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Primary Cares: A Performance Improvement (PI) Activity Designed to Improve the Diagnosis and Management of COPD and As

Primary Cares: A Performance Improvement (PI) Activity Designed to Improve the Diagnosis and Management of COPD and Asthma. Sponsorship and Support Statements.

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Primary Cares: A Performance Improvement (PI) Activity Designed to Improve the Diagnosis and Management of COPD and As

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  1. Primary Cares: A Performance Improvement (PI) Activity Designed to Improve the Diagnosis and Management of COPD and Asthma

  2. Sponsorship and Support Statements This activity is being co-sponsored by The American College of Allergy, Asthma & Immunology (ACAAI) in cooperation with The Peer•Point Medical Education Institute, LLC. This activity is supported by an independent educational grant from AstraZeneca LP.

  3. Accreditation Statements Physician Accreditation The American College of Allergy, Asthma & Immunology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Physician Credit Designation The American College of Allergy, Asthma & Immunology designates this PI CME activity for a maximum of 20 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nursing AccreditationThe Peer•Point Medical Education Institute, LLC, is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Nursing Credit Designation This program is accredited for 15 contact hours and contains 0.2 hours of pharmacology (Rx) content.

  4. Faculty Sheldon Spector, MD (Activity Faculty Chair) Director California Allergy and Asthma Medical Group Los Angeles, California Leonard M. Fromer, MD Assistant Clinical Professor of Family Medicine UCLA School of Medicine Los Angeles, California Board Member, TransforMED, LLC Leawood, Kansas

  5. Faculty Speaker Sheldon Spector, MD Dr. Spector has been a consultant for, served on the advisory boards for, served as a speaker, and received research grants from AstraZeneca, Genentech, Schering-Plough, Sepracor, Abbott, sanofi-aventis, Merck, Johnson & Johnson, Novartis, Skypharma, and Medpointe Healthcare Inc. Received research grants from, Amgen, Boehringer-Ingelheim, CTI Inc, Eli-Lilly, Glaxo Smith-Kline, Ig Pro, Karmel Sonics, Ono Pharma, Perrigo/TKL, and Sepracor.

  6. Learning Objectives Upon completion of this PI activity, participants should be able to demonstrate the following knowledge, competence, and performance-based objectives: • Utilize the diagnostic benefits of offering office-based/hospital-based spirometric evaluations for their at-risk patients (knowledge, competence) • Demonstrate understanding of spirometric performance/ interpretation skills and other techniques to enhance diagnosis and management of asthma and COPD (knowledge, competence) • Use spirometric results to distinguish between those patients with asthma vs. COPD and provide appropriate first-line therapy(s) for each condition (performance) • Improve the long-term care of their patients with COPD or asthma by assessing symptoms and assuring therapies are making an objective difference (competence, performance).

  7. Gaps in Diagnosing COPD • PCPs provide care for some aspect of COPD in 80%of Americans • Most experts advocate for PCPs to include spirometry into their office procedures • Only 1/3 of newly diagnosed COPD patients had undergone spirometry • 50% of asthmatics have never undergone spirometry Mannino DM, et al. Chest. 2002;121(5 Suppl):121S-126S.; Yawn BP, Wollan PC. Int J Chron Obstruct Pulmon Dis. 2008;3(2):311-317.; Moore PL. Am J Med. 2007;120(8 Suppl 1):S23-S27.; Chavannes N, et al. Respir Med. 2004;98(11):1124-1130.; Han MK, et al. Chest. 2007;132(2):403-409.; Chapman KR, et al. Eur Respir J. 2008;31(2):320-325.

  8. Gaps in Diagnosing COPD • 13.6 million Americans have been diagnosed with COPD. This means that another 15 million patients that actually have COPD have been misdiagnosed or underdiagnosed • This translates to nearly 50% of Americans with COPD are not given the correct diagnosis • National Institute of Health report: currently COPD is the 4th leading cause of death in the United States, and expected to be the 3rd leading cause of death by 2020 Chronic Obstructive Pulmonary Disease (COPD) Fact Sheet. (Available at www.lungusa.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html#note_12. Accessed December 6, 2010); Mannino DM, et al. Respir Care. 2002;47(10):1184-1199.; Barr RG, et al.Am J Med. 2005;118(12):1415.

