Optimal Management of COPD Patients in the 21 st Century

Transcription

1 Optimal Management of COPD Patients in the 21 st Century Stephen K. Field, MD, CM, FRCPC, FCCP Clinical Professor of Medicine Division of Respiratory Medicine University of Calgary and Alberta Health Services Mackid Symposium 15 April, 2016

2 Outline of my talk Guidelines & where they are heading Burden of COPD in Canada/Alberta Unmet needs of COPD patients Contribution to COPD care by other health professionals Proposal for CRE support for primary care doctors

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4 Pulmonary rehabilitation Psychological & social care Smoking cessation Nutrition intervention Oxygen therapy Surgery Vaccination Interdisciplinary teams Patient education Home telehealth

5 Exercise training improves: Exercise tolerance Muscle deconditioning Dyspnea Health-related quality of life Adapted from 1. Casaburi, ZuWallack. N Engl J Med 2009; 2. Reardon et al. Respir Med 2005; 3. Porszasz et al. Chest 2005; 4. Riario-Sforza et al. Int J Chron Obstruct Pulmon Dis 2009; 5. Salhi et al. Chest 2010; 6. Garcia-Aymerich et al. Am J Respir Crit Care Med 2007

6 Update: Short acting bronchodilators: salbutamol, ipratropium, combination LAAC tiotropium, glycopyrronium, umeclidininum, aclidinium LABA salmeterol, formoterol, indacaterol, vilanterol, olodaterol Dual bronchodilators: Ultibro, Anoro, Duaklir, Inspiolto Combination: Advair, Symbicort, Zenhale, Breo* Triple inhalers Theophylline, roflumilast, azithromycin Will there be a role for biologics? Anti IL 5, anti IL 13, antineutrophil agents (e.g. CXCR2 antagonists) *In contradistinction to asthma no role for ICS monotherapy in COPD

7 COPD in the Calgary Zone data 6,944 ED and UCC visits for AECOPD 55.6% admitted or transferred 12.6 hours average length of stay in ER hospital days average (median 6.55 days) Average cost per admission: $10,000 (2008 data)* Data provided by AHS Emergency Department UCC Urgent Care Centre *Chapman KR, Bhutani M, Bourbeau J, Chan CK, Field SK, Flood D, Fitzgerald JM, Grossman R, Hernandez P, Levy R, Marciniuk D, Stickland M, Rea RM. The hospital burden of COPD in Canada. Am J Respir Crit Care Med 2010;181:A1500

8 Consequences of AECOPD Accelerated loss of lung function Poorer health status/qol Subsequent AECOPDs are more likely t 4 14% in hospital mortality 43% dead within 12 months of hospitalization* 27% mortality among AECOPD discharges # t Hurst et al Susceptibility to exacerbation in Chronic Obstructive Pulmonary Disease. NEJM 2010;363: *Connors AF Jr, Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1996;154(4Pt1): # Nie JX, Wang L, Upshur REG. Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease. Can Respir J 2009;14(8):485 9

9 Mortality Increases with Frequency of AECOPD Probability of surviving AEs p< AEs p=0.069 >3 AEs p< Time (months) Soler Cataluña JJ, et al.: Thorax 2005; 60(11):

10 Frequent flyers In 2011, 400/1806 COPD patients attended ER more than once, up to 10 times/yr* Why? Limited access to outpatient care Many still don t have a primary care physician Medicentres: care model often not conducive to ideal management unfamiliar with patients rapid throughput * Data provided by AHS Emergency Department

11 COPD pathway Often confusing for patients & families After consultation, patients are usually discharged from specialist care with: new prescriptions, often unfamiliar delivery devices instructions to stop smoking & immunization encouraged to participate in a rehab/exercise program although recommendations are appropriate, often not followed, or only partially followed, to the detriment of patient care

12 COPD patient pathway through the system Consultation experience is stressful for patients & family members Instructions are misunderstood or forgotten often inadequate time during consultation to insure that patients are properly instructed to use their new inhaler device(s) correctly limited access to family doctors contributes to poor adherence to specialists recommendations Poorly controlled COPD patients are a significant burden on both out & inpatient resources within Alberta Health Services

13 Canada One of the lowest MD/Population in OECD* Access to medical services/wait times are an increasing challenge Health care costs are increasing faster than GDP Increasing demand for other health care professionals to provide medical care *OECD Organization for Economic Cooperation & Development

14 Canadian experience with COPD care by non MD health care workers Patients previously hospitalized with AECOPD Case manager/contact Directed self management Education about COPD lifestyle counseling diet, smoking cessation Action plan Bourbeau J, et al. McGill University group Arch Intern Med 2003

15 Self Management Education: Reduces Hospitalization Hospitalizations/patient-year % reduction % reduction Standard care Self-management Year 1 Year 2 Gadoury M-A, et al. Eur Respir J 2005;26(5):853-7.

