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

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 PeerPoint
  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 Accreditation The PeerPoint 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
  80of 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. 2002121(5
Suppl)121S-126S. Yawn BP, Wollan PC. Int J
Chron Obstruct Pulmon Dis. 20083(2)311-317.
Moore PL. Am J Med. 2007120(8 Suppl 1)S23-S27.
Chavannes N, et al. Respir Med.
200498(11)1124-1130. Han MK, et al. Chest.
2007132(2)403-409. Chapman KR, et al. Eur
Respir J. 200831(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. 200247(10)1184-1199. Barr
RG, et al. Am J Med. 2005118(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. 2008121(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. 2005116(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. 2005118(12)1415.
Schermer TR, et al. Thorax. 200358(10)861-866.
Mortimer KM, et al. Chest. 2003123(6)1899-1907.
Yawn BP, Wollan PC. Int J Chron Obstruct Pulmon
Dis. 20083(2)311-317. Ben SH, et al. Pulm
Pharmacol Ther. 200821(5)767-773.
11
Differentiating Asthma From COPD
12
Differentiating Asthma From COPD
Asthma COPD
A chronic inflammatory disorder of the airways in which specific cells and factors play a role Associated with significant and important comorbid conditions such as rhinitis and sinusitis Inflammation results in Recurrent symptoms Variable airflow obstruction that is mostly reversible Predominate bronchial hyperresponsiveness A preventable and treatable disease Associated with significant extrapulmonary effects and important comorbid conditions Characterized by airflow limitation that is Not fully reversible Usually progressive Associated with an abnormal inflammatory response to noxious particles or gases
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/Gui
delineitem.asp?l12l21intId989. Accessed
December 6, 2010.)
13
Differentiating Asthma From COPD
IL interleukin TNF tumor necrosis
factor. Adapted from Global Initiative for
Chronic Obstructive Lung Disease.
(http//www.goldcopd.org/Guidelineitem.asp?l12l2
1intId989.Accessed December 6, 2010.)
14
Differentiating Asthma From COPD
Asthma COPD
Airflow obstruction Intermittent Chronic
First-line monotherapy Inhaled corticosteroids Long-acting bronchodilators
Inflammatory cells Eosinophils, mast cells, CD4 T lymphocytes Neutrophils, macrophages, CD8 T lymphocytes
Lung pathophysiology Epithelial cell injury,inflammation Parenchymal tissue destruction (emphysema),small airway fibrosis
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/asthgdl
n.pdf. Accessed December 6, 2010.) Global
Initiative for Chronic Obstructive Lung Disease
(available at http//www.goldcopd.org/Guidelineite
m.asp?l12l21intId989. Accessed December 6,
2010).
15
Differentiating Asthma From COPD
Adapted with permission from Barnes PJ. Nature
Rev Immunol. 20088183-192.
16
Inflammation in COPD
Neutrophils
Macrophages
Eosinophils
CD4 cells
CD8 cells
Normal FEV1, FEV1/FVC
FEV1 30 to lt80, FEV1/FVC lt0.70
FEV1 80, FEV1/FVC lt0.70
FEV1 lt30, FEV1/FVC lt0.70
Adapted from Hogg JC et al. N Engl J Med.
20043502645-2653.
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/Gui
delineitem.asp?l12l21intId989. 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/Gui
delineitem.asp?l12l21intId989. 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/Gui
delineitem.asp?l12l21intId989. Accessed
December 6, 2010.)
21
Spirometric Measurements
Global Initiative for Chronic Obstructive Lung
Disease. (available at http//www.goldcopd.org/Gui
delineitem.asp?l12l21intId989. 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/Gui
delineitem.asp?l12l21intId989. 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/Gui
delineitem.asp?l12l21intId989. Accessed
December 6, 2010.)
26
Spirogram Patterns

• Normal
• Obstructive
• Restrictive

Global Initiative for Chronic Obstructive Lung
Disease. (available at http//www.goldcopd.org/Gui
delineitem.asp?l12l21intId989. 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/Gui
delineitem.asp?l12l21intId989. Accessed
December 6, 2010.)
28
Faculty Speaker

• Leonard M. Fromer, MD
• Dr. Fromer has served as a consultant and speaker
  for Bohringer Ingelheim.

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/Gui
delineitem.asp?l12l21intId989. 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.
201016(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?l12l2
1intId989.Accessed December 6, 2010.)
33
Spirometry in Asthma and COPD
Asthma COPD
Necessary to establish a diagnosis Low FEV1 is strongly predictive of risk for exacerbations Important in assessing control Essential for diagnosis Used to determine severity, which islinked to Treatment decisions Prognosis
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.
200110761-67. Global Initiative for Chronic
Obstructive Lung Disease. (available at
http//www.goldcopd.org/Guidelineitem.asp?l12l2
1intId989. 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
Asthma COPD
Elastic recoil Normal Decreased
Diffusion capacity (DLCO) Normal or Increased Decreased
Lung volume Normal Hyperinflation
Bronchodilator response Flow-dominant Volume-dominant
Sciurba FC. Chest. 2004126117S-124S.
36
Hyperinflation is a Hallmark of COPD

• Increases FRC (EELV)
• Decreases IC
• Increases volume at which tidal breathing occurs
• Worsens with exercise and reduces exercise
  tolerance (dynamic hyperinflation)

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. 20043502689-2697.ODonnell DE et al. Am
J Resp Crit Care Med. 2001164770-777. Stubbing
DG et al. J Appl Physiol. 198049511-515.
37
Spirometric Diagnosis of COPD

• COPD is confirmed by postbronchodilator FEV1/FVC
  lt 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/Gui
delineitem.asp?l12l21intId989. Accessed
December 6, 2010.)
38
Staging COPD

