, only 75% of patients with a COPD exac-
erbation recovered to baseline lung function at week 5, and 7% still
had not recovered at 3 months.36
The transition from hospital to PA/LTC represents an important
checkpoint where the adoption of simple evaluations (eg, for patient
assessment and device selection) and treatment measures (eg, use of
long-acting bronchodilator therapy) has the potential to improve
outcomes during and beyond the transition. Formulary issues must
also be considered in the decision to prescribe a specic product
during care transitions. A recent consensus supported by the Society
for Post-Acute and Long-term Care Medicine (American Medical Di-
rectors Association), the Society of General Internal Medicine, and the
American Geriatrics Society summarizes issues and best practices to
ensure a safe transition from PA/LTC back to the community for any
patient.37
Facility-Based COPD Action Plan
Facilities should design and implement protocols based on avail-
able clinical practice guidelines for COPD staging, medication decision
making, and monitoring breathlessness and exacerbation risk.17,18 A
COPD action plan should cover assessment of disease severity, medi-
cation reconciliation, patient assessment, exacerbation risk assess-
ment, and device evaluation. Furthermore, the tools developed by the
authors in Figure 1 and Table 1 can aid in performing a few of these
tasks.
Preventing or reducing shortness of breath and exacerbations
should be top priorities in PA/LTC settings. Categorizing COPD severity
and obtaining an exacerbation history is paramount at admission.
Health care providers need to recognize red ags for potential or
incipient exacerbations. These indicators may include an increased
need for oxygen therapy; an escalating daily symptom burden; a
respiratory infection; increased antitussive medication use; a reduced
peak expiratory ow rate; increased rescue SABA or SABA/short-
acting muscarinic antagonist use or use of SABA/short-acting musca-
rinic antagonist treatments as daily maintenance therapy; nighttime
awakenings; nonadherence (patient does not accept or complete his
or her breathing treatments); declining ability to perform activities of
daily living; an increase in dyspnea, fatigue, tachypnea, tachycardia,
increase in amount or character of sputum production, and confusion;
and/or an absence of scheduled long-acting bronchodilator therapy.
Monitoring of these items in patients with COPD may help to improve
outcomes, including18
e anxiety and depression caused by shortness of breath or other
symptoms,
e acute exacerbations of COPD,
e hospital transfers and readmissions for acute exacerbations of
COPD,
e sleep disturbances, and
e viral and bacterial infections.
Discussion
The authors identied several important unmet medical needs for
the care of patients with COPD in PA/LTC settings that should prompt
corrective action. Long-acting bronchodilator maintenance therapy is
underutilized, and this makes the reduction of COPD exacerbations,
hospitalizations, and readmissions more difcult. The authors
acknowledged that the evidence to steer practice toward the use of a
specic long-acting bronchodilator or delivery method in PA/LTC
settings is limited. However, the use of the assessment algorithm and
the device suitability checklist outlined here may help determine
whether long-acting maintenance bronchodilator therapy is needed,
and which device makes the most sense for the patient; whether it be
a pressurized metered-dose inhaler, DPI, or nebulized therapy.
The metrics for quality care in COPD have largely shifted to exac-
erbation, emergency visit, and hospital readmission reduction. These
will likely constitute signicant parameters in how Medicare and
private health care organizations measure value-based care for pa-
tients with COPD in PA/LTC and other settings in the future. Failure to
meet these standards will likely affect payments to individual in-
stitutions and clinicians.
One recommendation to reduce exacerbations and hospitaliza-
tions is to align facility staff with the goals of care for patients with
COPD. The next is for the implementation of a facility-wide COPD
action plan to monitor changes in patient activity, overall health,
breathing status, and rescue medication use. Other medications,
including palliative and symptom-control medications (eg, morphine
for dyspnea) should be considered when consistent with the patients
goals of care. Lastly, assignments for specic tasks outlined by the
facilitys COPD action plan should be given to health care team
members, including consultant pharmacists, nurses, and social
workers, to establish accountability for the care delivered to PA/LTC
residents with COPD, including but not limited to assessment and
education aimed at the patient and/or patients caregivers.
