Transcript Diapositiva 1 - CHEST Delegation

ACCP Italian Delegate Meeting
COPD Early Diagnosis, Early Treatment
Using the Best First
EARLY Diagnosis of COPD.
The COPD Alliance Model
CLAUDIO MICHELETTO, MD, FCCP
RESPIRATORY MEDICINE
Mater Salutis Hospital – Legnago - VR
Conflict of interest disclosure
I have no, real or perceived, conflict of interest
that relate to this presentation
Lifetime risk of COPD with highly sensitive
and highly specific case definition
13 022 536 individuals
lived in Ontario at the time
of the study
Lifetime risk of physiciansdiagnosed COPD was
27.6 %
Gershon AS, Lancet 2011
Gershon AS, Lancet 2011
Soriano JB, Zielinski J, Price D. Lancet 2009; 374: 721-32
Underdiagnosis of COPD
Criteria of COPD
Diagnosed (%)
• NHANES III, USA
BTS
37
• IBERPOC, Spain
ERS
22
CNSLD
35
BTS
31
clinical
25
• DIMCA, Netherlands
• OLIN, Sweden
• An European
assumption
Though being symptomatic, only a half of the subjects with severe COPD
are properly labelled;
COPD is usually NOT DIAGNOSED until it is clinically apparent and
already advanced.
Lindberg A, et al. Resp Med 2005; 100: 264-72
Trends in Age-Standardized Death Rates for the 6 Leading Causes of Death in the United
States, 1970-2002 Rates are age-adjusted to the 2000 US standard population.
Jemal, A. et al. JAMA 2005;294:1255-1259
Prevalence and underdiagnosis of chronic obstructive
pulmonary disease among patients at risk in primary care
Hill K, Goldstein RS, Guyatt GH et al. Can Med Ass J 2010; 182 (7), 673-678
We suoght to measure the prevalence of spirometrically
confirmed COPD in an at-risk population of adults
aged 40 years or more with a smoking history of at
least 20 pack-years who visited a primary care
practioner for any reason and to describe their
characteristics.
Of the 1003 participants who completed spirometry:
• 208 met the spirometric criteria for COPD
• prevalence of 20.7 %
•67 (32.7 %) reported having received a prior
diagnosis of COPD
Recruitment and flow of participants
Hill K et al. CMAJ 2010;182:673-678
Prevalence and underdiagnosis of chronic obstructive
pulmonary disease among patients at risk in primary care
Hill K, Goldstein RS, Guyatt GH et al. Can Med Ass J 2010; 182 (7), 673-678
Among adult patients visiting a primary care practitioner,
as many as one in five with known risk factors met
spirometric criteria for COPD.
Although more than three-quarters of the patients with
COPD reported at least one respiratory symptom,
two-thirds were unaware of their diagnosis.
These findings suggest that adults who attend a primary
care practice with known risk factors for COPD are
important targets for screening and early intervention.
Confronting COPD. Italian data
Diagnosis of COPD or chronic bronchitis
• 60% of patients usually visited their GP for COPD
(an average of 3 visits/patient) in the last 12 months;
• > 40% of patients were under the care of a specialist
(an average of 1.2 visits/patient) in the same period;
• 19% of total visits were unscheduled;
• 11% of patients were hospitalized during the last 12 months
(n=130 hospitalizations, such as  3 episodes/patient);
•
6% visited the ER;
Dal Negro R. et al. Resp Med 2003; 97 :S43-50
• 35% of patients were currently receiving prescription
medications, namely ICS; theophylline, short-acting
beta-2 agonists;
• 50% of patients received antibiotics (up to 20
courses) in the last 12 months;
• most of treatments were unrespective of int. guidelines
Dal Negro R, et al. Resp Med 2003; 97 :S43-50
Dal Negro R, et al. Respir Med 2003
COPD management in primary care,
what are the challenges ?
