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

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Active Detection of Chronic Obstructive Pulmonary Disease and Asthma in the General Population Vol 158. pp 1730 1738, 1998. Center of disease control and prevention. – PowerPoint PPT presentation

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


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 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

4
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

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
11
(No Transcript)
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
Lung volume reduction surgery
Bullectomy
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 gt 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 gt 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 gt 30 or gt 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 (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

39
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.
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 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.
47
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
48
Ages
Gender
PHYSICIAN DEMOGRAPHICS
Specialty
Years in Practice
49
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
53
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.

54
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.

55
References
  • National Heart, Lung, and Blood Institute. Data
    Fact Sheet Chronic Obstructive Pulmonary
    Disease. Bethesda, MD National Institutes of
    Health 2003 Accessedwww.nhlbi.nih.gov/health/publ
    ic/lung/other/copd_fact.pdf on 15 March 2007. NIH
    publication no. 03-5229.
  • Active Detection of Chronic Obstructive Pulmonary
    Disease and Asthma in the General Population Vol
    158. pp 17301738, 1998.
  • Center of disease control and prevention.
    Surveillance summaries MMWR 200251
  • Alternative projections of mortality and
    disability by cause 1990-2020 Global Burden of
    Disease Study. Lancet 1997 May 24 Vol. 349
  • National Heart Lung Blood Institute Factbook
    FY-2006. Bethesda,MD National Institutes of
    Health/National Heart, Lung, and Blood Institute
    2007
  • Primary care diagnosis of alpha-1 antitrypsin
    deficiency issues and opportunities. Cleve Clin
    J Med. 2007 Dec74(12)869-74
  • American Lung Association Epidemiology and
    Statistics Unit, Research and Program Services.
    Trends in chronic bronchitis and
    emphysemamorbidity and mortality Internet. New
    York American Lung Association www.lungusa.org
    (click on Research tab, then Data Statistics
    tab).
  • Impact of patient characteristics, education and
    knowledge on emergency room visits in patients
    with asthma and COPD a descriptive and
    correlative study
  • Knowledge of Guidelines for the management of
    COPD Survey of primary care physicians. Olivier
    T.Rutschmann, Jean-Paul Janssens, Bernard
    Vermeulen and Francois P . Sarasin. Respiratory
    medicine 2004 98 932- 937
  • Global Strategy for the diagnosis, Management and
    prevention of Chronic Obstructive Pulmonary
    Disease Updated 2008.
  • Barnes PJ. The pharmacological properties of
    tiotropium. Chest 2000 117 63S-6S.
  • Hanania NA, Kalberg C, Yates J et al. The
    bronchodilator response to salmeterol is
    maintained with regular, long-term use in
    patients with COPD. Pulm Pharmacol Ther 2005 18
    19-22.
  • Cazzola M, Di Marco F, Santus P et al. The
    pharmacodynamic effects of single inhaled doses
    of formoterol, tiotropium and their combination
    in patients with COPD. Pulm Pharmacol Ther 2004
    17 35-9.
  • Choi J, Na J, Kim Y. The effect of tiotropium and
    inhaled corticosteroid combination therapy in
    chronic obstructive pulmonary disease (COPD) and
    chronic obstructive bronchial asthma (COBA)
    associated with irreversible pulmonary function.
    Am J Respir Crit Care Med 2007 175 A130.
  • Calverley PM, Pauwels R, Vestbo J et al. Combined
    salmeterol and fluticasone in the treatment of
    chronic obstructive pulmonary disease a
    randomised controlled trial. Lancet 2003 361
    449-56
  • Singh D, Brooks J, Hagan G et al. Superiority of
    "triple" therapy with salmeterol/fluticasone
    propionate and tiotropium bromide versus
    individual components in moderate to severe COPD.
    Thorax 2008 63 592-8.
  • ClinicalTrials.gov Identifier NCT00496470
    http//clinicaltrials.gov/ct2/show/NCT00496470).

56
Thank you!
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