Conclusions
Current awareness of unmet medical needs in patients with COPD
in PA/LTC settings is low, and current practice is often not aligned with
clinical guidelines for COPD. Long-acting bronchodilator maintenance
therapy is underutilized, and a standardized method for device se-
lection based on the individual needs of patients is lacking, both of
which can expose patients to increased risk for exacerbations and
hospitalizations, and for poor symptom control and quality of life.
With changes to the health care system occurring rapidly, adoption of
a standardized facility-based COPD action plan aligned with available
guidelines, and meant to improve the individualization of patient care,
is strongly recommended.
Acknowledgments
We thank Sean M. Gregory, PhD, for providing medical writing and
editorial assistance on the manuscript.
References
1. Ford ES. Trends in mortality from COPD among adults in the United States.
Chest 2015;148:962e970.
2. Ford ES. Hospital discharges, readmissions, and ED visits for COPD or bron-
chiectasis among US adults: Findings from the nationwide inpatient sample
2001-2012 and Nationwide Emergency Department Sample 2006-2011. Chest
2015;147:989e998.
3. Carlin BW. COPD and associated comorbidities: A review of current diagnosis
and treatment. Postgrad Med 2012;124:225e240.
4. Mapel DW, Dalal AA, Johnson P, et al. A clinical study of COPD severity
assessment by primary care physicians and their patients compared with
spirometry. Am J Med 2015;128:629e637.
5. Make B, Dutro MP, Paulose-Ram R, et al. Undertreatment of COPD: A retro-
spective analysis of US managed care and Medicare patients. Int J Chron
Obstruct Pulmon Dis 2012;7:1e9.
6. Leidy NK, Kim K, Bacci ED, et al. Identifying cases of undiagnosed, clinically
signicant COPD in primary care: Qualitative insight from patients in the target
population. NPJ Prim Care Respir Med 2015;25:15024.
7. Ingebrigtsen TS, Marott JL, Nordestgaard BG, et al. Low use and adherence to
maintenance medication in chronic obstructive pulmonary disease in the
general population. J Gen Intern Med 2015;30:51e59.
8. Dal Negro RW, Bonadiman L, Tognella S, et al. Extent and prevalence of
cognitive dysfunction in chronic obstructive pulmonary disease, chronic non-
obstructive bronchitis, and in asymptomatic smokers, compared to normal
reference values. Int J Chron Obstruct Pulmon Dis 2014;9:675e683.
9. Dodd JW. Lung disease as a determinant of cognitive decline and dementia.
Alzheimers Res Ther 2015;7:32.
 M. Patel et al. / JAMDA 18 (2017) 553.e17e553.e22
10. Sachdev PS, Anstey KJ, Parslow RA, et al. Pulmonary function, cognitive
impairment and brain atrophy in a middle-aged community sample. Dement
Geriatr Cogn Disord 2006;21:300e308.
11. Singh B, Mielke MM, Parsaik AK, et al. A prospective study of chronic
obstructive pulmonary disease and the risk for mild cognitive impairment.
JAMA Neurol 2014;71:581e588.
12. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of
aerosol therapy: Evidence-based guidelines: American College of Chest Phy-
sicians/American College of Asthma, Allergy, and Immunology. Chest 2005;
127:335e371.
13. Zarowitz BJ, OShea T. Chronic obstructive pulmonary disease: Prevalence,
characteristics, and pharmacologic treatment in nursing home residents with
cognitive impairment. J Manag Care Pharm 2012;18:598e606.
14. Wheaton AG, Ford ES, Cunningham TJ, et al. Chronic obstructive pulmonary
disease, hospital visits, and comorbidities: National Survey of Residential Care
Facilities, 2010. J Aging Health 2015;27:480e499.
15. Eisenhower C. Impact of pharmacist-conducted medication reconciliation at
discharge on readmissions of elderly patients with COPD. Ann Pharmacother
2014;48:203e208.
