Transcript COPD MANAGEMENT FALLS SHORT AT RCRMC

COPD MANAGEMENT
FALLS SHORT AT
RCRMC
Jean Solomon, M.D.
BACKGROUND
*COPD – an enormous burden
- 4th leading cause of death
- 24 billion dollars (2000)
*DIAGNOSIS: previously hard-to-adopt, non-explicit
*GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE PULMONARY
DISEASE – formed to standardize recommendations for diagnosis and
management of COPD worldwide
*1998 – GOLD first convened and issued its recommendations
* 1998 recommendations: Patients diagnosis of COPD should be
confirmed by spirometry. Once confirmed, patient’s severity of disease
should be staged. Short-acting bronchodilators acceptable for most
patients. Management should then be stepwise. Inhaled steroids should
be reserved for patients who have severe or very severe disease, or for
patients who have demonstrated a response to steroids.
* In patients with symptoms of COPD (cough, sputum, dyspnea) and/or
exposure to risk factors (tobacco, occupation, indoor/outdoor pollution),
spirometry is then done to confirm airflow obstruction.
* FEV1/FVC of less than 70% postbronchodilator defines obstruction
* Value of FEV1 postbronchodilator defines stage (severity)
STAGING OF COPD
GOLD system uses a combination of FEV1 and patient symptoms
STAGE 0 – At risk – Risk factors and chronic symptoms, but normal spirometry
STAGE I – Mild – FEV1/FVC ratio less than 70%. FEV1 at least 80% of
predicted value. May have symptoms
STAGE II – Moderate – FEV1/FVC ratio less than 70%. FEV1 50% to less than
80% of predicted value. May have chronic symptoms.
STAGE III – Severe – FEV1/FVC ratio less than 70%. FEV1 30% to less than
50% of predicted value. May have chronic symptoms.
STAGE IV – Very severe – FEV1/FVC ratio less than 70%. FEV1 less than
30% of predicted value.
OR
chronic symptoms.
FEV1 less than 50 % of predicted value plus severe
HYPOTHESIS: The majority of our hospital’s primary care clinic patients diagnosed
with COPD received the diagnosis on clinical grounds alone, without documented
confirmation of the diagnosis by spirometry.
METHODS: retrospective analysis of 150 patients with the diagnosis of COPD by
reviewing the charts of these patients. Charts were pulled randomly by Medical
Records personnel according to the requirement of patient had to have the
diagnosis of COPD at some point and patient had to have been a clinic outpatient.
INCLUSIONS; Outpatients of both Family Care Clinic and Internal Medicine
Primary Care Clinic. Patients with the diagnosis of COPD.
EXCLUSIONS: Patients treated only in clinics other than primary care clinics.
Patients treated only as inpatients in the hospital. Patients without the diagnosis of
COPD.
RESULTS
PATIENT DEMOGRAPHICS
The final number of charts reviewed for this project was 150.
GENDER; Female: 77 (51%)
Male 73 (49%)
AGE; 20’s: 0 (0%)
30’s: 4(2%)
40’s: 18(2%)
50’s: 69 (46%)
60’s: 43 (29%)
70’s: 12(8%)
80’s: 4(2%)
RACE; Cauc: 55 (37%)
AA: 19 (13%)
Asian/Pacific: 5 (3%)
Other: 3 (2%)
Unknown: 52 (35%)
Hispanic: 16 (11%)
SMOKERS (PAST OR PRESENT)
Yes: 132 (88%)
Never: 18 (12%)
MEDICATIONS PRESECRIBED FOR THEIR COPD
-Albuterol: 104 (69%)
-Inhaled Corticosteroids: 61 (41%)
-Spiriva (tiotropion): 54 (36%)
-Atrovent (ipratropium): 41 (27%)
-Combivent: 10 (7%)
-Servent diskus: 2 (1%)
-Theophylline: 1(0.01%)
-Long-term oxygen: 17 (11%)
CLINIC PATIENT WENT TO
Family Care Clinic: 82 (55%)
Internal Medicine Clinic: 68 (45%)
RESULTS
*SPIROMETRY PERFORMED IN THE PAST 10 YEARS IN A PATIENT WHO AT
SOME POINT WAS GIVEN THE DIAGNOSIS OF COPD; 51 (34%)
*SPIROMETRY NOT PERFORMED; 99 (66%)
*OF THE PATIENTS WHO HAD SPIROMETRY, SPIROMETRY CONFIRMED
THE DIAGNOSIS OF COPD; 22 (43%)
*DID NOT CONFIRM: 16 (31%)
*RESULTS OF THE SPIROMETRY NOT ENTERED IN CHART; DO NOT KNOW
IF IT CONFIRMED; 13 (25%)
*WITHIN 3 MONTHS OF SPIROMETRY, THE RESULTS WERE MENTIONED;
22 (43%)
*RESULTS NOT MENTIONED; 24 (47%)
*PATIENT DID NOT RETURN TO CLINIC AFTER SPIROMETRY ORDERED;
NO OPPORTUNITY TO MENTION RESULTS; 5 (10%)
*WITHIN 3 MONTHS OF SPIROMETRY, THE SEVERITY WAS MENTIONED;
19 (37%)
*WITHIN 3 MONTHS OF SPIROMETRY, MEDICATIONS WERE CHANGED;
12 (23%)
STAGE OF DISEASE ACCORDING TO SPIROMETRY RESULTS
STAGE 0: 22 (43%)
STAGE I: 3 (6%)
STAGE II: 7 (14%)
STAGE III: 7 (14%)
STAGE IV: 1 (2%)
*FEV1 NOT RECORDED IN CHART, SO STAGING COULD NOT BE DONE;
11 (22%)
*PERCENTAGE OF ALL PATIENTS REVIEWED (150) WHO ARE USING
INHALED STEROIDS; 61 (41%)
*PERCENTAGE OF ALL PATIENTS REVIEWED (150) WHO HAVE BEEN
STAGED BY SPIROMETRY AS SEVERE OR VERY SEVERE; 8 (5%)
DISCUSSION OF RESULTS
*150 randomly selected patients carrying the diagnosis of COPD
were evaluated in this retrospective analysis. The patients were
distributed across age groups, with the majority in their 50’s and
60’s. Females slightly outnumbered males. Caucasians were most
heavily represented. The prevalence of smoking in this population
was 88%. Few people in the RCRMC primary care clinics with the
diagnosis of COPD receive spirometry to confirm the diagnosis
(34%). Of those who received spirometry, 43% had confirmation of
the diagnosis of COPD. And of those who had spirometry, within 3
months of the test, the results were mentioned in only 43% cases,
the severity of disease was mentioned in only 37%, and
medications were changed in only 23% of cases.
LIMITATIONS
*Post-bronchodilator FEV1 was often not performed during the
spirometry, which could lead to incorrect staging. (That is, the FEV1
entered was pre-bronchodilator.) The sample size was small.
CONCLUSION
*Few patients diagnosed with COPD in our RCRMC primary care clinics
have that diagnosis confirmed by spirometry (34%). Therefore, few receive
disease staging to direct management. Not using spirometry leads to
misdagnosis and to stage-inappropriate treatment. Short-acting
bronchodilators, which are appropriate for all stages of COPD, are
underutilized (69%) in our COPD-diagnosed patients. Inhaled steroids, on
the other hand, which are reserved for severe or very severe staged
patients, or for those with a proven response to steroids (usually by a trial),
are prematurely utilized (by 41% of the COPD patients, of whom only 5%
had spirometry-confirmed severe or very severe disease).