  9. Gaps in Diagnosing COPD • Underdiagnosis and misdiagnosis of COPD are missed opportunities to intervene early and change disease trajectory • Early treatment improves lung function, health-related QoL, exacerbations, and early mortality • In one large survey, 850/1000 PCPs believed COPD was “self-inflicted” • 1/3 felt that there was nothing that could be done for those that continued to smoke Radin A, Cote C. Am J Med. 2008;121(7 Suppl):S3-12.; Decramer M, et al. Lancet. 2009; 374: 1171-1178.; Jones R, Ostrem A. Prim Care Respir J. 2010; Nov 19. [Epub ahead of print]; Zanconato S. Pediatrics. 2005;116(6):e792-e797.

  10. Gaps in Diagnosing COPD • Lack of training and awareness of spirometry guidelines for both asthma and COPD • Providers reluctance on owning a spirometer because of perceived lack of validity • COPD patients often present with/for other medical conditions making recognition difficult. Patients fail to report symptoms and providers fail to make inquires • Spirometry reversibility assessments should be considered a primary diagnostic measure Barr RG, et al. Am J Med. 2005;118(12):1415.; Schermer TR, et al. Thorax. 2003;58(10):861-866.; Mortimer KM, et al. Chest. 2003;123(6):1899-1907.; Yawn BP, Wollan PC. Int J Chron Obstruct Pulmon Dis. 2008;3(2):311-317.; Ben SH, et al. Pulm Pharmacol Ther. 2008;21(5):767-773.

  11. Differentiating Asthma From COPD

  12. Differentiating Asthma From COPD National Heart, Lung and Blood Institute. National Asthma Education and Prevention Program. (available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed December 6, 2010.); Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  13. Differentiating Asthma From COPD Asthma COPD Allergens CigaretteSmoke Alveolar macrophage Epithelial Cells Epithelial Cells Mast Cell CD4+ Cell(Th2) CD8+ cell (Tc1) Neutrophilis Eosinophils Bronchoconstriction andairway hyperresponsiveness Small airway fibrosis and alveolar destruction Eotaxin, IL-4, IL-5, IL-13 TNF- α, IL-8, IL-1β, IL-6 Not Fully Reversible Airflow Limitation Reversible IL = interleukin; TNF = tumor necrosis factor. Adapted from Global Initiative for Chronic Obstructive Lung Disease. (http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989.Accessed December 6, 2010.)

  14. Differentiating Asthma From COPD *In patients with persistent asthma.†In patients with COPD of at least moderate severity. National Heart, Lung and Blood Institute. National Asthma Education and Prevention Program. (available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed December 6, 2010.) Global Initiative for Chronic Obstructive Lung Disease (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010).

  15. Differentiating Asthma From COPD Asthma COPD Inflammation Airway Smooth Muscle Basement Membrane Fibrosis Alveolar Disruption Adapted with permission from Barnes PJ. Nature Rev Immunol. 2008;8:183-192.

  16. Inflammation in COPD 100 80 60 Airways With Measurable Cells (%) 40 20 0 Neutrophils Macrophages Eosinophils CD4+ cells CD8+ cells Normal FEV1, FEV1/FVC FEV1 30% to <80%, FEV1/FVC <0.70 FEV1 ≥80%, FEV1/FVC <0.70 FEV1 <30%, FEV1/FVC <0.70 Adapted from Hogg JC et al. N Engl J Med. 2004;350:2645-2653.

  17. Spirometry in the Primary Care Setting

  18. Why Perform Spirometry? • Measure airflow obstruction to help make a definitive diagnosis of COPD • Confirm presence of airway obstruction • Assess severity of airflow obstruction in COPD • Detect airflow obstruction in smokers who may have fewor no symptoms • Monitor disease progression in COPD • Assess one aspect of response to therapy • Assess prognosis (FEV1) in COPD • Perform pre-operative assessment Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  19. Why Perform Spirometry?(cont.) • Make a diagnosis and assess severity in a range of other respiratory conditions • Distinguish between obstruction and restriction as causes of breathlessness • Screen workforces in occupational environments • Assess fitness to dive • Perform pre-employment screening in certain professions Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  20. Types of Spirometers • Bellows spirometers: • Measure volume • Electronic desk top spirometers: • Measure flow and volume • Real-time display • Small hand-held spirometers: • Inexpensive and quick to use • No print out Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  21. Spirometric Measurements Inspiratory reserve volume Inspiratory capacity Total lung capacity Tidal volume Expiratory reserve volume Vital capacity Residual volume Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  22. Lung Volume Capacity VOLUMES CAPABILITIES IRV TLC IC Volume VC VT ERV FRC RV Time Middleton's Allergy: Principles and Practice, 7th ed. Volume 2, Chapter 42, pp732. 2008