16. Rennard S, Thomashow B, Crapo J, et al. Introducing the COPD Foundation
Guide for Diagnosis and Management of COPD, recommendations of the COPD
Foundation. COPD 2013;10:378e389.
17. Global Initiative for Chronic Obstructive Lung Disease: Global Strategy for the
Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary
Disease (Updated 2016). Available at: http://www.goldcopd.org. Accessed
December 12, 2016.
18. AMDAdThe Society for Post-Acute and Long-term Care Medicine. COPD
Management in the Post-Acute and Long-term Care Setting Clinical Practice
Guideline. Columbia, MD: AMDA; 2016.
19. Barjaktarevic IZ, Arredondo AF, Cooper CB. Positioning new pharmacotherapies
for COPD. Int J Chron Obstruct Pulmon Dis 2015;10:1427e1442.
20. Casaburi R, Kukafka D, Cooper CB, et al. Improvement in exercise tolerance
with the combination of tiotropium and pulmonary rehabilitation in patients
with COPD. Chest 2005;127:809e817.
21. Cooper CB, Celli BR, Jardim JR, et al. Treadmill endurance during 2-year
treatment with tiotropium in patients with COPD: A randomized trial. Chest
2013;144:490e497.
22. Braido F, Baiardini I, Cazzola M, et al. Long-acting bronchodilators improve
health related quality of life in patients with COPD. Respir Med 2013;107:
1465e1480.
23. Vogelmeier C, Paggiaro PL, Dorca J, et al. Efcacy and safety of aclidinium/
formoterol versus salmeterol/uticasone: A phase 3 COPD study. Eur Respir J
2016;48:1030e1039.
553.e21
24. Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-glycopyrronium versus
salmeterol-uticasone for COPD. N Engl J Med 2016;374:2222e2234.
25. Schlueter M, Gonzalez-Rojas N, Baldwin M, et al. Comparative efcacy of xed-
dose combinations of long-acting muscarinic antagonists and long-acting
beta2-agonists: A systematic review and network meta-analysis. Ther Adv
Respir Dis 2016;10:89e104.
26. Anzueto A, Niewoehner DE, Leimer I, et al. A post hoc pooled analysis of ex-
acerbations among US participants in randomized controlled trials of tio-
tropium. Respir Med 2013;107:1912e1922.
27. Dalal AA, Candrilli SD, Davis KL. Outcomes and costs associated with initial
maintenance therapy with uticasone propionate-salmeterol xinafoate 250
microg/50 microg combination versus tiotropium in commercially insured
patients with COPD. Manag Care 2011;20:46e50. 53e45.
28. Bollu V, Ejzykowicz F, Rajagopalan K, et al. Risk of all-cause hospitalization in
COPD patients initiating long-acting or short-acting beta agonist therapy. J Med
Econ 2013;16:1082e1088.
29. Bollu V, Ernst FR, Karalidis J, et al. Hospital readmissions following initiation
of nebulized arformoterol tartrate or nebulized short-acting beta-agonists
among inpatients treated for COPD. Int J Chron Obstruct Pulmon Dis 2013;8:
631e639.
30. Chen YJ, Makin C, Bollu VK, et al. Exacerbations, health services utilization, and
costs in commercially-insured COPD patients treated with nebulized long-
acting beta2-agonists. J Med Econ 2016;19:11e20.
31. Dwyer TM, Abraham GE. Spirometry: How should we order this bedrock of
diagnosis and management for Asthma and COPD? Respir Care 2012;57:
1692e1695.
32. Dhand R, Dolovich M, Chipps B, et al. The role of nebulized therapy in the
management of COPD: Evidence and recommendations. COPD 2012;9:58e72.
33. Dodd JW, Getov SV, Jones PW. Cognitive function in COPD. Eur Respir J 2010;
35:913e922.
34. Mahler DA, Waterman LA, Ward J, et al. Comparison of dry powder
versus nebulized beta-agonist in patients with COPD who have subop-
timal peak inspiratory ow rate. J Aerosol Med Pulm Drug Deliv 2014;
27:103e109.
35. Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospi-
talized patients with asthma or COPD. J Gen Intern Med 2011;26:635e642.
36. Seemungal TA, Donaldson GC, Bhowmik A, et al. Time course and recovery of
exacerbations in patients with chronic obstructive pulmonary disease. Am J
Respir Crit Care Med 2000;161:1608e1613.
37. Lindquist LA, Miller RK, Saltsman WS, et al. SGIM-AMDA-AGS consensus
best practice recommendations for transitioning patients healthcare from
skilled nursing facilities to the community. J Gen Intern Med 2017;32:
199e203.
553.e22 M. Patel et al. / JAMDA 18 (2017) 553.e17e553.e22

Appendix

Table A1
Unmet Medical Needs for COPD Patients in PA/LTC Settings Based on Real-World Clinical Observations

 Lack of knowledge and use of COPD diagnostics, patient stratication strategies, and evidence-based guidelines for treatment.
 Lack of long-acting maintenance medication across the COPD patient care pathway from acute hospital care to PA/LTC to outpatient settings.5 Many health care
providers are not following appropriate COPD guidelines.
B Treatments are not changed even after failure of current regimens.
B Short-acting bronchodilators are often used as maintenance medications and are fraught with multiple issues, including frequent dosing, more nursing time,
patient disturbance at night, and waxing and waning of symptoms. Long-acting bronchodilators are recommended in current COPD guidelines but are often
not prescribed.
 Communication breakdown occurs often between hospital, outpatient, and PA/LTC settings, which may result in the following:
B Poor historical data for the patient, including vital information such as pulmonary function tests
B Acute care facilities are not regularly involved in chronic disease management, so this needs to be a focus of PA/LTC facilities.
B Medication reconciliation is frequently omitted, incomplete, or inaccurate during care transitions.
 Absence of trained respiratory therapists on staff in most PA/LTC facilities.
 Decit in health care provider training on physical, cognitive, and respiratory assessments; available treatment options; and device use.
 Decit in assessing patient competence with prescribed devices. This can lead to the addition of new medications without determining why previously prescribed
medications failed. A different device or formulation may be more appropriate than adding a new medication.
 The PA/LTC physician may be reluctant to question or change orders made by a pulmonologist.
 Lack of opportunities for patients/caregivers to have their concerns and preferences for therapy addressed by physicians and other practitioners, affecting
person-centered care.

Table A2
Unmet Medical Needs Related to Transitioning COPD Patients From the Hospital to Outpatient or Post-acute and Long-term Care

 No standardized strategy for improving care to prevent readmissions within the rst 30 days following hospitalization for an exacerbation of COPD
 Lack of communication and care coordination among hospitalists, pulmonologists, pharmacists, and PA/LTC facility attending physicians, including medical
directors, nurse practitioners, and other clinicians
 Access to hospital EMR and data from outpatient setting often not available; discharge/transfer summary and progress notes from most recent hospital visit,
rationale for treatment decisions, PFTs, and other critical clinical data often not available
 Patients are often not being followed by a pulmonologist when in the PA/LTC facility, or may not have a consultation with one when hospitalized
 Important comorbidities may not be adequately addressed, and may contribute to hospital readmissions
B Comorbidities that may worsen COPD symptoms: sleep apnea, CHF, CKD, depression, anxiety, or pain
 Lack of smoking cessation programs
 Need to optimize the use of post-acute wings/facilities
B Assess disease status and future risk
B Develop COPD treatment plans that include exacerbation prevention and long-term maintenance therapy
 Lack of utilization of pulmonary rehabilitation
 Lack of family support for PA/LTC residents
 Payor type/formulary inuences medication selection in the post-acute setting
 High-quality goals of care discussions are not occurring, and this contributes to potentially unnecessary and unwanted hospital readmissions

CHF, congestive heart failure; CKD, chronic kidney disease; EMR, electronic medical records; PFT, pulmonary function test.