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1 EVALUATION OF THE MEDICATION UTILIZATION OF COPD PATIENTS AT THE MIAMI VA HEALTHCARE SYSTEM Simone Edgerton, PharmD. PGY 1 Pharmacy Resident Miami VA Healthcare System Miami, Florida Simone.edgerton2@va.gov Disclosure Statement Disclosure statement: These individuals have the following to disclose concerning possible financial or relationships with commercial entities (or their competitors) that may be referenced in this presentation. Simone Edgerton: Nothing to disclose Julia Ortega: Nothing to disclose Mara Carrasquillo: Nothing to disclose Michael Campos: COPD research doing trials for Spiration, Astra Zeneca, and Sunovion Presentation Objective Describe the management of COPD patients at the Miami VA Healthcare System What is COPD? Epidemiological Data Diagnosis 3 rd leading cause of death globally Exposure chronic obstructive pulmonary disease/ 12, deaths in the U.S., representing 1 in every 2 deaths (25) 13.7 million US adults aged 25 years had a diagnosis of COPD (211) Symptoms Spirometry Testing Post bronchodilator FEV1/FVC <.7 1
2 Spirometry Classification Combined Assessment Pharmacologic Treatment Stage Severity FEV1 Result GOLD 1 Mild FEV1 8% predicted GOLD 2 Moderate 5% FEV1 <8% predicted GOLD 3 Severe 3% FEV1 <5% predicted GOLD 4 Very Severe FEV1 <3% predicted Risk COPD Classification of Airflow Limitation (C) (A) mmrc 1 CAT 1 Symptoms (mmrc or CAT) (D) (B) mmrc 2 CAT Risk Exacerbation History Patient Group A B C D Recommended Choice SAMA prn or SABA prn LAMA or LABA ICS + LABA or LAMA ICS + LABA or LAMA Alternative Choice LAMA or LABA or SABA + SAMA LAMA + LABA LAMA + LABA or LAMA + PDE 4 inhibitor or LABA + PDE 4 inhibitor ICS + LABA + LAMA or ICS + LABA + PDE 4 inhibitor or LAMA + LABA or LAMA + PDE 4 inhibitor Glossary: SA: short acting; LA: long acting; MA: muscarinic antagonist; BA: beta 2 agonist; ICS: inhaled corticosteroid; PDE 4: phosphodiesterase 4 Other Possible Treatments SABA and/or SAMA or SABA and/or SAMA or Carbocysteine or N acetylcysteine or SABA and/or SAMA or Purpose Study Objectives Study Design To review the medication utilization trends of the COPD patients at the Miami VA Healthcare System through a multifaceted approach 1. Describe the management of the COPD patients 2. Determine the GOLD classification of airflow limitation of the COPD patients 3. Review the non pharmacologic and pharmacologic measures used for the treatment of COPD IRB reviewed Conducted at the Miami VA Healthcare System from January 215 January 216 Patient identification and parameter list was obtained through computerized patient record system (CPRS) 4 patients were reviewed 2
3 Study Design Parameters Reviewed Parameters Reviewed Inclusion Criteria Age 18 years ICD 1 diagnosis of the following: COPD Chronic Bronchitis Emphysema Exclusion Criteria Any other pulmonary diagnosis Indication Spirometry Testing GOLD Classification Patient COPD Group Smoking history Vaccination history (influenza, pneumococcal) Medications Prescribers/Clinics Exacerbations Indication (N = 4) Spirometry Testing % Results COPD 1% COPD/Asthma.25% COPD/Lung cancer 2% Asthma Excluded.25% No COPD or Asthma 24% 76% Yes 296 (76%) No 95 (24%) Series Indication 3
4 GOLD Classification GOLD Classification (N = 296) (N = 296) % 24% 76% Yes 296 (76%) No 95 (24%) Number of Patients % 23% 7% 3% 7% No patient group classification Patient group classification 26 (7%) 9 (3%) GOLD 1 GOLD 2 GOLD 3 GOLD 4 Series GOLD Classification (N = 296) (N = 9) Active Smoker % % 8% 4% 15% Provider Reported Patient Group Classification Number (%) Pulmonary 85 (94%) Primary care 5 (6%) 69% 31% Yes 125 (31%) No 266 (69%) A B C D Unknown Series
5 Influenza Vaccine Pneumococcal Vaccine Medications ICS + LABA 276 (72%) 1% SABA LAMA 222 (57%) 271 (69%) SABA + SAMA 64 (16%) 5% 5% Yes 194 (5%) No 197 (5%) 9% Yes 353 (9%) No 38 (1%) Medications ICS LTRA LABA LABA + LAMA SAMA PDE 4 Inhibitor Alpha agonist 44 (11%) 34 (9%) 26 (8%) 5(1.5%) 4(1%) 2 (.5%) 1 (.3%) Series Oral Steroid for COPD Antibiotics for COPD Prescribers/Clinics 3 68% 25 79% 21% Yes 83 (21%) No 38 (79%) 77% 23% Yes 88 (23%) No 33 (77%) Primary care 32% Pulmonary Series Prescribers 5
6 Hospitalizations (N = 97) Pharmacotherapy Correct medication management: 56/9 (62%) 62% 38% COPD exacerbation 37 (38%) Not COPD related 6 (62%) Conclusions Patients that cannot be assessed due to no spirometry testing: 2/9 (2%) Incorrect medication management: 32/9 (36%) Incorrect Medication Management (N = 32) Recommendations Patient Group A B C D N (%) 6 (19%) 17 (53%) 5 (16%) 4 (12%) LAMA or LABA When Not LABA or LAMA Not When ICS When Not ICS Not When Recommendations Spirometry testing should be performed on all patients with suspicion of COPD Patient classification should be done on all patients who receive spirometry testing Recommend to create pharmacologic algorithms for COPD treatment Reassess the 32 patients with inappropriate medication management Influenza and pneumococcal vaccination should be offered to all patients with COPD 6
7 Self Assessment Question Self Assessment Question Acknowledgement What were the two most common medications used in this study? A. ICS and PDE 4 inhibitor B. ICS and LABA C. SAMA and Alpha agonist D. Alpha agonist and PDE 4 inhibitor What were the two most common medications used in this study? A. ICS and PDE 4 inhibitor B. ICS and LABA C. SAMA and Alpha agonist D. Alpha agonist and PDE 4 inhibitor Julia Ortega, PharmD Mara Carrasquillo, PharmD Michael Campos, MD Questions leadership conversation starters/ References 1. WHO website. COPD. Available at: Accessed on January 4, Ford ES, Croft JB, Mannino DM, et.al. COPD Surveillance United States, Chest. 213; 144 (1): Global Initiative for Chronic Obstructive Lung Disease: Pocket Guide to COPD Diagnosis, Management and Prevention, Updated 215. Available at: 5_Feb18.pdf. Accessed on January 4, 216. EVALUATION OF THE MEDICATION UTILIZATION OF COPD PATIENTS AT THE MIAMI VA HEALTHCARE SYSTEM Simone Edgerton, PharmD. PGY 1 Pharmacy Resident Miami VA Healthcare System Miami, Florida Simone.edgerton2@va.gov 7
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