• Prevention
• Earlier and more accurate diagnosis
• More accurate assessment and phenotyping
• Appropriate therapeutic intervention
• Early improved pathways of care
Screening
Case-Finding
A “man on the street”
Patient being seen by a physician
May not have symptoms
Has respiratory symptoms
May be a cigarette smoker
Has COPD risk factors
No cost and no reimbursement
Medicare will pay $ 20 fo the test
Enright P, Kaminsky D. Resp Care 2003; 48 (12): 1194-1201
Criteria for early detection of disease
1.
The disease would progress and cause substantial
morbidity or mortality
2.
Treatment is available and is more effective when used
at the early stage
3.
There is a feasible, affordable, safe, and relatively
simple testing method that is accurate enough to avoid
producing large number of false-positive or falsenegative results
4.
There is an action plan that minimizes adverse effects
Marshall KG. CMAJ 1996; 154 (10): 1493-1499
Criteria for early detection of disease
1.
The disease would progress and cause substantial
morbidity or mortality
2.
Treatment is available and is more effective when used
at the early stage
3.
There is a feasible, affordable, safe, and relatively
simple testing method that is accurate enough to
avoid producing large number of false-positive or
false-negative results
4.
There is an action plan that minimizes adverse effects
Marshall KG. CMAJ 1996; 154 (10): 1493-1499
spirometry is a:
• reliable
• simple
• non-invasive
• safe
• non-expensive procedure
for detection of airflow obstruction
Soriano JB, Zielinski J, Price D. Lancet 2009; 374: 721-32
Diagnose COPD: assessment of
severity
• Assess severity of airflow obstruction using reduction in FEV1
NICE
clinical
guideline
12 (2004)
ATS/ERS
2004
GOLD 2008
NICE clinical
guideline 101
(2010)
Postbronchodilator
FEV1/FVC
FEV1 %
predicted
Postbronchodilator
Postbronchodilator
Postbronchodilator
< 0.7
80%
Mild
Stage 1 (mild)
Stage 1 (mild)*
< 0.7
50–79%
Mild
Moderate
Stage 2
(moderate)
Stage 2
(moderate)
< 0.7
30–49%
Moderate
Severe
Stage 3
(severe)
Stage 3
(severe)
< 0.7
< 30%
Severe
Very severe
Stage 4 (very
severe)**
Stage 4 (very
severe)**
* Symptoms should be present to diagnose COPD in people with mild airflow obstruction
** Or FEV1 < 50% with respiratory failure
[new 2010]
Shortcomings of FEV1/FVC in
defining airflow obstruction
FEV1/FVC, %
80
75
70
GOLD
False negative
False positive
65
LLN (NHANES)
60
25
50
Age (yr)
75
Enright & Kaminsky, Respir Care 2003
24.2 %
15.3 %
Lamprecht B, et al. Pulm Med 2011; 1, 1-6
Lamprecht B, et al. Pulm Med 2011; 1, 1-6
Distribution of overdiagnosed and severity levels of COPD
according to sex and age group.
The overdiagnosis of COPD
affected 4.6 % of subjects aged
40 to 80 years
García-Rio F et al. Chest 2011;139:1072-1080
Ways to reduce spurious prevalence of
COPD using GOLD criteria
1.Only testing people with a high pre-test probability of
COPD (clinical diagnosis, smoking history)
2.Confirming that airway obstruction persists after inhaling
a bronchodilator (post-BD FEV1)
3.Requiring that the FEV1 be <80% of predicted (i.e.,
GOLD II or more)
Barriers to performing spirometry in a community setting:
• Lack of access to calibrated
spirometers
• Inadequate training in performing
spirometry
• Lack of quality-control systems to
ensure accurate results
• Inadequate interpretation skills
among health professionals
performing the test
Price D, et al. Prim Care Resp J 2009; 18 (3): 216-23
The 10-year COPD programme in
Finland: effects on quality of
diagnosis, smoking prevalence,
hospital admissions and mortality
The major aims of this 10-year Programme in Finland, a
country with a population of 5 million, included:
1. A reduction in COPD prevalence
2. Improvement in COPD diagnosis, especially in primary care
3. A reduction in the number of moderate to severe cases of
the disease
4. Reduction in the number of COPD-related hospitalisations
5. Reduction in treatment costs due to COPD
Kinnula LV, et al. Prim Care Resp J 2011; 20 (2): 178-83
Kinnula LV, et al. Prim Care Resp J 2011; 20 (2): 178-83
Kinnula LV, et al. Prim Care Resp J 2011; 20 (2): 178-83
- 52.9 %
Recent trends in COPD prevalence in
Spain: a repeated cross-sectional
survey 1997-2007
Underdiagnosis
IBERPOC EPISCAN
1997
2007
78 %
73 %
Same
Undertreatment
81 %
54 %
Better
Undertreatment in
severe COPD
50 %
10 %
Better
Previous spirometry ?
