Awareness and compliance with Guidelines for the management of Stable COPD in Current Outpatient practices and patients’

1. Awareness and compliance with Guidelines for the management of Stable COPD in Current Outpatient practices and patients’ knowledge of COPD Catholic Health System Department of Internal Medicine Research Symposium June 9, 2010 Mateen Rahman, PGY III Mentor: Dr Nashat Rabadi, MD

2. Chronic Obstructive Pulmonary Disease: COPD is a slowly progressive lung disease involving the airways and pulmonary parenchyma resulting in a gradual loss of lung function. The symptoms of COPD range from chronic cough, sputum production, and wheezing to more severe symptoms such as dyspnea, poor exercise tolerance, and right heart failure.

3. Prevalence of COPD • In the United States: • affects more than 5% of the adult population • 4th leading cause of death • 12th leading cause of morbidity • Global Burden of Disease Study • projected that COPD will become the 3rd leading cause of death in 2020 Females > Males • Chronic bronchitis • 26.8 cases per 1,000 individuals in men and 52.6 cases per 1,000 in women • Emphysema • 16.6 cases per 1,000 individuals in men and 12.8 cases per 1,000 individuals in women

4. Cost of COPD care • In the US in 2000: • 8 million office visits • 1.5 million emergency room visits • > 600,000 hospitalizations • In 2004, the cost of COPD care was approximately $37.2 billion. • $20.9 billion in direct health care expenditures • $7.4 billion in indirect morbidity costs • $8.9 billion in indirect mortality costs

5. Pathophysiology of COPD

6. Management of COPD COPD is often not diagnosed until there are clinical symptoms and the disease is moderately advanced. National Health and Nutritional Examination Survey  72% of subjects with mild airflow limitation did not have a current diagnosis of obstructive lung disease Case Identification: History: Physical Examination:

7. Spirometry

8. Additional Investigations Chest X-ray Arterial Blood gases Alpha-1 antitrypsin deficiency screening

9. Stages of COPD based on Spirometry

10. Pharmacological Agents in Management of COPD Bronchodilator Therapy

12. Classification Duration of action Mechanism of action Short acting Beta agonist Muscarinic antagonist Long acting

13. Monotherapy Long acting Beta agonist Muscarinic antagonist

14. Combination Therapy Long acting Beta agonist + Long acting Muscarinic antagonist Long acting Beta agonist + Inhaled corticosteroids Long acting Muscarinic antagonist + Inhaled corticosteroids LABA / ICS + LAMA

15. Other Pharmacological Treatments Vaccinations Alpha-1 antitrypsin augmentation therapy Systemic Steroids Methyxanthines

16. Non-Pharmacological Treatment Smoking cessation Pulmonary Rehabilitation Exercise training Nutritional counseling

17. Non-Pharmacological Treatment Oxygen Therapy Surgery Bullectomy Lung volume reduction surgery Lung Transplantation

18. Awareness and compliance with Guidelines for the management of Stable COPD in Current Outpatient practices and patients’ knowledge of COPD • Study Objective • To determine the awareness and rate of compliance with the guidelines for management of stable COPD as published by GOLD committee/ATS/ERS. • To determine the level of the patients’ knowledge of COPD disease and exacerbation

19. Awareness and compliance with Guidelines for the management of Stable COPD in Current Outpatient practices and patients’ knowledge of COPD • Experimental Design • Observational study comprising of retrospective analysis of patients’ charts which contained ICD codes for COPD • Prospective analysis of interview which was conducted among local primary care physicians about the awareness of guidelines pertaining to COPD management • Prospective analysis of telephone interviews with patients about knowledge of their COPD disease, their status and awareness about exacerbations • Methodology • Data collected from different primary care clinics across Buffalo • Total number of charts = 150

20. Awareness and compliance with Guidelines for the management of Stable COPD in Current Outpatient practices and patients’ knowledge of COPD • Inclusion Criteria • All patients being ICD Coded for COPD • Exclusion Criteria • Restrictive Lung Disease • Asthma • Any patient with contraindication for the use of any inhaled therapy • Statistical Analysis • Since this is an observational study, compliance & knowledge were measured in percentages and proportions

