Care of Underserved Patient with COPD 03/01/2018 Neeta Thakur MD - - PowerPoint PPT Presentation

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Care of Underserved Patient with COPD 03/01/2018 Neeta Thakur MD - - PowerPoint PPT Presentation

Oct 17, 2023 46 likes •187 views

3/2/2018 Disclosures Neeta Thakur, MD MPH Spouse is employee at Roche/Genentech Care of Underserved Patient with COPD 03/01/2018 Neeta Thakur MD MPH Neeta.Thakur@ucsf.edu Learning Objectives 14 times To review the burden of COPD

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3/2/2018 1

Neeta Thakur MD MPH Neeta.Thakur@ucsf.edu

Care of Underserved Patient with COPD 03/01/2018 Disclosures

  • Neeta Thakur, MD MPH
  • Spouse is employee at Roche/Genentech

Learning Objectives

  • To review the burden of COPD
  • To review the updates in COPD guidelines using a case-base approach
  • Screening
  • Categorizing
  • Treatment
  • To learn the evidence for and options for implementing adjunct therapies for patients with COPD from

vulnerable populations

  • Education
  • Exercise
  • Emerging Threats COPD and Climate Change
  • Hot Days
  • Trigger exposure
  • Air Pollution

14 times more likely to have poor respiratory health

High SES Low SES

Schraufnagel AJRCCM 2013

In the U.S., people of low SES represent 20%

  • f the population, but

make up 2/3 of the population with COPD

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SLIDE 2

3/2/2018 2 Exposures over the life course lead to COPD in adulthood and worsen disease

Risk Factors for COPD

Environmental

  • TOBACCO TOBACCO

TOBBACO

  • Cigarette, pipe, cigar, secondhand

tobacco exposure

  • Biomass fuel cooking
  • SES
  • Occupational dusts and

fumes

  • Previous hx of TB

Host Factors

  • Alpha-1 antitrypsin

deficiency (young age, smoking hx not congruent with symptoms, degree of

  • bstruction)
  • HIV – accelerated decline
  • Long-standing asthma

Methods for addressing Disparity

  • Improve Case Detection
  • Improve access to evidence-based care and management
  • Increase smoking cessation efforts, decrease exposure to

bio-mass fuel and occupational exposure

High SES Low SES

Case 1

  • A 58 yo M presents with 9 months progressive SOB and fatigue
  • Reports cough productive of thick white sputum every morning

Tobacco Hx

  • 30 pack-yr,
  • Current ¼ ppd smoker

ROS

  • Denies chest pain, weight loss, F/C/NS
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3/2/2018 3

When to Consider COPD

goldcopd.org2017, Hill CMAJ 2010

Patients >40 years + 20 pack-year history of smoking, visiting a primary care physician for any reason (n=1003) Screening for COPD Previous diagnosis of COPD (n=67; 32.7%) Patients meeting criteria for COPD (n=208; 20.7%) Dx of COPD, No evidence of

  • bstruction (n=43; 5.6%)

No previous diagnosis of COPD (n=141; 67.3%)

Overall Prevalence

  • Age > 40 yo
  • SYMPTOMATIC: Dyspnea worse with exercise, chronic

cough, chronic sputum production

  • CASE FINDING: History of exposure to known risk

factors

goldcopd.org2017, Hill CMAJ 2010, Martinez JAMA 2016

Does everyone need to be screened?

When to Consider COPD

NO

When should we screen?

Next diagnostic steps could include

  • CXR – for alternative diagnoses
  • Chest CT – another method for alternative diagnoses
  • Full PFTs – not essential for management but can further characterize severity
  • Spirometry with bronchodilator reversibility testing – essential for management

Post-bronchodilator FEV1/FVC < 0.70 confirms presence of persistent airflow limitation

goldcopd.org, 2017

Classification of severity of airflow limitation in COPD

goldcopd.org, 2017

Based on post-bronchodilator FEV1 In patients with FEV1/FVC < 0.70 GOLD 1: Mild FEV 1 ≥ 80% GOLD 2: Moderate 50% ≤ FEV1 < 80% GOLD 3: Severe 30% ≤ FEV1 < 50% GOLD 4: Very severe FEV1 < 30%

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3/2/2018 4

Case 1, revisited

  • A 55 yo M presents with 9 months progressive SOB
  • Also c/o cough productive of thick white sputum QAM
  • 30 pk yr smoking history, current ¼ ppd smoker
  • Denies chest pain, weight loss, F/C/NS

But what if he does not meet spirometric criteria for COPD? What should we make of his symptoms? COPD Assessment Test (CAT)

Woodruff NEJM 2016

50 vs 65%

Symptoms (CAT≥10) are common in smokers with preserved pulmonary function

NON- smokers Current/ Former Smokers NO COPD Current/ Former Smokers Mild/Mod COPD

Medication use

Symptomatic ever-smokers with preserved spirometry

  • 42% used bronchodilators
  • 23% used inhaled glucocorticoids

…They are currently using a range of respiratory medications without any evidence base.

