Optimizing COPD Management in Primary Care

Transcription

1 Clinical Updates for Nurse Practitioners and Physician Assistants: 2018 Optimizing COPD Management in Primary Care Sandra Adams, MD, MS Professor, Division of Pulmonary Diseases and Critical Care Medicine UT Health San Antonio Staff Physician, The South Texas Veterans Health Care System Founder, President WipeDiseases Foundation San Antonio, TX Fernando Martinez, MD, MS Chief, Division of Pulmonary and Critical Care Medicine Bruce Webster Professor of Medicine Joan and Sanford I. Weill Department of Medicine Weill Cornell Medical College New York-Presbyterian Hospital/Weill Cornell Medical Center New York, NY Frank Rahaghi, MD, MHS, FCCP Director of Advanced Lung Disease Clinic Director, Pulmonary Hypertension Clinic Head of Alpha-1 Foundation Clinical Resource Center Chairman, Dept. of Pulmonary and Critical Care Cleveland Clinic Florida Weston, FL Faculty Alanna Kavanaugh, FNP-BC, MSN, CCRN Nurse Practitioner Weill Cornell Medical College - Pulmonary, Critical Care Instructor of Practice for Graduate and Undergraduate Program - College of Mount Saint Vincent New York, NY Arunabh Talwar, MD, FCCP Director, Pulmonary Hypertension and Advanced Lung Disease Program North Shore University Hospital, Manhasset, NY Professor of Medicine Hofstra North Shore-LIJ School of Medicine Hofstra University Hempstead, NY 2 Disclosures Dr. Adams has received Contracted Research support from AstraZeneca Pharmaceuticals LP, Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo, GlaxoSmithKline, Novartis Pharmaceuticals, and Sunovion Pharmaceuticals, Inc. Ms. Kavanaugh has no financial relationships to disclose. Dr. Martinez has served as a Consultant for AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, and Sunovion. He has served on the Speakers Bureau for AstraZeneca and GlaxoSmithKline, and received Contracted Research support from AstraZeneca, Boehringer Ingelheim and GlaxoSmithKline. Dr. Rahaghi has served as a Consultant for Actelion, AstraZeneca, Baxter, Boehringer Ingleheim, Gilead, Reata and United Therapeutics. He has served on the Speakers Bureau for Actelion, Baxter, Boehringer Ingleheim and United Therapeutics and has received Contracted Research support from Actelion, AstraZeneca, Baxter, Bellerophon, Boehringer Ingleheim, Merck, Reata and United Therapeutics. Dr. Talwar served on the Speakers Bureau for Boehringer Ingelheim. He is also on the advisory board for Genentech. This educational activity is supported by an educational grant from GlaxoSmithKline

2 Learning Objectives 1. Describe case finding strategies to identify patients with unrecognized, clinically significant COPD 2. Tailor COPD pharmacotherapy according to current recommended therapeutic guidelines which incorporate unique patient needs and characteristics 3. Discuss strategies to facilitate the appropriate use of inhaled therapies for COPD including proper inhaler technique 4. Recognize appropriate strategies to prevent and manage COPD exacerbations and provide transitions of care post hospitalization 4 PRE-TEST QUESTIONS 5 Pre-test ARS Question 1 How often do you use COPD Case Finding strategies to identify patients at high likelihood of suffering from COPD that should be treated? 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 6 2

3 Pre-test ARS Question 2 How confident are you in your ability to select appropriate inhaled therapies for patients with COPD, based on disease severity and patient characteristics? 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 7 Approximately how many patients with COPD do you see on a weekly basis, in any clinical setting? 1. None Pre-test ARS Question 3 7. > 25 8 Global Strategy for Diagnosis, Management and Prevention of COPD Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients Global Initiative for Chronic Obstructive Lung Disease 9 3