  23. Lung Volume in Various Patients FRC VC VC VC FRC FRC VC FRC RV Asthma Middleton's Allergy: Principles and Practice, 7th ed. Volume 2, Chapter 42, pp732. 2008

  24. COPD Measurements • FEV1―Forced expiratory volume in one second: • The volume of air expired in the first second of the blow • FVC ―Forced vital capacity: • The total volume of air that can be forcibly exhaled in one breath • FEV1/FVC ratio: • The fraction of air exhaled in the first second relative to the total volume exhaled Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  25. Normal Trace Showing FEV1 and FVC FVC 5 4 FEV1 = 4L FVC = 5L FEV1/FVC = 0.8 Volume, liters 3 2 1 1 2 3 4 5 6 1 Time, sec Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  26. Spirogram Patterns • Normal • Obstructive • Restrictive Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  27. Flow Volume Curves As Seen In Normal Patients With Obstructive And Restrictive Disease 8 Normal 6 Flow, L/sec 4 Obstructive Restrictive 2 8 6 4 2 0 Volume, L Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  28. Faculty Speaker Leonard M. Fromer, MD Dr. Fromer has served as a consultant and speaker for BohringerIngelheim.

  29. Feasibility of Performing Spirometry in PCP Practices • Critical triad: • Workflow • Improving the patient care process • Return on Investment • You will receive compensation for performing spirometry as it is indicated by evidence based guidelines Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  30. Application of the Chronic Care Model to COPD • Clinical decision support: • COPD guidelines • Self-management Support: • Education, plans, support, motivational interviewing, OARS technique • Delivery System Design: • Integrated team approach, integrated and team based collaborative care approach • Community Resources: • Rehab, clubs, support groups • Healthcare Organizations (HCO): • Partnerships with durable medical equipment (DME) suppliers and insurers • Clinical Information Systems: • Registries, tracking disease management Braman SS, Lee DW. Curr Opin Pulm Med. 2010;16(2):83-88.

  31. An Evidence-based Medicine Approach to Making a COPD Diagnosis

  32. COPD: Signs and Symptoms IL = interleukin; TNF = tumor necrosis factor. Adapted from Global Initiative for Chronic Obstructive Lung Disease. (http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989.Accessed December 6, 2010.)

  33. Spirometry in Asthma and COPD National Heart, Lung and Blood Institute. National Asthma Education and Prevention Program. (available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed December 6, 2010); Fuhlbrigge AL et al. J Allergy Clin Immunol. 2001;107:61-67.; Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  34. Diseases Associated With Airflow Obstruction • COPD • Asthma • Bronchiectasis • Cystic Fibrosis • Lung cancer (greater risk in COPD) • Obliterative Bronchiolitis

  35. Spirometric Findings Used for Differentiation Sciurba FC. Chest. 2004;126:117S-124S.

  36. Increases FRC (EELV) Decreases IC Increases volume at which tidal breathing occurs Worsens with exercise and reduces exercise tolerance (dynamic hyperinflation) Hyperinflation is a Hallmark of COPD Total LungCapacity(TLC) IC Tidal Ventilation FRC/ EELV No Bronchodilator With Bronchodilator HealthyPatients PatientsWith COPD Patients With COPD During Exercise IC = inspiratory capacity; FRC = functional residual capacity; EELV = end expiratory lung volume. Adapted from Sutherland ER et al. N Engl J Med. 2004;350:2689-2697.ODonnell DE et al. Am J Resp Crit Care Med. 2001;164:770-777.; Stubbing DG et al. J Appl Physiol. 1980;49:511-515.

  37. Spirometric Diagnosis of COPD • COPD is confirmed by post–bronchodilator FEV1/FVC < 0.7 • Post-bronchodilator FEV1/FVC • Measured 15 minutes after 400µg albuterol or equivalent Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  38. Staging COPD • Stage I: Mild COPD (FEV1/FVC<0.70; FEV1>80% predicted) • Chronic Cough and sputum production may be present • Stage II: Moderate COPD (FEV1/FVC<0.70; FEV1<80% predicted) • Exertional dyspnea, cough/sputum may be present • Stage III: Severe COPD (FEV1/FVC <0.70; FEV1<50% predicted) • Dyspnea, fatigue, impacts quality of life (QoL) • Stage IV: Very Severe COPD (FEV1/FVC<0.70; FEV1<30% predicted or FEV1<50% with chronic respiratory failure) Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  39. ■ ■ ■ ■ ▲ ▲ ▲ ▲ Bronchodilator Responsiveness 0.8 0.7 0.6 0.5 Mean Δ FEV1 (SE) 0.4 0.3 0.2 0.1 0 5* 105* 855* 1855* Patients With Asthma Ipratropium (anticholinergic) Patients With COPD Ipratropium (anticholinergic) Patients With COPD Albuterol (β2-Agonist) Patients With Asthma Albuterol (β2-Agonist) SE = standard error.*5 µg dose taken initially. Additional doses of 100 µg, 750 µg, and 1000 µg taken at 20, 40, and 60 min, respectively, for a cumulative dose of 1855 µg at 60 min.†Increasing log doses. Adapted from Higgins BG et al.Eur Resp J. 1991;4:415-420.

