Cara McDermott, PharmD, is taking big steps to impact care for all patients while advancing geriatric research with her work in building the continuum of care for people with COPD — a leading cause of death in the United States after cancer, cardiovascular disease, and stroke.
With a new one-year pilot grant from the Nursing Home EXplanatory Clinical Trials Supporting Transformation by Enhancing Partnerships (NEXT STEPs) network, a National Institute on Aging (NIA) initiative to advance evidence-based care, Dr. McDermott will rely on electronic health record data (EHR) from skilled nursing facilities (SNF) rather than the claims data that nursing home research has relied upon to date.
National EHR data from the NIA’s national Long-Term Care Data Cooperative, a resource for clinical trials and observational research in SNFs, will provide more comprehensive information on symptoms, vital signs, and medication administration; all necessary for understanding COPD severity, medication use, and high disease burden.
Now that a fuller picture of the symptomatology and symptom burden of COPD patients in SNFs is possible, investigators can start comparing medications used to symptom burden on the same day, an advance on prior studies.
“And it allows us to look at disease severity and medication administration, which is really important with a disease like COPD and its high symptom burden. So, we will actually know what participants are getting, not just what they've been prescribed,” Dr. McDermott said.
Findings from the study may also be applied to other diseases that commonly present in SNFs, such as heart or kidney failure, potentially impacting all patient care by identifying care trajectories, optimizing medication regimens, and reducing symptom burden, ultimately helping patients participate in rehabilitation during their SNF stay and transition to home from the SNF, she added.
The ultimate goal of Dr. McDermott’s body of research under this grant, “Optimizing Medications to Reduce Hospitalizations for Multimorbid Adults with COPD,” is to tailor existing care transition interventions to target people with COPD at the highest risk of rehospitalization, focusing on people with COPD who are hospitalized and then discharged to an SNF.
Good Trajectories for All Patient Care
As multimorbidity skyrockets among American adults and the age of multimorbidity onset drops, the innovative grant will leverage new data to improve care continuity and address multimorbidity.
“We're seeing it (multimorbidity) occur at younger and younger ages, and we're seeing people who aren't necessarily older adults who have to go to SNFs for rehab,” Dr. McDermott said. “So, it's applicable, not just to older adults, but also middle-aged adults who are experiencing multimorbidity. If we can get them on better trajectories earlier, then we might be able to avoid poor outcomes even more so when they're older, frailer, and more likely to have medication-related adverse events.”
The two aims of the study are to determine the effectiveness of COPD medication receipt on rehospitalization and SNF discharge to home, accounting for COPD disease severity, and then quantify the impact of benzodiazepine and hypnotic medication use on the outcomes of hospitalization and home discharge, controlling for appropriate COPD medication use.
A major concern with COPD medications is discontinuation of a drug or it being incorrectly maintained during care transitions, such as moving from an inpatient hospital to an SNF.
People with COPD use benzodiazepines and hypnotics more often than people without COPD, which puts them at risk of falls, altered mental status, and other poor outcomes that prevent them from returning home or lead to higher rates of rehospitalization.
COPD exacerbations and rehospitalizations are expensive and impact quality of life, but interventions to date have tended to focus primarily on dementia. This is particularly frustrating to patients and providers alike, especially since the Centers for Medicare and Medicaid Services has a quality measure for SNFs based on the annual risk-standardized rate of unplanned, all-cause hospital readmissions. More readmissions thus penalize patients and providers alike.
People with COPD also tend to have high rates of anxiety, depression, pain, and insomnia. As a result, there is concern about medications that cross into the central nervous system may cause an altered mental status, resulting in a predisposition to falls. This is further complicated for COPD patients who are often prescribed corticosteroids that thin the bone, leading to a higher rate of fractures after falling.
“Of course, hip fractures are associated with mortality, so we want to minimize this as much as possible, McDermott said. “This research helps patients in terms of getting their medications that they need, and also hopefully getting their symptoms under control, which, in turn, allows them to participate in rehab so that they can go home. Many of them never go home. So, if we can optimize their medications to reduce symptom burden, then perhaps we can get them over the finish line to get out of the hospital, participate in rehab, and go home.”
The Big Question
But the big question is how benzodiazepine and hypnotic use is tied to suboptimal COPD regimens. People with COPD tend to have very high rates of polypharmacy, or five or more medications, but the class of medication is just as important as the number, McDermott noted.
“Somebody could have six medications and the medications are appropriate given their comorbidities, or somebody could have three medications that may not be necessary and give them a very high risk of falls and delirium,” she added. “If we can make sure that people's COPD regimens are optimized before they go to the SNF, then can we reduce the use of these potentially harmful medications because their symptoms are under control, and thus avoid adverse events down the pike. That's important for older adults in general because prescribing cascades are very common to them, so we want to avoid prescribing cascades and polypharmacy whenever possible.”
Dr. McDermott’s previous work with ambulatory patients has paved the way for her focus on more complex and frail patients transitioning between hospitals, skilled nursing facilities, and the outpatient setting.
She has a K23 award from the National Heart, Lung, and Blood Institute around reducing polypharmacy and fall risk for multimorbid adults with COPD that largely focuses on people in outpatient settings or not in SNFs, a different group of participants whose disease severity fluctuates. Data from the pilot will support her R01 application to do more work with care transitions for people living with multimorbidity and COPD who are going from hospitals to nursing homes.
As part of the K23 grant, she adapted an intervention that will be tested this year to address potential care continuum gaps and optimize care, thereby reducing overall needs for people with COPD in the outpatient setting.
In this new study, which is scheduled to conclude in September 2026, she is collaborating with the Duke Hope Collaborative to align and interpret the findings from her national data with their local efforts, informing future interventions and grant applications. Duke Hope Collaborative consists of multiple skilled nursing facilities across local counties with member facilities working closely with Duke Health around the goal of providing better, more coordinated care for shared patients.
See also: Duke HOPE Smooths Transition to Skilled Nursing Facilities.