Breaking the cycle of COPD
Key takeaways from the 2018 International COPD Conference
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Despite the establishment of evidence-based guidelines and greater awareness, the worldwide prevalence of COPD continues to grow. Its worsening burden calls for the critical evaluation of interventions to diagnose the disease, manage its symptoms, and prevent exacerbations—so we can break its destructive cycle. As we learned from the 2018 International COPD Conference, much of this effort comes from managing it proactively at 3 key points along the treatment journey: PCP care, pulmonologist care, and discharge. Let’s take a closer look at each.
PCP care: Breaking the cycle with prevention
The burden of undiagnosed COPD
Mannino DM, et al. Chronic obstructive pulmonary disease surveillance–United States, 1971-2000. MMWR Surveill Summ. 2002 Aug 2;51(6):1-16.
Care today
MeiLan Han, MD, MS presented that undiagnosed COPD is associated with up to 1/3 of exacerbation-like events. She highlights in the chart below why it is so important to arrest the development of COPD in its early years, before progression ramps up.* *Labonte LE, et al. Undiagnosed chronic obstructive pulmonary disease contributes to the burden of health care use. Data from the CanCOLD study. Am J Respir Crit Care Med. 2016 Aug 1;194(3):258-98. doi:10.1164/rccm.201509-1795OC.
Han highlighted that the optimal window for early intervention is between 20-30 years of age. The best place to achieve an early diagnosis is with primary care practitioners. Unfortunately, this is not happening. Her term—"Therapeutic Nihilism”—explains why: This is when both primary care providers and patients lack awareness of COPD and its symptoms and how to detect it.
What is Therapeutic Nihilism?
Han MK, et al. Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective. Lancet Respir Med. 2016 Jun;4(6):473-526. doi:10.1016/S2213-2600(16)00094-1. Epub 2016 May 13.
A better way
Han suggests a new method to diagnose COPD that fits into primary practice. Comprised of five questions and a PEF score, it is called the CAPTUREÔ Instrument. With the use of this method, PCPs can better identify COPD early, intervene early, and avoid the catastrophic clinical and financial outcomes of uncontrolled progression.
Sample CAPTURE™ Instrument questions
Have you ever lived or worked in a place with dirty or polluted air, smoke, second-hand smoke, or dust?
Does your breathing change with seasons, weather, or air quality?
Does your breathing make it difficult to do things such as carry heavy load, shovel dirt or snow, jog, play tennis, or swim?
Compared to other your age, do you tire easily?
In the past 12 months, how many times did you miss work, school, or other activities due to a cold, bronchitis, or pneumonia?
Martinez FJ, Mannino D, Leidy NK, et al. A new approach for identifying patients with undiagnosed chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2017 Mar 15;195(6):748-756. doi:10.1164/rccm.201603-0622OC.
Pulmonologist care: Breaking the cycle with earlier identification
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Alvar Agusti, MD posited that we may be looking in the wrong places to arrest the disease. The traditional paradigm is that COPD is a smoker’s disease. However, the percentage of patients with COPD who are non-smokers is high.
Sundeep S Salvi, Peter J Barnes
Lancet 2009, 374: 733-43
Salvi SS, Barnes PJ. Chronic obstructive pulmonary disease in non-smokers. Lancet. 2009 Aug 29;374(9691):733-743. doi:10.1016./S0140-6736(09)61303-9.
While we focus on the adult years for managing COPD, the earliest interventions are shown to redefine long-term outcomes. Infant mortality rates from respiratory distress have dropped significantly in the Unites States from 1968 to 2010, which is attributed largely to our ability to successfully manage pre-term births. This points to the potential correlation between fetal development and adult disease.
Infant mortality rate for Respiratory Distress Syndrom U.S., 1968-2010
Vital Statistics of the United States. Centers for Disease Control and Prevention: National Center for Health Statistics. www.cdc.gov/nchs.
Lungs that are not fully developed are less able to maintain their function under the cumulative effects of the environment and aging.
COPD beyond new paradigm, novel opportunities
Agusti A, Faner R. COPD beyond smoking: new paradigm, novel opportunities. Lancet Respir Med. 2018 May;6(5):324-326. doi:10.1016/S2213-2600(18)30060-2. Epub 2018 Feb 26.
To change the paradigm of COPD identification, ask yourself:
Are other organs underdeveloped?
Is our clinical practice the same?
Do these patients have the same disease, prognosis, and treatment?
Do our drug therapies need to be repositioned?
A better way
The best way to assess lung function as a risk factor for COPD is to identify these patients early in life. Agusti strongly recommends spirometry for school-age children, especially those who were born pre-term.
Discharge: Breaking the cycle of readmissions with better risk factor identification
Care today
One of the largest groups of COPD patients who are readmitted within 30 days are known as “frequent flyers.” In a past article, COPD insider covered a number of strategies to reduce frequent flyer readmissions. This was also a significant topic of discussion at the 2018 International COPD Conference. 30-day COPD readmissions are receiving greater attention as more hospitals take part in value-based reimbursement contracts. Mark Dransfield, MD presented compelling data that show certain qualities correlate with frequent readmissions and that by focusing on them, costly penalties can be avoided. Perhaps most surprising was Dransfield’s presentation of the following chart that counterintuitively shows the greatest concentration of readmissions occurring shortly after discharge, not at the end of the 30-day period as would have been expected. Yet despite receiving greater attention, 30-day COPD readmission rates have remained unchanged.
Jacobs DM, et al. Early hospital readmissions after an acute exacerbation of chronic obstructive pulmonary disease in the nationwide readmissions database. Ann Am Thorac Soc. 2018 Jul;15(7):837-845. doi:10.1513/AnnalsATS. 201712-913OC.
A better way
Dransfield presented key risk factors to help identify these patients prior to an exacerbation. These factors should be internalized by all stakeholders involved in discharge, and should be incorporated into every discharge program.
Leading indicators of a COPD readmission:
Yet knowing these leading indicators is only half the battle. Being able to gather this information, analyze it, and intervene when necessary remains a significant barrier to better outcomes. Dransfield examined emerging technologies to see whether they held promise for early detection in a cost-effective, reproducible manner. He suggests that having patients input key data into a telemonitoring questionnaire on a daily basis will allow machine-learning algorithms to detect those patients at greatest risk and treat their symptoms. While these technologies are not currently being used by every care practice, they hold incredible promise to help reduce COPD readmissions, optimize resource utilization, and avoid significant financial penalties.
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