Clinical and Health Affairs
What Are You Doing for the 76 Patients with COPD in Your Practice?
By Jill Heins Nesvold, M.S., Angie Carlson, Ph.D., Barbara Yawn, M.D., M.Sc., FAAFP, and Ken Joslyn, M.D., M.P.H.
Abstract
Chronic obstructive pulmonary disease (COPD) is the 4th leading cause of death in the United States. To understand the scope of the disease in Minnesota, researchers from the American Lung Association of Minnesota and the Minnesota COPD Coalition conducted an assessment that included a review of mortality data from the Minnesota Department of Health, hospitalization and emergency department visit data from the Minnesota Hospital Association, and administrative data from Medica Health Plans. They also surveyed more than 1,900 patients with COPD about their needs. This paper reviews their findings on the prevalence of the condition and offers suggestions for providing optimal care to patients with this disease.
Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction that is progressive but partially reversible. The airflow limitation is associated with an inflammatory response related to exposure to noxious substances.
Chronic obstructive pulmonary disease is the 4th leading cause of death in the United States. According to the Centers for Disease Control and Prevention (CDC), an estimated 10 million adults in the United States reported physician-diagnosed COPD in 2000.1 That same year, COPD was responsible for 8 million physician office and hospital outpatient visits, 1.5 million emergency department visits, 726,000 hospitalizations, and 119,000 deaths.1 That is only part of the story, as an estimated 24 million people have evidence of impaired lung function, indicating that COPD is underdiagnosed.1
In 2006, researchers from the American Lung Association of Minnesota and the Minnesota COPD Coalition conducted an assessment to determine the scope of COPD in Minnesota and to better direct the American Lung Association’s programming efforts. This project consisted of a review of data on patients with COPD—including Minnesota Department of Health mortality data from 1990 through 2005, Minnesota Hospital Association hospitalization and emergency data from 1996 through 2005, Medica Health Plans administrative data from 2004 for members with COPD (including outpatient visits, pharmacy benefits, and oxygen therapy), and results of a survey about the needs of more than 1,900 patients with COPD. Twelve medical practices were recruited to assist with distributing the survey. Clinic sites were selected based on a convenience sample and included public/academic and private specialty and primary care practices located in the Minneapolis/St. Paul area and greater Minnesota.
COPD Practice Tip
Many patients have chronic obstructive pulmonary disease (COPD) and don’t know it. Although there is no consensus or guideline for assessing at-risk patients, the Global Initiative for Chronic Obstructive Lung Disease has created a short questionnaire to identify people who are more likely to have COPD. If a patient answers yes to 3 or more of the following questions, a physician should consider further assessment for COPD:
1. Do you cough several times most days?
2. Do you bring up phlegm or mucus most days?
3. Do you get out of breath more easily than others your age?
4. Are you older than 40 years?
5. Are you a current or former smoker?
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Data from Medica indicated an annual COPD prevalence rate of 3.8 per 100 continuously enrolled members who were 40 years of age and older. Of the 7,782 members with COPD, 56% were female and 78% were age 60 and older. This prevalence rate was confirmed by the 2005 Behavioral Risk Factor Surveillance Study conducted by the Minnesota Department of Health, which found that 3.4% of people interviewed reported being told by a doctor that they had COPD, emphysema, or chronic bronchitis.2
Until recently, COPD was considered to be a disease that affected men more than women. However, national COPD mortality rates in recent years have been higher for women than for men. In 2000, for the first time, the number of women who died from COPD surpassed the number of men who died from the disease.3 Mortality rates among white men have remained relatively steady since the early 1980s. However, rates have steadily increased among women and African Americans, with the highest increases occurring among white women.3
Caring for Patients with COPD
The majority of Minnesotans with COPD receive their care from primary care providers. Sixty-seven percent of patients with COPD, who were identified through the American Lung Association of Minnesota survey of people with COPD and verified by Medica Health Plans’ administrative data, receive their care from a family or internal medicine physician or a nurse practitioner.4 With the average primary care provider seeing a total of 2,000 patients, we estimate that on average a provider would have 76 patients with COPD in his or her panel.
Chronic obstructive pulmonary disease has traditionally been diagnosed only after patients become significantly symptomatic—in reality, after they’ve had the disease for years. If a physician suspects COPD, a spirometry test can confirm the diagnosis. In 2008, a biannual spirometry test became one of the Healthcare Effectiveness Data and Information Set measures for individuals with COPD. Yet Medica’s data indicated that only 1 out of every 5 patients with claims evidence of COPD had undergone a spirometry test within the past 12 months.