Woodruff NEJM 2016

Target Smoking Cessation

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3/2/2018 5

Case 2

  • 64 yo W 40 pk-yr smoker with COPD, quit 2 yrs ago
  • c/o cough, chest tightness, fatigue, and DOE
  • Exercise tolerance of 2 blocks
  • ED visits x 2 in the past 6 months for COPD flares
  • HTN, hyperlipidemia, CAD
  • CXR w/large lung volumes and flattened diaphragms
  • Post-bronchodilator FEV1 0.81 (27%)
  • ratio 0.29

Combined COPD assessment

Spirometric Grade

  • Airflow limitation using

GOLD classification (post-FEV1)

  • Population-level
  • utcomes
  • Useful for prognosis

Symptoms & Future risk

  • Modified British Medical

Research Council (mMRC) Dyspnea Scale

  • COPD Assessment Test

(CAT)

  • Exacerbations in the

previous 12 months

  • Guide treatment

Goldcopd.org2017

Classification of severity of airflow limitation in COPD

Based on post-bronchodilator FEV1 In patients with FEV1/FVC < 0.70 GOLD 1: Mild FEV 1 ≥ 80% GOLD 2: Moderate 50% ≤ FEV1 < 80% GOLD 3: Severe 30% ≤ FEV1 < 50% GOLD 4: Very severe FEV1 < 30%

goldcopd.org, 2014

Goldcopd.org 2017

mMRC Dyspnea Scale

Grade Intensity or amount of activity that provokes SOB

Strenuous physical activity

1

Hurrying on the level or walking up slight incline

2

Walking at own pace on the level

3

Walking a few minutes on the level

4

Unable to leave the house or getting dressed/undressed

Stenton C Occup Med (Lond) 2008;58:226-227

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3/2/2018 6

Symptoms: COPD Assessment Test

Modified from 2009 GlaxoSmithKline

Never Cough always No phlegm (mucus) Full of phlegm (mucus) No chest tightness Very tight chest No SOB up a hill or 1 flight of stairs Very SOB up a hill or 1 flight of stairs Not limited doing any activities at home Very limited doing activities at home Confident leaving home Not confident leaving home Sleep soundly Do not sleep soundly Lots of energy No energy at all 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Assess Risk for Exacerbations

  • Past events treated with oral steroids predicts future

risk

  • HIGH risk based on frequency and severity

≥ 2 per year ≥ 1 hospitalization

Goldcopd.org 2017

Korpershoek International Journal of COPD 2017

Future risk (exacerbations) Symptoms (mMRC, CAT)

GOLD: “Combined assessment”

Hosp ≥ 1/yr Exac ≥ 2/yr Exac/yr ≤ 1 No hosp Hosp ≥ 1/yr Exac ≥ 2/yr Exac/yr ≤ 1 No hosp mMRC 0-1 CAT <10 mMRC 0-1 CAT <10 mMRC ≥2 CAT ≥10 mMRC ≥2 CAT ≥10

Goldcopd.org 2017

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3/2/2018 7

Future risk (exacerbations) Symptoms (mMRC, CAT)

GOLD: “Combined assessment”

Hosp ≥ 1/yr Exac ≥ 2/yr Exac/yr ≤ 1 No hosp Hosp ≥ 1/yr Exac ≥ 2/yr Exac/yr ≤ 1 No hosp mMRC 0-1 CAT <10 mMRC 0-1 CAT <10 mMRC ≥2 CAT ≥10 mMRC ≥2 CAT ≥10

Goldcopd.org 2017

Adherence / Technique 6 Minute Walk

Case 2

  • 64 yo W 40 pk-yr smoker with COPD, quit 2 yrs ago
  • c/o cough, chest tightness, fatigue, and DOE (CAT > 10)
  • Exercise tolerance of 2 blocks (mMRC ≥ 2)
  • ED visits x 2 in the past 6 months for COPD flares (≥ 2)
  • HTN, hyperlipidemia, CAD
  • CXR w/large lung volumes and flattened diaphragms
  • Post-bronchodilator FEV1 0.81 (27%) (< 30%)
  • ratio 0.29

GOLD: “Combined assessment”

Goldcopd.org 2017

Future risk (exacerbations) Symptoms (mMRC, CAT) Hosp ≥ 1/yr Exac ≥ 2/yr Exac/yr ≤ 1 No hosp Hosp ≥ 1/yr Exac ≥ 2/yr Exac/yr ≤ 1 No hosp mMRC 0-1 CAT <10 mMRC 0-1 CAT <10 mMRC ≥2 CAT ≥10 mMRC ≥2 CAT ≥10