4 Risk factors for COPD Smoking accounts for 80% of all COPD diagnosis 20% are nonsmokers Other etiologies: Second hand smoke Environmental exposures Cooking or heating with wood, peat, dung Occupational exposures Undertreated asthma Genetics alpha 1 antitrypsin deficiency 10 COPD SYMPTOMS Chronic cough usually the first symptom that occurs in COPD initially intermittent Chronic expectoration Dyspnea Symptom for which patients with COPD seek medical advice. Persistent, daily, progressive over time, exacerbated by exercise and respiratory infections Global Initiative for Chronic Obstructive Lung Disease 11 Undiagnosed COPD is associated with increased mortality 1.0 Survival probability Non-OLD Undiagnosed OLD Diagnosed OLD OLD: obstructive lung disease Time (yrs) Martinez CH, et al. Annals ATS. 2015; 12:

5 and exacerbation-like events Undiagnosed COPD vs. Diagnosed COPD Labonte LE et al. AJRCCM 2016; 194: COPD is Underdiagnosed Barriers to Diagnosis of COPD in Primary Care Care Providers Time Limitations Failure to probe at-risk patients about symptoms and activity levels and lack of good case-finding methods Limited spirometry availability and expertise to interpret Patients Under-recognized symptoms leading to delayed presentation Poor awareness of COPD Lack of knowledge regarding COPD risk factors and appropriate diagnostic testing Haroon, et al. Int J COPD 2015;10(1): Screening vs. Case Finding Many individuals at increased risk for COPD self restrict activity to minimize symptoms. USPSTF recommendation is based on lack of evidence, not negative evidence. GOLD recommends case-finding in symptomatic patients but does not recommend screening in asymptomatic populations. Future trials are needed to better assess the effects of screening and treatment of at risk individuals in primary care on long-term health outcomes. Siu, et al. JAMA 2016;315:

6 Case Finding: A New Approach Joint partnership between NHLBI and COPD Foundation 5-item questionnaire plus Peak Expiratory Flow Designed to identify individuals who are symptomatic or have history of exacerbations In a case control study, CAPTURE exhibited an sensitivity of 95.7% and an specificity of 67.8% for differentiating cases from no-copd control subjects. Martinez FJ et al, AJRCCM 2017; 195: COPD Diagnosis Requires Spirometry SYMPTOMS cough sputum dyspnea EXPOSURE TO RISK FACTORS tobacco (10-20 pack/years) occupation indoor/outdoor pollution SPIROMETRY The Global Initiative for Obstructive Lung Disease 2017 Report Why is spirometry underused? Survey of 29 primary case offices 2/3 of offices owned a spirometer Spirometry performed on 50% of patients with COPD, asthma, or respiratory symptoms Main Reasons Cited for Not Performing Spirometry Unsure of impact on care 41% Unfamiliar with test 38% Lack of training 34% Concern about reimbursement 28% Equipment too costly 28% Concern about quality control 28% Kaminsky DA, et al. Respir Care. 2005;50:

7 Spirometry: Obstructive Disease 5 Normal 4 Volume, liters FEV 1 = 1.7L FVC = 3.3L FEV 1 /FVC = 0.51 Obstructive Time, seconds 19 Classification of Airflow Limitation Severity Grade in COPD based on Post Bronchodilator FEV 1 I: Mild FEV1 80% predicted All Grades Require FEV 1 / FVC < 0.7 At this stage, the patient may not be aware that their lung function is abnormal. II: Moderate 50% FEV1 < 80% predicted III: Severe 30% FEV1 < 50% predicted IV: Very Severe FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure Symptoms usually progress at this stage, with shortness of breath typically developing on exertion. Shortness of breath typically worsens at this stage and often limits patients daily activities. At this stage, quality of life is very appreciably impaired and exacerbations may be life-threatening. 20 Pre-test ARS Question 4 71-year-old with 4-year history of exertional breathlessness, osteoporosis with past compression fracture, rheumatic fever, syringomyelia, and past pneumonia. Admitted to hospital with first COPD exacerbation, and discharged home after treatment. Never smoked, but extensive passive smoking Mother died from early-life emphysema (nonsmoker) Workup: CAT score = 15; mmrc dyspnea score = 2 Decreased breath sounds, no wheezing/rales; little cough or sputum FEV1 63% predicted What is this patient s GOLD Group? 1. GOLD A 2. GOLD B 3. GOLD C 4. GOLD D 21 7