16 Self Management Education: Substantial Cost Savings $8,000 p=0.16 p=0.046 p=0.024 $6,674 $6,674 $6,674 Cost per patient ($) $6,000 $4,000 $5,177 $4,525 $4,246 Standard care Self-management $2, Caseload (number of patients) Bourbeau J, et al. Chest 2006;130:

17 JGH group: benefits of a nurse navigator Reduced respiratory ER visits* Decreased respiratory hospitalizations* Reduced total hospital days* Decreased hospitalizations for AECOPD* Reduced hospital days for AECOPD* Savings >$260,000 * p<0.05 Dajczman E et al. Can Respir J 2013;20(5):351 6

18 Rocker G et al QEII hospital Halifax Chest 2013 DOI: /Chest Multidisciplinary team, 3 FTE After hospital, F/U Q2wk X 2/12, Q1/12 X 3/12 Hospital & home based support Disease education, focus on patient & family Written action plan for self care of AECOPD Written action plan for dyspnea crises Advance Care planning

19 Rocker G et al QEII Halifax Chest 2013 DOI: /Chest months pre vs 6 months post: n=89 ER visits 173 >66 (62% reduction) Hospitalizations 107 >37 (68% reduction) Hospital bed days 1129 >382 (66% reduction) $749,000 savings (3 times cost of program) No improvement in QOL (CRQ)

20 Not all self management programs work Unless patients follow instructions, they will not benefit Fan VS et al Ann Intern Med 2012, VA study no benefit but intervention group did not receive antibiotics or prednisone earlier than control group Bucknall et al BMJ 2012 no benefit vs control group BUT patients who adhered to instructions DID benefit Programs can work Need good learners and need good educators, CREs would provide good education

21 Certified Respiratory Educators (CRE) Rigorously trained to educate & help manage asthma, COPD, & to counsel smoking cessation And chronic cough * * CCAP group Can Respir J 2009, Chest 2009

22 Challenges in COPD management (potential roles for CREs) Patient education: pathophysiology & rationale for treatments & Smoking cessation Vaccination Adherence Proper inhaler technique initial instruction remediation Action plan

23 Patient Education Program Smoking cessation Basic Education (pathophysiology & rationale for treatments) Effective inhaler technique Self management with case manager participation Early recognition and treatment of AECOPD Strategies to alleviate dyspnea Advanced directives and/or end of life issues ODonnell DE, et al. Can Respir J 2008;15(Suppl A):1A 8A

24 CREs provide smoking cessation counseling Stress of COPD social & financial consequences create conditions that make smoking cessation less likely & increase likelihood of relapse 52% who achieve smoking abstinence relapse at least once Although controversial, counseling & support are felt to be important for relapse prevention If smokers aren t encouraged to quit repeatedly, success rate for permanent smoking cessation is <5% Nakajima M. Predictors of Risk for Smoking Relapse in Men & Women: A Prospective Examination. Psychol Addict Behav 2012 Feb 20. [Epub] Carson KV. Training health professionals in smoking cessation. Cochrane Database Syst Review 2012 Kerr DC. The timing of smoking onset, prolonged abstinence and relapse in men: a prospective study from ages 18 to 32 years. Addiction 2011 Nov;106(11):

25 CREs can encourage vaccination Both influenza & pneumococcal vaccination are recommended for COPD patients In Alberta, only 41% of eligible are vaccinated flu vaccine report.html

26 Poor adherence to maintenance therapy Salmeterol/fluticasone Budesonide/formoterol Fluticasone Budesonide 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% New Patients 0-15 Days Days Days Days Days Days Days Days Days Days Days Days Days After 3 months, over 50% of patients stopped maintenance therapy. After a year, adherence decreased to below 30%. Adapted from Brogan National Private Payer data. April 2007 March Patient retention rate 26

27 Adherence Regular follow up by CREs, either by phone or face to face could reinforce adherence Use of spacer to reduce throat irritation &/or optimize bronchial deposition of medication Recommend change of delivery device to optimize adherence/preference/benefit (if required)

28 Inhaler technique Many COPD patients don t use inhalers correctly Unless inhalers are used properly, patients don t benefit & may suffer the same adverse health outcomes as non adherent patients Proper inhaler use is a multistep process & improper technique at any point jeopardizes medication delivery & subsequent clinical outcomes Even patients instructed in proper inhaler use experience deterioration in quality of their technique over time & benefit from periodic remedial instruction CREs can provide the necessary initial instruction & remediation Crompton GK, et al. The need to improve inhalation technique in Europe: a report from the aerosol drug management improvement team. Bosnic Anticevich SZ, et al. Metered dose inhaler technique: the effect of two Respir Med 2006;100: educational interventions delivered in community pharmacy over time. J Asthma 2010;47:251 6

29 Inhaler technique instruction & remediation Unrealistic to expect that primary care doctors (or specialists) can instruct patients to properly use of all of these types of inhalers. CREs are the obvious health care professionals to instruct patients how to use the different inhalers.

30 Action plan Canadian studies: At onset of an exacerbation, treat with oral prednisone +/ antibiotic Prednisone reduces relapses 1 Antibiotics improve outcomes with infectious exacerbations 2 Early intervention & treatment escalation, should reduce ER visits & hospitalizations 1. Aaron SD, et al New Engl J Med Anthonisen N, et al Ann Intern Med 1987

31 Proposal for a CRE managed clinic for patients with a history of exacerbations At periodic assessments: Patients will be questioned about: Smoking status Medical encounters since last visit Symptom control Acute exacerbations Adherence to specialist recommendations

32 Periodic management will consist of: Smoking cessation counseling (if needed) Medication adherence review Inhaler technique review/instruction +/ influenza/pneumococcal vaccination Reinforcement of action plan instructions Early intervention with AECOPD Provide resource when patient is unwell Involve specialist when needed to modify treatment

33 Summary COPD remains a major health burden in Canada AECOPDs adversely effect QOL accelerate lung function decline predict further AECOPDs represent a significant financial burden, both direct & indirect costs. Are significant contributors to mortality A CRE managed clinic should improve outcomes