Grade 4 Class D

Patient Group A, B, C, D : Tobacco cessaon, ↓ of risk factors, physical acvity, Flu & Pneumococcal vaccines Patient Groups B, C, D : Referral to pulmonary rehabilitation, Better Breather Courses Patient Groups C, D : Home oxygen if SpO2 ≤ 88%RA

Management of Stable COPD

D ↑ sx/High risk C ↓ sx/High risk B ↑ sx/Low risk A ↓ sx/Low risk

LAAC or LABA

Alternate choice: LAAC & LABA

ICS + LABA or LAAC

Alternate choices: LAAC & LABA

  • r

LAAC & PDE-4 inhibitor

  • r

LABA & PDE-4 inhibitor

ICS + LABA and/or LAAC

Alternate choices: LAAC & LABA

  • r

LAAC & PDE-4 inhibitor

  • r

ICS + LABA & PDE-4 inhibitor

goldcopd.org, 2017

Albuterol PRN or Ipratropium PRN

Alternate choice: Combivent PRN

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3/2/2018 8

Case 2

64 yo woman 40 pack-year smoker Quit 2 years ago Do you screen for lung cancer?

National Lung Screening Trial

N Engl J Med. 2011; 365: 395-409.

53,454 randomized to annual CXR vs. CT scans

National Lung Screening Trial (NLST) Inclusion:

  • Age 55 - 74 years
  • History of cigarette

smoking > 30 pack yrs

  • If former smokers,

quit within 15 years

N Engl J Med. 2011; 365: 395-409.

Exclusions

  • Prior diagnosis of lung cancer
  • Chest CT within 18 months
  • Hemoptysis
  • Unexplained weight loss

USPSTF

  • STOP once a person has not smoked

for 15 years

  • Health problem (functional status)

that substantially limits life expectancy

  • r the ability or willingness to have

curative lung surgery

N Engl J Med. 2011; 365: 395-409.

Overall 39% with positive results 96% were FALSE positive

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3/2/2018 9

N Engl J Med. 2011; 365: 395-409.

Increased detection of lung cancer

  • 20% Relative Reduction

in Lung Ca mortality

  • 6% Reduction in all cause

mortality

  • ARR = 0.46%
  • NNS = 217

N Engl J Med. 2011; 365: 395-409.

USPSTF Grade B recommendation

What happens with Screening?

  • False-positive results: benign

nodules

  • Futile detection of small

aggressive tumors or indolent disease

  • Complications from diagnostic

work-up

  • Anxiety of test findings
  • Radiation exposure
  • Cost
  • 39% CTs “positive” (Nodules

≥4 mm)

  • Additional evaluation
  • 80% imaging
  • 4% Bronchoscopy
  • 4% Surgery
  • 2% CT guided biopsy

What are the Risks?

N Engl J Med. 2011; 365: 395-409.

up to 3% malignant

What’s the cost-benefit for our population?

Am Health & Drug Benefit 2014; 7(5): 272-282

  • 2012-2014 CMS (MEDICARE) beneficiary data
  • 50% uptake of screening
  • Age 55-80, >30pk yr, quit<15yrs
  • 4.9 million beneficiaries met criteria for screening in 2014 (10% of

beneficiaries)

  • Cost of Screening
  • NLST
  • I-ELCAP
  • Smoking Cessation counseling
  • Current average life expectancy of 3 years  INCREASE by 4years
  • Cost of Treatment
  • 2014 data on cost by Cancer

State

$241/screen OR 19,000K for each year saved

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3/2/2018 10

Is it Covered?

Medicare Part B covers a lung cancer screening with Low Dose Computed Tomography (LDCT) once per year Who's eligible? People with Part B who meet all of these conditions:

  • Age 55-77
  • Asymptomatic
  • Current smoker or quit smoking within the last 15 years
  • 30 pack years history

https://www.medicare.gov/coverage/lung-cancer-screening.html

http://www.lung.org/assets/documents/lung-cancer/interactive- library/lung-cancer-insurance-chart.pdf

Case 2, revisited

64 yo woman 40 pack-year smoker Quit 2 years ago

  • c/o cough, chest tightness, fatigue, and DOE
  • Exercise tolerance now of < ½ block

What else can we do?

Multidisciplinary Approaches for better care

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3/2/2018 11

Who is part of the health care team for COPD?

  • Primary Care Provider
  • Lung/COPD Specialist
  • Nursing
  • Respiratory Therapist
  • Physical Therapist
  • Social Work / Case Management

Patient Education

  • <10 % of patients have perfect use of inhalers
  • Even with proper training, this wanes with time
  • GOLD 2017 guideline recommends regular teaching
  • Evidence for Patient Education

Solution

  • For all patients: Better Breathers
  • www.lung.org for classes in your area

Better Breathers

  • Goal: Improve self-management through

education for patients and caregivers.