8 GOLD COPD multidimensional assessment approach Diagnosis = Assessment of airflow limitation + Assessment of symptoms/risk of exacerbations Exacerbation History FEV1/FVC<0.7 Grade FEV 1 (% pred.) <30 > 2 or >1 leading to hospitalization 0 or 1 (not leading to hospital admission) C A mmrc 0-1 CAT < 10 CCQ < 1 D B mmrc 2+ CAT 10+ CCQ Modified Medical Research Council (mmrc) Dyspnea Scale Grade Description of Breathlessness 0 Not troubled by breathlessness except on strenuous exercise Shortness of breath when hurrying on level ground or walking up a slight hill Walks slower than people of the same age on level ground because of breathlessness or has to stop for breath when walking at own pace on level ground Stops for breath after walking about 100 meters or after a few minutes on level ground Too breathless to leave the house or breathless when dressing or undressing Ferris BG. Am Rev of Respir Dis. 1978;118: COPD Assessment Test Score I never cough I cough all the time 1 I have no phlegm in my chest at all My chest does not feel tight at all When I walk up a hill or flight of stairs I am not breathless I am not limited doing any activities at home I am confident leaving my home despite my lung condition I sleep soundly My chest is completely full of phlegm My chest feels very tight When I walk up a hill or stairs I am very breathless I am very limited doing activities at home I am not at all confident leaving my home because of my lung condition I don t sleep soundly because of my lung condition I have lots of energy I have no energy at all 3 Total Score 15* *Score 10 represents significant symptoms Jones PW, et al. Eur Resp J. 2009;34:

9 Available pharmacotherapies Bronchodilators Anti-inflammatory Short acting b 2-agonists Albuterol Levalbuterol Muscarinic antagonist Ipratropium Combination Albuterol + ipratropium Long acting b 2-agonists (LABA) Arformoterol Formoterol Indacaterol Olodaterol Salmeterol Muscarinic antagonist (LAMA) Aclidinium Glycopyrrolate Tiotropium Umeclidinium Combination (LABA/LAMA) Formoterol + Glycopyrrolate Indacaterol + Glycopyrronium Tiotropium + Olodaterol Vilanterol + Umeclidinium Adapted from Corticosteroids Combination (LABA/ICS) Formoterol + Budesonide Salmeterol + Fluticasone propionate Vilanterol + Fluticasone furoate Combination (LABA/LAMA/ICS) Vilanterol + Umeclidinium + Fluticasone furoate Other oral agents PDE4 inhibitor Roflumilast Macrolide Azithromycin Steroids Prednisone Dexamethasone Methylprednisolone 25 Most COPD Patients Do Not Receive Recommended Treatment Overall evidence suggests 30%-70% receive no therapy or suboptimal treatment. 70% 60% 50% 40% 30% 20% 10% 0% No treatment SABA alone SAAC ICS LAAC SAAC + ICS LABA + ICS Ach + LABA + Other combo Commercial population Medicare population ICS LACC, long-acting anticholinergic; SACC, short-acting anticholinergic 26 Make B et al. Int J Chron Obstruct Pulmon Dis. 2012;7:1-9. GOLD 2017 Strategy Individualization of Treatment Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and costs, and the patient s response, preference and ability to use various drug delivery devices. GOLD, Global Initiative for Chronic Obstructive Lung Disease. Vogelmeier CF, et al. Am J Respir Crit Care Med. 2017;195:

10 Pre-test ARS Question 5 71-year-old with 4-year history of exertional breathlessness, osteoporosis with past compression fracture, rheumatic fever, syringomyelia, and past pneumonia. Admitted to hospital with first COPD exacerbation, and discharged home after treatment. She returns to see you with no long acting medications. She has no sputum production but has breathlessness with CAT of 15 and mmrc of 2. Her FEV1 is 63% predicted. Never smoked, but extensive passive smoking Mother died from early-life emphysema (nonsmoker) What therapy would you recommend? 1. Start rofumilast 2. Start LABA 3. Start LAMA/LABA 4. Start LABA/LAMA/ICS 28 GOLD therapeutic recommendations Group C Further Exacerbation(s) LAMA + LABA LAMA LABA + ICS Group D Consider roflumilast if FEV1 < 50% pred and patient has chronic bronchitis Further Exacerbation(s) Further Exacerbation(s) LAMA LAMA + LABA + ICS LAMA + LABA Consider macrolide Persistent symptoms/further exacerbations LABA + ICS Group A Continue, stop or try alternative class of bronchodilator Group B LAMA + LABA Evaluate effect A bronchodilator Persistent symptoms A long-acting bronchodilator (LABA or LAMA) The Global Initiative for Obstructive Lung Disease 2017 Report ICS/LABA vs. LABA/LAMA for Exacerbations Wedzicha JA, et al. N Engl J Med 2016; 374:

11 ICS/LABA decreased the rate of on-treatment moderate/severe exacerbations compared with LAMA/LABA 1,2 Annual rate of mod./sev. exacerbations (95% CI) % reduction p = (95% CI: 1.14, 1.29) 1.07 (95% CI: 1.02, 1.12) Relative risk reduction in mortality: FF/VI vs UMEC/VI 38.7% HR 0.61 (95% CI: 0.40, 0.93) p = UMEC/VI n = 2,069 FF/VI n = 4,133 Note: The n reflects the number of patients included in each analysis from the ITT population. Patients were excluded if they had pre-defined data missing; this varied according to the analysis. The ITT population comprised: 4,151 patients treated with FF/UMEC/VI, 4,134 patients treated with FF/VI and 2,070 patients treated with UMEC/VI. 1. Lipson DA, et al. N Engl J Med. 2018;378: ; 2. GlaxoSmithKline. Data on File. RF/TLY/0096/17(1). 31 Risk Factors Associated With CXR-Confirmed Pneumonia in Patients With COPD Treated With ICS 1,2 Older age ( 65 years old) Low body mass index (BMI < 25 kg/m 2 ) Very severe COPD (FEV 1 < 30% predicted) Prior pneumonia 1. Crim C et al. Ann Am Thorac Soc. 2015;12: Dransfield MT et al. Lancet Respir Med. 2013;1: Group D Consider roflumilast if FEV1 < 50% pred and patient has chronic bronchitis Further Exacerbation(s) Further Exacerbation(s) GOLD therapeutic recommendations LAMA + LABA + ICS Consider macrolide Persistent symptoms/further exacerbations LAMA LAMA + LABA LABA + ICS The Global Initiative for Obstructive Lung Disease 2017 Report

12 LABA/LAMA/ICS decreases exacerbations compared with LAMA and LAMA/LABA Vestbo J, et al. Lancet 2017;389: Papi A, et al. Lancet 2018;391: LABA/LAMA/ICS reduces moderate/severe exacerbations compared with individual dual combinations in same device Annual rate of mod./sev. exacerbations (95% CI) % (95% CI: 10, 20) p < (95% CI: 1.02, 1.12) 0.91 (95% CI: (0.87, 0.95) 25% (95% CI: 19, 30) p < (95% CI: 1.14, 1.29) 0.91 (95% CI: 0.87, 0.95) Relative risk reduction in mortality: FF/UMEC/VI vs UMEC/VI 42.1% HR 0.58 (95% CI: 0.38, 0.88) p = FF/UMEC/VI FF/VI n = 4,145 n = 4,133 UMEC/VI n = 2,069 Note: The n reflects the number of patients included in each analysis from the ITT population. Patients were excluded if they had pre-defined data missing; this varied according to the analysis. The ITT population comprised: 4,151 patients treated with FF/UMEC/VI, 4,134 patients treated with FF/VI and 2,070 patients treated with UMEC/VI. Lipson DA, et al. N Engl J Med. 2018;378: Roflumilast response is seen in chronic bronchitics with distinct phenotypes Martinez FJ et al. Am J Resp Crit Car Med. Published on 2018 May 15 as doi: /4ccm OC 36 12

