Optimum COPD Care in 2010 Why Not Now? David E. Taylor, M.D. Pulmonary/Critical Care Ochnser Medical Center

Transcription

1 Optimum COPD Care in 2010 Why Not Now? David E. Taylor, M.D. Pulmonary/Critical Care Ochnser Medical Center

2 Observations from Yesterday EPIC is epidemic No EMR No Way!!! Accountability/Benchmarking Commitment to smoking cessation The 20% Solution 20% more patients 20% less reimbursement It s more about managing change than managing COPD

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10 NIH Funding and Mortality (2002) HIV DM Cancer CV COPD Deaths 16,371 71, , , ,816 $/death 179,158 14,

11 NICE Guidelines for COPD Diagnosis Office-based spirometry Smoking cessation Effective inhaled therapy Pulmonary rehabilitation Supplemental oxygen Specialist referral Management of exacerbations Use of non-invasive ventilation

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13 NIH / NHLBI Initiative 4 Reasons to Learn More About COPD 4 th leading cause of death in the U.S. One death every 4 minutes 4 things you can do Be aware of risk factors Recognize symptoms Ask your doctor about a simple breathing test Follow treatment advice

14 NIH / NHLBI Initiative 4 Reasons to Learn More About COPD 4 things you can do Smoking cessation and avoid respiratory irritants Take medication as prescribed Pulmonary rehabilitation Vaccination (influenza and pneumonia)

15 Severity of Airflow Obstruction FEV 1 (% predicted) NICE 2004 ATS/ERS 2004 GOLD 2008 NICE 2010 > 80% N/A Mild Stage 1 Stage 1 * 50-79% Mild Moderate Stage 2 Stage % Moderate Severe Stage 3 Stage 3 <30% Severe Very Severe Stage 4 Stage 4

16 Challenges in Diagnosis Limited success introducing spirometry to primary care setting Technology cost Technical support Quality control

17 Challenges in Management Outpatient ownership Primary care vs. Pulmonary Timely clinic access Inpatient care Standardized order sets Hospitalist model

18 Disease Severity Surgery Oxygen Pulmonary Rehabilitation Inhaled Corticosteroids Bronchodilators Self-Management Education and Smoking Cessation

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20 Lung Health Study: Mortality rates at 14.5 years by cause by American College of Physicians Anthonisen N R et al. Ann Intern Med 2005;142:

21 Lung Health Study: Smoking Cessation Improves Survival Anthonisen N R et al. Ann Intern Med 2005;142: by American College of Physicians

22 Smoking Cessation Improves Lung Function Lung Health Study Anthonisen et al. AJRCCM 2002

23 Challenges in Smoking Cessation Societal attitudes about smoking Smoke-free campuses Addiction bias Cost of pharmacologic agents Relapse

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25 Vaccination Improves COPD Influenza vaccination in COPD patients Reduced pneumonia/influenza hospitalizations Reduced risk of death Pneumococcal vaccination Reduced pneumonia hospitalizations +/- mortality benefit

26 Challenges in Vaccination Patient capture/identification Patient responsibility vs. institutional responsibility Patient resistance to vaccination

27 Severity of Airflow Obstruction FEV 1 (% predicted) GOLD 2008 NICE 2010 > 80% Mild Stage 1 Short-acting (beta agonist or anticholinergic) 50-79% Moderate Stage 2 Long-acting (beta agonist or anticholinergic) 30-49% Severe Stage 3 LABA + anticholinergic + Inhaled steroid <30% Very Severe Stage 4 LABA + anticholinergic + Inhaled steroid

28 Bronchodilator Use Improves COPD Reduced exacerbations for moderate/severe disease Long-acting beta agonists Long-acting anticholinergic Reduced dyspnea and improved QOL Combination bronchodilator therapy with inhaled corticosteroids

29 Challenges in Bronchodilator Use Cost of pharmacologic agents Generic short-acting but non-generic longacting bronchodilators Beta-agonist vs. anticholinergic inhalers Hand-held vs. nebulizer administration

30 The TORCH Study Calverley PMA, et al. N Engl J Med 2007;356: Combination vs. salmeterol alone over three years: Salmeterol 50mcg only Salmeterol + fluticasone (50/500mcg) P value All-cause mortality ( 1 endpoint) 13.5% 12.6% 0.48 NS Moderate/severe exacerbations 0.97/yr 0.85/yr Exacerbations requiring hospitalisation 0.16/yr 0.16/yr 0.79 NS Pneumonia 13.3% (0.04/yr) 19.6% (0.07/yr) <0.001 NNT to prevent one moderate/severe exacerbation in one year is 8 (combination vs. salmeterol alone) NNH to cause one case of pneumonia in one year is 33 (combination vs. salmeterol alone)

31 Challenges in Inhaled Steroid Use Cost of pharmacologic agents In combination with bronchodilator vs. separate device Risk of oropharyngeal candidiasis Potential risk of pneumonia Potential risk of reduced bone density

32 Pulmonary Rehabilitation Improves COPD In moderate to severe COPD (FEV 1 less than 50%) Improved dyspnea and health status Reduced hospitalization May improve exercise capacity

33 Challenges in Pulmonary Rehabilitation Limited community options Reimbursement issues

34 Oxygen Supplementation Improves COPD Improves patient survival Resting hypoxemia Cor pulmonale Best results with ~24 hour use

35 Challenges in Oxygen Supplementation Cost of various modalities Tank vs. liquid vs. portable concentrator Reimbursement Hypoxemia at rest vs. exertional desaturation Patient compliance issues

36 Challenges in COPD Surgery High morbidity/mortality in lung volume reduction surgery and transplant Limited applicability Experimental trials of other modalities at limited number of sites

37 Disease Severity Surgery Oxygen Pulmonary Rehabilitation Inhaled Corticosteroids Bronchodilators Self-Management Education and Smoking Cessation

38 Added Motivation in COPD Care JCAHO Certification Program Healthcare Effectiveness Data and Information Set (HEDIS) scores Influenza vaccination Smoking cessation support Spirometry in diagnosis of COPD Reimbursement in Medicare Advantage linked to HEDIS performance in the near future

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42 Observations from Yesterday EPIC is epidemic No EMR No Way!!! Accountability/Benchmarking Commitment to smoking cessation The 20% Solution 20% more patients 20% less reimbursement It s more about managing change than managing COPD