  • American Lung Association

http://www.lung.org/support-and-community/better- breathers-club/

For patients that qualify: Pulmonary Rehabilitation

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3/2/2018 12

Pulmonary Rehabilitation

0% 9% 31%

goldcopd.org, 2014, Waschki CHEST 2011

The survivors walked about 1,600 steps more each day than the non-survivors

Inactivity predicts mortality in COPD

Pulmonary Rehabilitation

  • COPD patients benefit from exercise

training

  • Improves exercise tolerance, QOL and

symptoms of dyspnea and fatigue

  • 6 weeks is effective, but the longer the

program continues, the more effective the results

  • If exercise training is maintained at

home, the patient’s health status remains above pre-rehabilitation levels

goldcopd.org, 2014, Waschki CHEST 2011

Pulmonary Rehabilitation

HEALTH SYSTEM BARRIERS:

  • Our patient’s frequently do not qualify

for Pulmonary Rehabilitation.

  • Inadequate insurance
  • Lifetime max of 2 sessions for Medicare

patients

COMMUNITY BARRIERS:

Our patient’s frequently lack access to community exercise opportunities due to disease specific restrictions.

Waschki et al, 2011 Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study.

What are my options?

  • Medicare A&B 
  • Pays for rehab (up to 16 weeks in lifetime)
  • Look for alternatives
  • YMCA
  • Walking groups
  • PBS sit and be fit (am show)
  • Encourage step goals using free mobile apps
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3/2/2018 13

Emerging Threat

Climate Change

1870

288 ppm

1960

316 ppm

2016

404 ppm

Atmospheric CO2 Departures

Emerging Threat – Climate Change

  • What is it?
  • Shifts in the global and local

temperature and weather patterns

  • Greenhouse gases (mostly CO2) are

responsible for much of this shift in the last century

  • Traps heat at the Earth’s surface
  • Melting of artic sea and land ice
  • Removal of moisture from Earth to air

1870

288 ppm

1960

316 ppm

2016

404 ppm

Atmospheric CO2 Departures

NOAA, National Geographics,

Emerging Threat – Climate Change

  • Natural Disasters

Bombcyclone Boston Skirball Fire L.A. Harvey Houston Maria Puerto Rico

Emerging Threat – Climate Change

  • Natural Disasters
  • Extreme Heat
  • In San Francisco
  • 1961 – 1980: 4 extreme heat days per year

(>85◦ F)

  • 1981– 2010: 1 recorded day >90◦ F
  • 2017: 14 extreme heat days (>85◦ F) and 5

recorded days >90◦ F ***Record Breaking 106 degrees on September 1, 2017

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3/2/2018 14

Emerging Threat – Climate Change

  • Why we care?
  • Vulnerable populations are at highest risk
  • Housing
  • Poor air quality
  • Ozone
  • Fires
  • Boosted aeroallergen production
  • Prolong pollen season from warmer

weather and CO2

  • Access to clean water
  • Drought in California
  • Flooding in PR
  • What to do, how to prepare patients?

How to prepare our patients

  • Extreme Heat Days
  • Set a plan with patients
  • Cool refuge (libraries, malls, community centers)
  • Fans not as effective if temps >90◦ F
  • Stay hydrated (avoid alcohol)
  • Azdhs.gov - Heat Safety - Older Adult Toolkit
  • Fires/Air pollution/Aeroallergens
  • HEPA filters
  • Keep windows closed
  • Watch for mold growth
  • N-95 mask (not the best option)
  • Stay Indoors

Summary

  • Who to Screen?
  • Symptomatic adults (>40yrs) with risk factors
  • Spirometry
  • How to Categorize?
  • Spirometry
  • Exacerbations
  • Symptoms
  • What are Management options?
  • Know the care team
  • Education
  • Exercise

Questions?

References

  • GOLDcopd.org
  • Hill et al. Prevalence and underdiagnosis of chronic obstructive pulmonary

disease among patients at risk in primary care. CMAJ. 2010; 182 (7): 673-78.

  • Martinez et al. Screening, Case-Finding, and Outcomes for Adults With

Unrecognized COPD. JAMA. 2016; 315 (13): 1343-44.

  • Woodruff. Clinical Significance of Symptoms in Smokers with Preserved

Pulmonary Function. NEJM. 2016; 374: 1811-21.

  • The National Lung Screening Trial Research Team. Reduced Lung-Cancer Mortality

with Low-Dose Computed Tomographic Screening. NEJM. 2011; 365: 395-409

  • http://www.lung.org/assets/documents/lung-cancer/interactive-library/lung-

cancer-insurance-chart.pdf

  • http://www.lung.org/support-and-community/better-breathers-club/
  • Waschki et al. Physical activity is the strongest predictor of all-cause mortality in

patients with COPD: a prospective cohort study. CHEST. 2011; 140 (2): 331-42.