13 Pre-test ARS Question 6 71-year-old woman with 4-year history of exertional breathlessness, confirmed airflow obstruction, little sputum production, recent COPD hospitalization, CAT score 15; mmrc dyspnea score 2 (GOLD D). Current medications include LABA/LAMA/ICS. She has not had an exacerbation in the last year Current eosinophil count is 100 cells/mcl What change to therapy would you recommend? 1. Add macrolide 2. Add rofumilast 3. Make no change to therapy 4. Withdraw ICS, keep LAMA/LABA CAT: COPD Assessment Test mmrc: modified Medical Research Council SAMA: short-acting muscarinic antagonist LAMA: long-acting muscarinic antagonist LABA: long-acting beta-agonist ICS: inhaled corticosteroid 37 ICS added to LABA reduces exacerbation frequency with increasing blood eosinophil count Bafadhel M et al. Lancet Respiratory Medicine 2018;(6): ICS can be withdrawn in COPD patients with no more than one exacerbation in previous year, and low eosinophil count Chapman KR et al. Am J Respir Crit Care Med 2018 Published online 2018 May 20 as doi: /rccm OC 39 13

14 Questions to Consider 40 Numerous inhaled delivery devices can be challenging Single-dose dry powder inhalers Multi-dose dry powder inhalers Metered-dose inhalers Metered-dose inhalers with valved holding chamber Slow-mist inhaler Nebulizers 41 Adherence to inhaled medications is poor among COPD patients Prospective study (N=244 COPD patients; N=160 post exacerbation) Electronic monitoring of compliance with diskus device: Mean adherence 22.6% Adherence >80% in only 6% Sulaiman I, et al. Am J Respir Crit Care Med 2016; 195:

15 Pre-test ARS Question 7 According to GOLD recommendations, how often should healthcare professionals assess inhaler technique in a patient with COPD? 1. Every visit 2. Every other visit 3. Twice every year 4. Once every year 43 Key Points on Inhalation Devices The choice of inhaler device has to be individually tailored and will depend on access, cost, prescriber and most importantly, patient s ability and preference. It is essential to provide instructions and to demonstrate the proper inhalation technique when prescribing a device, to ensure that inhaler technique is adequate and re-check at each visit that patients continue to use their inhaler correctly. Inhaler technique (and adherence to therapy) should be assessed before concluding that the current therapy requires modification 2017 Global Initiative for Chronic Obstructive Lung Disease 44 Non-pharmacological therapy of stable COPD Patient Essential Recommended Local guidelines A Smoking cessation Physical activity B, C, D Smoking cessation Pulmonary rehabilitation Physical activity Flu and pneumococcal vaccination Flu and pneumococcal vaccination

16 Pulmonary rehabilitation improves dyspnea Behnke 200a Cambach 1997 Goldstein 1994 Gosselink 2000 Griffiths 2000 Gell 1995 Gell 1998 Hernandez 2000 Simpson 1992 Singh 2003 Wijkstra 1994 Total Mean Difference (95% CI) 2.26 (1.34, 3.18) 1.20 (0.36, 2.04) 0.66 (0.12, 1.20) 0.82 (0.17, 1.47) 1.18 (0.85, 1.51) 1.30 (0.64, 1.96) 1.00 (0.20, 1.80) 0.78 (0.02, 1.54) 1.20 (0.37, 2.03) 0.88 (0.35, 1.41) 0.90 (0.13, 1.67) 1.06 (0.85, 1.26) Favors Control Favors treatment Lacasse et al, Cochrane Database of Systematic Reviews 2006; Issue 4; Art. No.: CD NON-PHARMACOLOGIC TREATMENT Prescription of supplemental oxygen to COPD patients Arterial Hypoxemia defined as: PaO 2 < 55mmHg (8kPa) or SaO 2 < 88% or PaO 2 >55 but < 60mmhg (> 8 but < 8.5 kpa) with right heart failure or erythrocytosis Prescribe supplemental oxygen and titrate to keep SaO2 90% Recheck in 60 to 90 days to assess: If oxygen is still indicated If prescribed supplemental oxygen is effective 2017 Global Initiative for Chronic Obstructive Lung Disease 47 Long term oxygen does not prolong time to death or 1 st Hospitalization or improve quality of life in COPD patients with moderate hypoxemia Prospective study in 738 COPD patients with moderate hypoxemia/desaturation Resting saturation 89%- 93% or desaturation 80% but <90% during six minute walk Randomized to Oxygen or no Oxygen CI = confidence interval; HR = hazard ratio; LTOT = long-term oxygen therapy; no. = number. Long-Term Oxygen Treatment Trial Research Group. N Engl J Med. 2016;375:

17 Pre-test ARS Question 8 63 y/o man with severe COPD (FEV 1 40% predicted), CAT score 20, mmrc score 3, no chronic sputum production, CAD (s/p PCI last year). Had 2 episodes of bronchitis last year and 1 hospitalization for pneumonia. Reports 5 days of increased breathlessness and no cough or sputum production. Medications: amlodipine, metoprolol succinate, aspirin, SABA prn, LAMA Exam: BMI 18 kg/m 2, O 2 sat at rest with room air 91%, decreased breath sounds What therapeutic option would you recommend? 1. Prescribe antibiotic 2. Discontinue metoprolol 3. Add LABA (LABA/LAMA) 4. Add prednisone at 40 mg daily for five days 5. Add prednisone at 40 mg with two week taper 49 Consequences of COPD Exacerbations Negative impact on quality of life Impact on symptoms and lung function Accelerated lung function decline EXACERBATIONS Increased economic costs Increased Mortality 2015 Global Initiative for Chronic Obstructive Lung Disease 50 Management of Exacerbations OVERALL KEY POINTS: An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy. Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections. The goal for treatment of COPD exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events. Short-acting inhaled beta 2 -agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation Global Initiative for Chronic Obstructive Lung Disease 51 17

18 Management of Exacerbations COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. They are classified as: Ø Mild (treated with short acting bronchodilators only, SABDs) Ø Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or Ø Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure Global Initiative for Chronic Obstructive Lung Disease 52 Global Strategy for Diagnosis, Management, and Prevention of COPD: Manage Exacerbations: Treatment Options Antibiotics should be given to patients with: Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence Who require mechanical ventilation 2017 Global Initiative for Chronic Obstructive Lung Disease 53 GOLD recommendation A dose of 40 mg prednisone per day for 5 days is recommended (Evidence B), although there are insufficient data to provide firm conclusions concerning the optimal duration of corticosteroid therapy of acute exacerbations of COPD most studies showed no benefit from more than 5 days of therapy Global Initiative for Chronic Obstructive Lung Disease, p

19 Pre-test ARS Question 9 Which of the following is associated with increased risk of early readmission in a patient admitted with COPD exacerbation? 1. Female gender 2. Caucasian race 3. Longer length of stay 4. Younger age (<65 years) 55 Hospital Readmission Reduction Program (HRRP) $13 billion cost for COPD admissions each year In 2014, readmissions for any reason within 30 days after hospital admission for COPD counts towards penalty No one-size-fits-all solution Possible solutions Inpatient and transition care teams Pulmonary rehabilitation In the UK, COPD is second most common cause of emergency admissions Multiple proposed projects to reduce ED admissions for COPD Many of these projects focused on care integration Shah T et al. Chest. 2016;150: The Majority of Medicare Readmissions Occur in the First 15 days After AECOPD Discharge Jacobs DM et al. Ann ATS. 2018; 15:

20 Numerous factors are associated with Medicare readmission Characteristic OR (95% CI) Age > 80 years 0.97 ( ) Female gender 0.89 ( ) Black race 1.06 ( ) Charlson ( ) Dually eligible for Medicare and Medicaid 1.22 ( ) Longer length of stay 1.03 ( ) ICU use 1.03 ( ) Discharge to SNF 1.42 ( ) Discharge home with home care 1.36 ( ) Shah T, et al. Chest 2015; 147: Lack of continuity of care among Medicare beneficiaries >65 years of age associates with greater preventable hospitalization Characteristic HR (95% CI) Continuity of care 0.98 ( ) Female 1.17 ( ) Black 1.07 ( ) Hispanic 1.07 ( ) Medicaid dual eligibility 1.06 ( ) Total preventable hospitalizations in the prior year 1.17 ( ) Nyweide DJ, et al. JAMA Intern Med 2013; 173: doi /jamainternmed POST-TEST QUESTIONS 60 20