21. Chart Review of patients with ICD codes of COPD • Whether spirometry was performed initially at the time of diagnosis • Alpha-1 antitrypsin level in COPD patients less than 40 yrs with positive family history • Pulse oximetry • Treatment according to stages with current medication regimen • Whether a pulmonologist is involved in the care of the patient • Pulmonary rehabilitation • Vaccinations • Smoking cessation counseling

22. Study ObservationsMale vs. Female

23. Percentage of patients under the care of a pulmonologist

24. Percentage of patients who have had PFTs 36% 36% PFT 64 %

25. Patients fulfilling the criteria for Alpha 1 Antitrypsin deficiency screening

26. Percentage of patients screened for alpha-1 antitrypsin deficiency

27. Patient classification according to COPD stage

28. Pharmacological treatment regimen in patients with Stage 1 COPD – FEV > 80% predicted

29. Percentage of patients with mild COPD on ICS 35.71% 64.28% Duration since the last PFT was on an average 3.3 yrs

30. Pharmacologic Treatment Regimen in Stage 2 (Moderate COPD)FEV1 > 50 to 79 % of predicted value

31. Pharmacologic Treatment Regimen in Stage 3 (Severe COPD)FEV1 30 to 49% of predicted value

32. Pharmacologic Treatment Regimen in Stage 4 (Very Severe COPD)FEV1 > 30 or > 50% with Chronic Respiratory Failure

33. Patients with inappropriate treatment regimen

34. Patients with inappropriate treatment under the care of a pulmonologist

35. Pulmonary Rehabilitation

36. Percentage of patients who underwent smoking cessation counseling

37. Patients who were vaccinated

38. Patients’ Awareness of COPD • Awareness of COPD exacerbations and how to handle them is also lacking. • Swedish study published in 2009 • revealed 80% of the patients had received information from health professionals or participated in education/rehabilitation • but a minority (< 20%) reported that their knowledge about how to handle the disease was good • Study published in American Journal of Medicine involving 1003 patients with compliance of 87% • only 10% of respondents knew their FEV1 compared with 79% who knew their blood pressure

39. Patient Questionnaire Total number of patients = 30 20 patients were contacted via telephone. 10 patients were interviewed directly. To assess patient knowledge about the following: • Do they know that they have COPD? • Do they know what PFTs/Spirometry are? • Does the patient know his/her FEV1 value? • Does the patient know their stage ? • Do they know what defines a COPD exacerbation? • Do they know how to handle an exacerbation? • Were they given education how to identify and handle exacerbations?

40. Does the patient know he/she has COPD?

41. Knowledge of PFTs

42. Does the patient know his/her FEV1?

43. Does the patient know what stage of COPD he/she has?

44. Does the patient know what a COPD exacerbation means?Does the patient know how to handle a COPD exacerbation?

45. Was the patient given information about how to identify a COPD exacerbation?

46. Physicians’ Awareness of COPD A national survey among Belgian physicians revealed practice of both GP’s and pulmonologists appeared to deviate substantially from guidelines. Use of systemic corticosteroids in stable COPD was 55% in PCP and 52% in pulmonologists. Similar prospective observational cross-sectional study targeting primary care physicians in the state of Geneva, Switzerland revealed major gaps in the knowledge of all core elements of guideline for the management of COPD . A study in Milan, Italy showed only 43% patient were on recommended treatment of COPD per GOLD guidelines.

47. Physician Questionnaire Number of physicians = 30 Do you know about the GOLD guidelines? Do you recommend the use of inhaled corticosteroids alone? Do you recommend the use of systemic corticosteroids for maintenance therapy? Do you send your patients for pulmonary rehabilitation? Do you have spirometry in your office?

48. Ages: Gender: PHYSICIAN DEMOGRAPHICS Specialty: Years in Practice:

49. Awareness of the GOLD guidelines

50. Physicians who recommend the use of ICS alone