  40. -30 -25 -20 -15 -10 -5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Airflow Obstruction inCOPD is Partially Reversible 15 Degree of Reversibility * 10 *65.6% showed a ≥15% increase in FEV1 Patients, % 5 0 Change in FEV1 % Adapted with permission from Tashkin DP et al. Eur Resp J. 2008;31:742-750.

  41. Bronchodilator Reversibility Testing • Provides the best achievable FEV1(and FVC) • Helps to differentiate COPD from asthma Must be interpreted with clinical history - neither asthma nor COPD are diagnosed by spirometry alone • Can be done on first visit if no diagnosis has been made • Best done as a planned procedure: pre- and post-bronchodilator tests require a minimum of 15 minutes • Short-acting bronchodilators need to be withheld for four to six hours prior to test Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  42. BronchodilatorReversibility Testing Preparation Stage of Testing • Tests should be performed when patients are clinically stable and free from respiratory infection • Patients should not have taken: • Inhaled short-acting bronchodilators in the previous six hours • Long-acting bronchodilator in the previous 12 hours • Sustained-release theophylline in the previous 24 hours Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  43. Bronchodilator Reversibility Testing Spirometry Stage of Testing • FEV1 should be measured (minimum three, within 5% or 150 ml) before a bronchodilator is given • The bronchodilator should be given by metered dose inhaler through a spacer device or by nebulizer to be certain it has been inhaled • The bronchodilator dose should be selected to be high on the dose/response curve Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  44. Bronchodilator Reversibility Testing • Some guidelines suggest nebulised bronchodilators can be given but the doses are not standardised. “There is no consensus on the drug, dose or mode of administering a bronchodilator in the laboratory.” Ref: ATS/ERS Task Force: Interpretive strategies for Lung Function Tests. ERJ 2005;26:948 • **Usually 8 puffs of 20 µg

  45. BronchodilatorReversibility Testing Results Stage of Testing • An increase in FEV1 that is both greater than 200 ml and 12% above the pre-bronchodilator FEV1 (baseline value) is considered significant • It is usually helpful to report the absolute change (in ml) as well as the percentage change from baseline to set the improvement in a clinical context Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=989. Accessed December 6, 2010.)

  46. An Evidence-based Medicine Approach to COPD Treatment

  47. Benefits of Smoking Cessation on FEV1 Never smokedor not susceptibleto smoke 75 Smoked regularly and susceptible toits effects 50 FEV1 (% of value at age 25) Stopped at 45 Disability 25 Stopped at 65 Death * * 0 25 50 75 100 Age (years) Adapted from Fletcher C et al. Br Med J. 1977;1:1645-1648.

  48. Stepwise Approach for Managing COPD I II III IV • FEV1/FVC <0.70 • FEV1 <30% predicted orFEV1 <50% predicted plus chronic respiratory failure • FEV1/FVC <0.70 • 30% ≤FEV1 <50% predicted • FEV1/FVC <0.70 • 50% ≤FEV1 <80% predicted • FEV1/FVC <0.70 • FEV1≥80% predicted Active reduction of risk factor(s); influenza, pneumococcal, and other vaccinations as needed Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators (when needed); Add pulmonary rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygenif chronic respiratory failure;Consider surgery Adapted from Global Initiative for Chronic Obstructive Lung Disease. (available at http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=2003.Accessed December 6, 2010.)

  49. Performance Improvement CME in COPD

  50. PerformanceImprovement-CME (PI-CME) • Necessity of PI-CME in COPD care: • COPD is a growing burden on the healthcare system in America • Outcomes for both male and female patients of all races with COPD are suboptimal • The quality of care is highly variable, many providers fail to meet the current standard • Increase awareness of updated GOLD guidelines designed to improve recognition and management of patients with COPD

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