Early diagnosis of COPD is important because it reinforces the need for smoking cessation. Approximately 90% of patients with COPD are former smokers. Smoking cessation is the only therapy known to extend life and slow disease progression, allowing patients to remain in the less-burdensome stages of COPD for longer periods. According to the national guideline Treating Tobacco Use and Dependence: 2008 Update, a physician advising a patient to quit smoking has a strong impact on whether or not they actually attempt to quit.5 Minnesota has a wealth of resources for smoking cessation (see “Resources for Physicians”).
Resources for Physicians
The Minnesota COPD Coalition offers the following resources to help primary care providers identify and manage patients with COPD:
- Training in the use and interpretation of spirometry in primary care;
- Quick-glance guides for physicians on COPD guidelines, spirometry, oxygen therapy, and coding;
- Materials to build awareness of what COPD is, who is at risk for the disease, and how to manage symptoms;
- A two-day course for allied health professionals on working with patients with COPD;
- An outreach course for physicians.
A number of smoking-cessation resources also are available including the American Lung Association’s HelpLine (800-LUNG-USA). For patients who may benefit from rehabilitation, the American Lung Association of Minnesota maintains a list of pulmonary rehab clinics in the state on its website, www.alamn.org/copd.
For more information about COPD or any of these resources, contact Jill Heins Nesvold, M.S., director of respiratory health, American Lung Association of Minnesota at jill.heins@alamn.org or 651/227-8014.
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Physicians do not seem to be aware of the effectiveness of therapies for managing COPD. In a survey of primary care providers, Yawn and Wollan found that only 15% believed COPD treatment was useful or very useful for improving symptoms.6 These results suggest a need for education about the tools available to diagnose and manage COPD. Pharmacotherapy can prevent exacerbations, provide relief of symptoms, and improve quality of life for patients.7 The 3 main classes of drugs used to treat COPD are bronchodilators, methylxanthines, and inhaled corticosteroids. Among the 7,782 people identified with COPD in Medica’s database, bronchodilator (ie, albuterol) use was reported for 38%, combination therapies (ie, both beta-agonist plus anticholinergic and beta-agonist plus inhaled steroids) for 36%, oral steroids (ie, prednisone) for 29%, anticholinergic agents (ie, ipitrompium) for 14%, inhaled corticosteroids (ie, fluticisone and budesonide) for 13%, theophylline for 2%, and Cromolyn and nedocromil for 0.1%. Thirty-eight percent had no pharmacy claims for COPD-related drug therapy.
Respondents to the American Lung Association of Minnesota survey confirmed that bronchodilators are the most-used medication for COPD, with 52% indicting they use them.4 Combination medications were used by 47% of respondents, inhaled steroids by 30%, anticholinergic agents by 27%, and oral prednisone by 12%.
Pulmonary rehabilitation, which includes aerobic exercise and nutritional and psychosocial counseling, has been shown to reduce hospital stays related to respiratory diseases and improve patients’ quality of life.8 However, of the Minnesotans with COPD who completed the American Lung Association of Minnesota survey, 66% reported that they had never heard of or been offered pulmonary rehabilitation.
Conclusion
Primary care providers need to be more vigilant about identifying patients with breathing problems and diagnosing COPD earlier. By doing so, they can encourage their patients who smoke to quit and thus slow the progression of the disease. They also can offer treatment to reduce exacerbations, improve symptoms, and increase patients’ quality of life. MM
Jill Heins Nesvold is director of respiratory health for the American Lung Association of Minnesota. Angie Carlson is a health research scientist with Data Intelligence. Barbara Yawn is family physician and researcher with Olmsted Medical Center. Ken Joslyn is medical director for Medica Health Plans.
References
1. Carlson ML, Ivnik MA, Dierkhising RA, O’Byrne MM, Vickers KS. A learning needs assessment of patients with COPD. Medsurg Nurs. 2006;15(4):204-12.
2. Minnesota Department of Health. 2005 Behavioral Risk Factor Surveillance System data.
3. Mannino D, Homa D, Akinbami L, Ford E, Redd S. Chronic Obstructive Pulmonary Disease Surveillance 1971-2000. MMWR Morb Mortal Wkly Rep. 2002;51
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4. American Lung Association of Minnesota. 2006 Lung Health Questionnaire. Unpublished data.
5. Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May.
6. Yawn BP, Wollan PC. Knowledge and attitudes of family physicians coming to COPD continuing medical education. Int J Chron Obstruct Pulmon Dis. 2008:3(2);311-7.
7. Lindberg A, Eriksson B, Larsson LG, et al. Seven-year cumulative incidence of COPD in an age-stratified general population sample. Chest. 2006;129:879-85.
8. Pierson DJ. Translating new understanding into better care for the patient with chronic obstructive pulmonary disease. Respir Care. 2004:49(1):99-109.