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

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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

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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.
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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 gt 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

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Cost of COPD care

• In the US in 2000
• 8 million office visits
• 1.5 million emergency room visits
• gt 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

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Pathophysiology of COPD

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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
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Spirometry
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Additional Investigations
Chest X-ray
Arterial Blood gases
Alpha-1 antitrypsin deficiency screening
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Stages of COPD based on Spirometry
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Pharmacological Agents in Management of
COPD Bronchodilator Therapy
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Classification
Duration of action
Mechanism of action
Short acting
Beta agonist
Muscarinic antagonist
Long acting
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Monotherapy
Long acting Beta agonist
Muscarinic antagonist
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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
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Other Pharmacological Treatments
Vaccinations
Alpha-1 antitrypsin augmentation therapy
Systemic Steroids
Methyxanthines
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Non-Pharmacological Treatment
Smoking cessation
Pulmonary Rehabilitation

Exercise training
Nutritional counseling
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Non-Pharmacological Treatment
Oxygen Therapy
Surgery
Lung volume reduction surgery
Bullectomy
Lung Transplantation
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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

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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

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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

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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

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Study ObservationsMale vs. Female
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Percentage of patients under the care of a
pulmonologist
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Percentage of patients who have had PFTs
36
36
PFT
64
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Patients fulfilling the criteria for Alpha 1
Antitrypsin deficiency screening
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Percentage of patients screened for alpha-1
antitrypsin deficiency
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Patient classification according to COPD stage
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Pharmacological treatment regimen in patients
with Stage 1 COPD FEV gt 80 predicted
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Percentage of patients with mild COPD on ICS
35.71
64.28
Duration since the last PFT was on an average 3.3
yrs
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Pharmacologic Treatment Regimen in Stage 2
(Moderate COPD)FEV1 gt 50 to 79 of predicted
value
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Pharmacologic Treatment Regimen in Stage 3
(Severe COPD)FEV1 30 to 49 of predicted value
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Pharmacologic Treatment Regimen in Stage 4 (Very
Severe COPD)FEV1 gt 30 or gt 50 with Chronic
Respiratory Failure
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Patients with inappropriate treatment regimen
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Patients with inappropriate treatment under the
care of a pulmonologist
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Pulmonary Rehabilitation
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Percentage of patients who underwent smoking
cessation counseling
37
Patients who were vaccinated
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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 (lt 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

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Patient Questionnaire

• 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?

Total number of patients 30
20 patients were contacted via telephone. 10
patients were interviewed directly.
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Does the patient know he/she has COPD?
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Knowledge of PFTs
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Does the patient know his/her FEV1?
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Does the patient know what stage of COPD he/she
has?
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Does the patient know what a COPD exacerbation
means?Does the patient know how to handle a
COPD exacerbation?
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Was the patient given information about how to
identify a COPD exacerbation?
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Physicians Awareness of COPD
A national survey among Belgian physicians
revealed practice of both GPs 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.
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Physician Questionnaire

• 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?

Number of physicians 30
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Ages
Gender
PHYSICIAN DEMOGRAPHICS
Specialty
Years in Practice
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Awareness of the GOLD guidelines
50
Physicians who recommend the use of ICS alone
51
Physicians who recommend the use of systemic
corticosteroids
52
Physicians who use office spirometry
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Recommendations

• Need more CME programs to enhance physician
  knowledge about the GOLD guidelines and
  management of COPD.
• Need patient education programs to improve
  patient knowledge of COPD.
• Need to encourage the use of spirometry in the
  primary care setting.

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Study Limitations

• Larger studies needed to determine actual
  physician compliance with GOLD guidelines.
• The number of patients interviewed was low.
• The number of physicians interviewed was low.

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References

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Thank you!