17 %
59 %
Better
Soriano JB, et al. Eur Resp J 2010; 36: 758-765
Recent trends in COPD prevalence in Spain:
a repeated cross-sectional survey 1997-2007
• To further reduce underdiagnosis, the
implementation and wider use of spirometry
screening in all setting, including quality
spirometry in primary care, pharmacies, and
elsewhere, require further research and
resources.
Soriano JB, et al. Eur Resp J 2010; 36: 758-765
Early detection of COPD in general practice
Ulrich SC, et al. Int J of COPD 2011
Feasibility and validation of telespirometry
in general practice: the Italian Alliance study
• 70 % of the test met the criteria for good or
partial co-operation, allowing spirometric
abnormalities to be detected in more than 40
% of the tracing
• The rate of telespirometries that could not be
evaluated at all was reasonably low (9.2 %)
Bonavia M, et al. Resp Med 2009
Office spirometry can improve the
diagnosis of obstructive airway disease
in primary care setting
• 9312 subjects were recruited and 7262 (78 %)
performed an acceptable telespirometric
examination
• Among symptomatic subjects, 1433/3725 (38 %)
had abnormal spirometries (682 with moderate
to severe obstruction)
Averame G, et al. Respir Med 2009
Mission
• The COPD Alliance was formed to provide primary care
clinicians with timely information, tools, and support to
facilitate the recognition, diagnosis, and treatment of
COPD.
• We are composed of multidisciplinary societies and
corporations whose commitment is to help primary care
clinicians improve their patients’ quality of life through
early recognition and management of COPD.
Founding members
• Five health-care societies, representing over
300,000 primary care and specialty clinicians,
have partnered together in the fight against
COPD. The promise of the COPD Alliance to
its clinicians, patients, and partners is to
facilitate appropriate identification, diagnosis,
and management of COPD. We are
committed to making a difference today
where it matters most—in the health of our
patients
Founding members
• AANP AMERICAN ACADEMY OF NURSE
PRACTITIONERS WWW.AANP.ORG
• AAPA AMERICAN ACADEMY OF PHYSICIAN
ASSISTANTS WWW.AAPA.ORG
• ACCP AMERICAN COLLEGE OF CHEST
PHYSICIANS WWW.CHESTNET.ORG
• ACOFP AMERICAN COLLEGE OF OSTEOPATHIC
FAMILY PHYSICIANS WWW.ACOFP.ORG
• ACOI AMERICAN COLLEGE OF OSTEOPATHIC
INTERNISTS WWW.ACOI.ORG
The COPD Alliance’s unified voice promotes early diagnosis of
COPD through enhanced awareness and understanding of this
preventable and treatable disease utilizing the acronym STEP:
S Screen patients at risk
T Test and diagnose utilizing spirometry when
indicated
E Educate patients about COPD
P Provide appropriate medical care and support
All Clinicians are encouraged to STEP forward in the fight
against COPD—the fourth leading cause of death
in the United States.
Four Easy STEPs to become COPD Prepared
To support clinicians in the four-STEP process
for the recognition, diagnosis, and treatment of
COPD, the COPD Alliance offers a variety of
free tools, resources, and education programs.
COPD ALLIANCE
•The resources include a COPD
patient screening tool, the Tobacco
Dependence Treatment ToolKit,
information regarding spirometry,
and several patient education
guides that clinicians can download
and distribute to patients in their
offices.