• Stage I Mild COPD (FEV1/FVClt0.70 FEV1gt80
  predicted)
• Chronic Cough and sputum production may be
  present
• Stage II Moderate COPD (FEV1/FVClt0.70 FEV1lt80
  predicted)
• Exertional dyspnea, cough/sputum may be present
• Stage III Severe COPD (FEV1/FVC lt0.70 FEV1lt50
  predicted)
• Dyspnea, fatigue, impacts quality of life (QoL)
• Stage IV Very Severe COPD (FEV1/FVClt0.70
  FEV1lt30 predicted or FEV1lt50 with chronic
  respiratory failure)

Global Initiative for Chronic Obstructive Lung
Disease. (available at http//www.goldcopd.org/Gui
delineitem.asp?l12l21intId989. Accessed
December 6, 2010.)
39
Bronchodilator Responsiveness
0.8
0.7
0.6
0.5
Mean ? FEV1 (SE)
0.4
0.3
0.2
0.1
0
105
1855
5
855
Patients With COPD Ipratropium (anticholinergic)
Patients With Asthma Ipratropium (anticholinergic)
Patients With COPD Albuterol (ß2-Agonist)
Patients With Asthma Albuterol (ß2-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. 19914415-420.
40
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. 200831742-750.
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/Gui
delineitem.asp?l12l21intId989. 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/Gui
delineitem.asp?l12l21intId989. 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/Gui
delineitem.asp?l12l21intId989. Accessed
December 6, 2010.)
44
Bronchodilator Reversibility Testing
Bronchodilator Dose FEV1 before and after
Albuterol 200 400 µg via large volume spacer 15 minutes
Terbutaline 500 µg via Turbohaler 15 minutes
Ipratropium 160 µg via spacer 45 minutes

• 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 200526948
• 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/Gui
delineitem.asp?l12l21intId989. 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.
197711645-1648.
48
Stepwise Approach for Managing COPD
Adapted from Global Initiative for Chronic
Obstructive Lung Disease. (available at
http//www.goldcopd.com/Guidelineitem.asp?l12l2
1intId2003.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

51
This PI-CME Activity

• Goals for participants
• Obtain a valuable, unbiased measurement of your
  current standard of care compared to the
  guidelines
• Increase awareness of the need to detect and
  appropriately treat COPD
• Improve comfort levels with managing patients
  with COPD
• Improve compliance with evidence-based guidelines
  (GOLD)

52
This PI-CME Activity

• Metrics to be assessed (based on comparison to
  GOLD guidelines)
• Identification of patient risk factors
• Percentage of patients correctly identified as
  at-riskor COPD
• Identification of patients correctly evaluated
  for COPD
• Percentage of patients correctly given spirometry

53
This PI-CME Activity

• Identification of COPD patients requiring
  treatment
• Percentage of patients advised on lifestyle
  modification
• Patients evaluated for smoking cessation
• Patients evaluated for and advised on
  appropriateexercise regimen

54
This PI-CME Activity

• Identification of patients who are suitable for
  guideline-appropriate pharmacotherapy
• Percentage of patients correctly selected for
  therapy
• Comparison of rationales for therapy
• Implementation of a guideline-approved therapy
  insuitable patients
• Percentage of patients given GOLD orientedCOPD
  therapies

55
This PI-CME Activity

• Structure of this activity
• Stages based on the AMA-approved structure for
  PI-CME
• Stage A Baseline Period
• Stage B Tools Implementation Period
• Stage C Closeout Period
• Complete all three stages in order to receive
  credit
• Practice data collected using 10 de-identified
  patients for Stages A and B (total of 20
  individual patients)

56
This PI-CME Activity

• Patient inclusion criteria for this activity
• All patients gt 35 years with a chief complaint of
  shortness of breath, wheezing or sputum
  production
• No signs/symptoms of respiratory infection
• AND patients with appropriate mental
  capabilities/capacities
• All data collection forms and the clinical
  practice tools will be made available online as
  you reach each relevant stage
• Fax numbers and email information can be found on
  each data collection form and this website
  homepage

57
This PI-CME Activity

• Stage A (Baseline Period)
• Baseline performance measure using data acquired
  from de-identified patients
• Fill out Patient Screening Log Questionnaire for
  10 patients meeting the inclusion criteria using
  a retrospective chart pull
• Fax or email completed questionnaires back to
  PeerPoint
• Get promoted to Stage B

58
This PI-CME Activity

• Stage B (Tools Implementation Period)
• Implement evidence-based tools to improve
  asthma/COPD management and re-measure practice
• Utilize the supplied clinical tools with your
  patients
• Fill out Patient Screening Log Questionnaire for
  10 new patients in the inclusion criteria as they
  come to the office
• Fax or e-mail completed questionnaires back to
  PeerPoint
• Get promoted to Stage C

59
This PI-CME Activity

• Stage C (Closeout Period)
• Complete the activity and receive your credit
• Complete activity evaluation and post-test
• Receive your credit
• Receive a confidential individualized report
  followed by an aggregate report (all
  participants) at activity close

60
Conclusions

• COPD
• Many gaps in diagnosis and management exist
• Spirometry must be done in all patients suspected
  of having COPD and/or asthma
• Utilizing GOLD recommendations may improve the
  prognosis
• Implementation of this Performance Improvement
  initiative is important because
• It will address and improve deficits in the
  diagnosis and management of patients with COPD
• It will help align your practice to current and
  future requirements for all primary care
  providers
• The PI skills you learn in this initiative can be
  translated to
• other aspects of your practice and other disease
  states

61
Thank You.

• PeerPoint Site Coordinator Contact
• Email PIinfo_at_peerpt.com
• Phone [phone]