Preventing “Silent Droppers”: Standardizing Interventions to Prevent Lung Function Decline in Patients with Cystic Fibrosis


Jennifer Bass, MD; Adrienne Aldredge, MS; Ashley Addington;
Richard Cohen, MD; Megan Danish; Susan Mikkelsen, MD;
Kay Pasquesi; Kimberly Rondeau; Megan Wackford;
Eric Walter, MD

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Northwest Permanente

Background: Patients with cystic fibrosis (CF) often experience progressive declines in lung function over time as measured by the forced expiratory volume in 1 second (FEV1). To account for age, race, and lung size (height), FEV1 is reported as a percentile of expected for that individual (FEV1%). The more a patient’s FEV1% declines, the higher the risk of poor outcomes including hospitalization, infection, and ultimately respiratory failure. By intervening early and carefully tracking follow-up when FEV1% declines occur, the care team can help patients better maintain lung function over time and reduce hospitalizations and complications.
Methods: All children and adults followed by the Kaiser Permanente Northwest CF Center who were able to do pulmonary function testing (age 6 and up) were included in the project. Our center developed an algorithm to recognize and treat pulmonary exacerbations (decreases in FEV1% of 5% or more from baseline). We tracked practitioner/patient adherence to the standardized protocol as well as scheduled follow-up. We monitored posttreatment FEV1% and compared it with baseline FEV1%. We reviewed monthly run charts tracking FEV1%, adherence to protocol and follow-up visits. We compared patients on standardized protocol with patients not adherent to protocol. Our outcomes were relative decline in FEV1% over time compared with baseline FEV1%, adherence to protocol, and percentage of patients with a follow-up visit in 2 to 6 weeks.
Results: From January 1, 2017 to December 31, 2018, there were 218 pulmonary exacerbations in which FEV1% decreased by 5% or more. Adherence to the protocol was associated with a better chance of posttreatment FEV1% recovery. Posttreatment, patients who adhered to the protocol (183) had a relative decline of 5.1% compared with those who did not adhere to the protocol (35) who had a relative decline of 13.7%. Children (< 18 years) had the best FEV1% recovery with relative decline of 0.4% upon follow-up. Those treated with intravenous antibiotics had a better chance of recovery than those who took oral antibiotics or only increased chest therapy (-3.9% vs -7.7% and -6.6%). Overall protocol adherence improved from 76.6% in year 1 to 91.7% in year 2. The percentage of patients with a follow-up appointment scheduled in 2 to 6 weeks averaged 80% to 82%. Median FEV1% for pediatric patients has improved from 80.3% in 2015 to 87.3% in 2017 and 91.3% in 2018.
Discussion: The CF patient population is small but medically complex. Patients require frequent interaction with the health care system. By standardizing our interventions for these patients, we ensured that clinic visits were used effectively to track progress, modify treatments, and schedule follow-up appointments. Protocol adherence was associated with improved outcomes, especially for children and those on intravenous antibiotics. FEV1% in our pediatric population is improving. Engaging all members of the care team to help design, implement, problem solve, and analyze the results from this project was key to our success. We have shared our project with other Kaiser Permanente Regions at an interregional CF meeting and at the North American Cystic Fibrosis Conference.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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