21 Post-test ARS Question 1 After completing this activity, how often do you intend to use COPD Case Finding strategies to identify patients at high likelihood of suffering from COPD that should be treated? 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 61 Post-test ARS Question 2 After completing this activity, how confident are you in your ability to select appropriate inhaled therapies for patients with COPD, based on disease severity and patient characteristics? 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 62 Post-test ARS Question #3 71-year-old with 4-year history of exertional breathlessness, osteoporosis with past compression fracture, rheumatic fever, syringomyelia, and past pneumonia. Admitted to hospital with first COPD exacerbation, and discharged home after treatment. Never smoked, but extensive passive smoking Mother died from early-life emphysema (nonsmoker) Workup: CAT score = 15; mmrc dyspnea score = 2 Decreased breath sounds, no wheezing/rales; little cough or sputum FEV1 63% predicted What is this patient s GOLD Group? 1. GOLD A 2. GOLD B 3. GOLD C 4. GOLD D 63 21

22 Post-test ARS Question #4 71-year-old with 4-year history of exertional breathlessness, osteoporosis with past compression fracture, rheumatic fever, syringomyelia, and past pneumonia. Admitted to hospital with first COPD exacerbation, and discharged home after treatment. She returns to see you with no long acting medications. She has no sputum production but has breathlessness with CAT of 15 and mmrc of 2. Her FEV1 is 63% predicted. Never smoked, but extensive passive smoking Mother died from early-life emphysema (nonsmoker) What therapy would you recommend? 1. Start rofumilast 2. Start LABA 3. Start LAMA/LABA 4. Start LABA/LAMA/ICS 64 Post-test ARS Question #5 71-year-old woman with 4-year history of exertional breathlessness, confirmed airflow obstruction, little sputum production, recent COPD hospitalization, CAT score 15; mmrc dyspnea score 2 (GOLD D). Current medications include LABA/LAMA/ICS. She has not had an exacerbation in the last year Current eosinophil count is 100 cells/mcl What change to therapy would you recommend? 1. Add macrolide 2. Add rofumilast 3. Make no change to therapy 4. Withdraw ICS, keep LAMA/LABA CAT: COPD Assessment Test mmrc: modified Medical Research Council SAMA: short-acting muscarinic antagonist LAMA: long-acting muscarinic antagonist LABA: long-acting beta-agonist ICS: inhaled corticosteroid 65 Post-test ARS Question #6 According to GOLD recommendations, how often should healthcare professionals assess inhaler technique in a patient with COPD? 1. Every visit 2. Every other visit 3. Twice every year 4. Once every year 66 22

23 Post-test ARS Question #7 63 y/o man with severe COPD (FEV 1 40% predicted), CAT score 20, mmrc score 3, no chronic sputum production, CAD (s/p PCI last year). Had 2 episodes of bronchitis last year and 1 hospitalization for pneumonia. Reports 5 days of increased breathlessness and no cough or sputum production. Medications: amlodipine, metoprolol succinate, aspirin, SABA prn, LAMA Exam: BMI 18 kg/m 2, O 2 sat at rest with room air 91%, decreased breath sounds What therapeutic option would you recommend? 1. Prescribe antibiotic 2. Discontinue metoprolol 3. Add LABA (LABA/LAMA) 4. Add prednisone at 40 mg daily for five days 5. Add prednisone at 40 mg with two week taper 67 Post-test ARS Question #8 Which of the following is associated with increased risk of early readmission in a patient admitted with COPD exacerbation? 1. Female gender 2. Caucasian race 3. Longer length of stay 4. Younger age (<65 years) 68 23