Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions Assessm ent and Managem ent of COPD Patients in Prim ary Care: Tools and Technologies to Guide Treatm ent Decisions Keith Robinson, MD, MS, FCCP Clinical Professor Florida International University College of Medicine Miami, FL Jointly provided by and This educational activity is supported by an educational grant from GlaxoSmithKline. Agenda I. Welcome and Introduction II. Screening Initiatives and COPD Diagnoses in Early Stages a) Patient profiles early in disease course b) Lung function decline in mild, moderate, and severe COPD c) Definition of a COPD exacerbation d) Identifying at-risk patients: tools and questionnaires (mMRC and CAT) e) PEF and spirometry: feasibility, necessity, and alternatives III. COPD Pocket Consultant Guide: Implementing Evidence-based Recommendations a) PCG and the COPD Care Algorithm b) COPD severity domains and guideline recommendations c) Pharmacologic escalation and de-escalation strategies: symptoms, severity, and exacerbation risk d) Comparison of different classes and combination of agents IV. Facilitating Compliance: New Pharmacologic and Non-pharmacologic Strategies a) Patient engagement and disease education b) Provider-patient communication tools, mobile app c) Safety and efficacy of new agents d) Comprehensive nonpharmacologic strategies V. Question & Answer Session; Post-test and Evaluation MEDX Atlanta – September 29, 2018
Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions The Impact of COPD • ~15 million people diagnosed (additional 12M are undiagnosed) – 14% of US population (age 40-79) have COPD – 2 nd -leading cause of disability – 3 rd -leading cause of 30-day readmissions – 3 rd -leading cause of death (2 nd to CV disease and cancer) • Mortality rate predicted to increase by 30% over the next decade • Exacerbations – ~800,000 hospitalizations (+ 3.5 million COPD 2 nd dx) – 1.5 million ER visits/year • Costs for COPD in the United States, 2010 = $50 billion and rising CDC. Chronic Obstructive Pulmonary Disease. http://www.cdc.gov/copd/. The COPD Foundation. Chronic Obstructive Pulmonary Disease (COPD). www.copd.org. National Heart, Lung and Blood Institute (NHLBI). COPD – Learn More, Breath Better. https://www.nhlbi.nih.gov/health/educational/copd/index.htm. Guarascio AJ et al. Clinicoecon Outcomes Res. 2013;5:235-245. Age-standardized Prevalence of COPD Adults Aged 18 or Older Han M et al. Lancet Respir Med . 2016;4:473-526. MEDX Atlanta – September 29, 2018
Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions COPD Screening and Diagnosis CASE 1 CASE 1 52-year-old Woman with Productive Cough and Breathlessness 52-year-old Woman with Productive Cough and Breathlessness • Social history • History of present illness – Works as a beautician – Cough x 5 days, yellow sputum and chest congestion after visiting family – 2 ppd for 30 years the prior weekend • ROS • Past medical history – Progressive exertional dyspnea – Hypertension x 10 years – Similar ‘bronchitis’ episode earlier • Physical examination this year treated with a Z-pack and – Afebrile, RR 22, mild distress, steroid taper in Urgent care Saturations 98% – Mild forced expiratory wheezing MEDX Atlanta – September 29, 2018
Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions Prevalence of COPD Is Higher in Women Age-adjusted prevalence of self-reported, physician-diagnosed COPD in US (adults aged ≥ 25 years) Han M et al. Lancet Respir Med . 2016;4:473-526. Screening for COPD Does Spirometry Decrease Morbidity or Mortality? 1 Reduced COPD No risk factors Medications 5 M/M 2 Asymptomatic Pulmonary Spirometry COPD Adults rehabilitation 6 Smokers, 3 other Harms Oxygen Harms exposures therapy 7 Reduced COPD Vaccines In asymptomatic patients, the USPSTF M/M 8 Harms does not recommend routine use of 4 spirometry to screen for obstructive Reduced Smoking Smoking cessation COPD lung disease cessation M/M counseling M/M = morbidity/mortality; USPSTF = US Preventive Services Task Force Guirguis-Blake JM et al. US Preventive Services Task Force Evidence Syntheses . 2016;14-05205-EF-1. MEDX Atlanta – September 29, 2018
Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions High Index of Suspicion for COPD Screening and Diagnosis High Index of Suspicion for COPD Screening and Diagnosis Pathways for the Diagnosis of COPD RISK FACTORS SYMPTOMS • Host factors • Shortness of breath • Tobacco • Chronic cough • Occupation • Sputum • Indoor/outdoor pollution SPIROMETRY Required to establish diagnosis Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. www.goldcopd.org. Used for educational purposes only. Early Disease: Spiromics • In patients not meeting current diagnostic criteria for COPD, 50% of current and former smokers had exacerbations, high symptom burden (CAT >10), activity limitation, and evidence of airway disease • This cohort were current smokers, younger (Mean age <65) and had a higher body mass index (BMI), chronic bronchitis diagnosis, as well as a history of childhood asthma Woodruff P et al. N Engl J Med. 2016;374:1811-1821. MEDX Atlanta – September 29, 2018
Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions Spiromics Patients with Significant Symptoms Have Increased Rate of Exacerbations Regardless of Airflow Obstruction 0.6 FEV 1 : FVC Cutoff to Define Obstruction 0.5 0.65 LLN 0.70 0.75 0.4 0.3 0.2 0.1 0.0 Controls Who Never Current or Former Current or Former Current or Former Current or Former Smoked Smokers, FEV 1 : FVC Smokers, FEV 1 : FVC Smokers, FEV 1 : FVC Smokers, FEV 1 : FVC ≥ Specified Cutoff, CAT ≥ Specified Cutoff, CAT <Specified Cutoff, CAT <Specified Cutoff, CAT ≥ 10 <10 <10 ≥ 10 Woodruff P et al. N Engl J Med. 2016;374:1811-1821. The Refined ABCD Assessment Tool: GOLD 2017 Assessment of symptoms/ Spirometrically Assessment of risk of exacerbations confirmed diagnosis airflow limitation Exacerbation history ≥ 2 or ≥ 1 leading to hospital admission Post-bronchodilator FEV 1 /FVC < 0.7 0 or 1 (not leading to hospital admission) CAT = COPD Assessment Test; FEV 1 = forced expiratory volume in one second; FVC = forced vital capacity; mMRC = Modified Medical Research Council Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. www.goldcopd.org. Used for educational purposes only. MEDX Atlanta – September 29, 2018
Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions GOLD Assessment Tools COPD Assessment Test (CAT) Rate 0-5 for each item Score I never cough I cough all the time mMRC Breathlessness Scale Grade Description of Breathlessness I have no phlegm (mucus) in My chest is completely full of phlegm (mucus) my chest at all 0 I only get breathless with strenuous exercise My chest does not feel tight My chest feels very tight I get short of breath when hurrying on level ground at all 1 or walking up a slight hill When I walk up a hill or one When I walk up a hill or one flight of stairs I am On level ground, I walk slower than people of the flight of stairs I am not very breathless 2 same age because of breathlessness, or have to breathless stop for breath when walking at my own pace I am not limited doing any I am very limited doing activities at home I stop for breath after walking about 100 yards or activities at home 3 after a few minutes on level ground I am confident leaving my home I am not at all confident leaving my home despite my condition because of my lung condition I am too breathless to leave the house or I am 4 breathless when dressing I sleep soundly I do not sleep soundly because of my condition I have lots of energy I have no energy at all Total Score: Karloh M et al. Chest . 2016;149:413-425. COPD Assessment(s) Self-reported Health Status • COPD Assessment Test (CAT) • modified Medical Research Council (mMRC) • Clinical COPD Questionnaire (CCQ) • St. George’s Respiratory Questionnaire (SGRQ) • Chronic Respiratory Questionnaire (CRQ) Karloh M et al. Chest. 2016;149:413-425. MEDX Atlanta – September 29, 2018
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