•We invite you to explore these
valuable resources by clicking on
any of the quadrants of the four
stages of STEP below.
Spirometry is an important tool in diagnosing COPD ?
• Confirm a diagnosis of COPD
• Show the severity of your patient’s
COPD
• Help you decide what medicines and
health instructions are appropriate for
your patient
• Show how well the prescribed
treatment and disease management
activities are working
How to screen for the risk of COPD
 The COPD Alliance1 recommends the utilization
of a simple validated2 questionnaire
that can help
identify people age ≥35
who are at risk for COPD
 A downloadable version entitled,
COPD Population ScreenerTM
can be found on www.COPD.org
 Persons that are deemed to
be at risk should be asked to
complete the screener while in the
waiting room
1The
COPD Alliance is composed of multidisciplinary societies, i.e., AANP, AAPA, ACCP,
ACOFP, ACOI
2 Martinez FJ et al. COPD.2008;5(2):85-95
Educate
It is essential that you take the time to educate
your patients about COPD, including symptoms,
diagnosis, and how to live better with the
disease.
Use the following resources to help your patients
learn more about COPD:
A BREATH OF FRESH AIR: LIVING WITH
COPD
PATIENTS GUIDES FOR COPD
SPIROMETRY DEMONSTRATION VIDEO
Resources for the clinicians
Copd.org
The COPD Alliance provides access to the following COPD resources for
clinicians and their patients, many of which are free and available for
download:
COPD Population ScreenerTM
This validated COPD screening tool uses five questions to determine a patient’s
risk for COPD and the potential need for spirometry testing. The screener is
available in English and Spanish.
Tobacco Dependence Treatment ToolKit
Help your patients stop smoking with the updated Tobacco Dependence
Treatment ToolKit from the American College of Chest Physicians. This userfriendly, interactive collection of tools will help you implement a proven
approach to treating tobacco dependence. Online features include
instruments for patient assessment, a video presentation on helping your
patients, and multiple search options.
GOLD Guidelines
The Gold Guidelines provide comprehensive, evidence-based guidelines for
COPD diagnosis, management, and prevention.
Spirometry Demonstration
This 5-minute instructional video shows patients and coaches how to perform a
spirometry test.
Resources for the clinicians
COPD: Importance of Early Diagnosis
The following downloadable slides can be used by clinicians to highlight
the importance of early diagnosis for COPD, and how and when to
screen patients for COPD.
Download slides
A Breath of Fresh Air: Living With COPD
Living With COPD is a "virtual flip chart" created by expert clinicians from
the American Academy of Nurse Practitioners. The flip chart includes
content to support the counseling of patients diagnosed with COPD or
at risk for the disease. Flip chart materials, including handouts, can be
downloaded for use on a computer or tablet.
Download Flip chart »
The Changing Face of COPD
A public service announcement (PSA) illustrates how the face of COPD is
changing and how primary care clinicians can help uncover the disease
by asking the right questions.
View Video »
Resources for the patients
• The COPD Alliance provides access to the following COPD
resources for clinicians and their patients, many of which are
free and available for download.
• COPD Population ScreenerTM
• This validated COPD screening tool uses five questions to
determine a patient’s risk for COPD and the potential need for
spirometry testing. The screener is available in English and
Spanish.
• View Screener »
• Patient Guides for COPD
• These unbranded patient guides offer valuable and easy-tounderstand information about understanding the diagnosis of
COPD, managing the disease through diet and exercise,
smoking cessation, and more.
• View Guides »
• © 2011 COPD Alliance
Thank you for
your attention
“ Primary care clinicians are
the gatekeepers for our health.
If they are unable to recognize
the signs of COPD or high-risk
individuals, the disease may
remain undiagnosed and,
consequently, the patient
will not receive appropriate
treatment.
By educating our
primary care clinicians,
we give them the tools
to identify high-risk patients,
confirm a diagnosis of COPD,
and provide initial treatment”
Brian Carlin, MD, FCCP
Chair, COPD Alliance