Disease Management of COPD –Requires Proper Tools
Disease management of Chronic Obstructive Pulmonary Disease (COPD) is a big challenge for health care providers in the United States. COPD is recognized by the Centers for Disease Control (CDC) as the third leading cause of death in the United States, an estimated 147,101 people will die this year due to COPD related illness.
The American Lung Association estimates that 11 million Americans have received a COPD diagnosis and 24 million Americans have the disease but have not been screened, tested with a spirometer/ peak flow meter or received a diagnosis. As a chronic condition COPD has created a challenge for hospitals when in October 2014, hospitals began to be judged on their 30-day, all-cause unplanned readmissions for COPD after an initial admission for a COPD exacerbation. This affects insurance reimbursement and in the case of Medicare or Medicaid, CMS has begun assessing penalties for hospitals that exceed national COPD readmission standards. Maximum cost of higher readmission rates in 2015 has been reported as 3% of a hospitals aggregate Medicare payment.
“CMS launched the Hospital Readmissions Reduction Program (HRRP) in 2012, initially targeting heart failure, pneumonia and acute myocardial infarction. COPD was added to this list of conditions in 2013, a time when 1 in 5 patients were readmitted within 30 days following an index admission for a COPD exacerbation.” – See more at: http://journal.copdfoundation.org/jcopdf/id/1052/Hospital-Readmissions-for-COPD-We-Can-Meet-the-Challenge#sthash.VtKPF1wL.dpuf
There is no single diagnostic test for COPD, however confirmation of airways obstruction needs to be confirmed using spirometer, making a diagnosis relies on clinical judgement based on a combination of history, physical examination and spirometry. Patients with COPD should be reviewed at least once per year, patients with very severe COPD when reviewed in primary care, should be seen at least twice a year.
The current NICE 2010 COPD Guidelines state:
- All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results.
- Spirometry can be performed by any healthcare worker who has undergone appropriate training and who keeps his or her skills up to date.
- The diagnosis should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with breathlessness on exertion, chronic cough, regular sputum productions, frequent winter bronchitis or wheeze.
- Spirometry should be performed:
at the time of diagnosis
• to reconsider the diagnosis, if patients show an exceptionally good response to treatment.
- Measure post-bronchodilator spirometry to confirm the diagnosis of COPD.
- Consider alternative diagnoses or investigations in:
– older people without typical symptoms of COPD where the FEV1/FVC ratio is < 0.7
– younger people with symptoms of COPD where the FEV1/FVC ratio is > 0.7.
- the values of spirometric tests performed at diagnosis should be recorded (both absolute and percent predicted)
- highlighting the diagnosis of COPD in the case record and recording this using Read codes on a computer database
- Measurement of oxygen SPO2 saturation levels
- Patients with COPD should be reviewed at least once per year, or more frequently if indicated. Patients with very severe COPD when reviewed in primary care, should be seen at least twice a year.
- All COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity.
- Follow up of all patients with COPD should include smoking cessation advice
Patients with COPD should be reviewed at least once per year, or more frequently if indicated. Patients with very severe COPD when reviewed in primary care should be seen at least twice a year.
How do you know which spirometer will assist you in meeting the current guidelines and fulfill the functionality you need?
Spirometry is based on the measurement of flow and volume and relies on trained staff and patient co-operation. Spirometers must also be operator friendly informative with clear graphical display of the test performed, quality assurance feedback of the maneuver and ideally computer generated interpretation of the results.
The model of spirometer used can assist the busy health professional in this role. Many desktop spirometers allow quick patient entry so a database of your patients can quickly be generated. Ideally all maneuvers should be stored for review and tests measured real time giving a clear indication of the patients effort and predicted target.
Automatic feedback to the operator as per the ATS/ERS 2005 Standardisation of Spirometry guidelines is essential to ensure the tests are reproducible and the patient can be guided on any part of the maneuver that is incorrect.
Results should be clearly displayed with both actual and percentage predicted values. Once the patient has achieved a reproducible number of tests (ATS/ERS 2005 guidelines) the spirometer should inform the operator so the test session can be stopped.
Both pre and post bronchodilator tests with comparative results in both ml change and % change should be displayed.
Throughout spirometry not only must the patient be engaged to ensure the results obtained are the optimum for that patient, but also the operator to ensure results are accurate and meet current guidelines – guidance from the device on maneuver quality, end of test criteria being met and automatic interpretation are invaluable.
Patient involvement can often be increased with the use of animations encouraging the patient to achieve a visual target or achieve a goal during their spirometry maneuver.
Spirometers must have an option to allow the operator to perform a routine quality assurance check. Calibration check should be performed on a daily basis using a 3 liter syringe 4. The results of the calibration check should be recorded and stored for good quality practice and also for audit purposes .
Spirometers that have the ability to either upload results to a spirometry software package, or connect directly to a PC give additional benefit to the health professional.
When selecting a spirometry package look for those that will interface with patient electronic record systems allowing results to be immediately transferred to Read codes and results and graphs of the patients test placed in patient records. Software packages that allow tailored searches and trending of patient’s results are extremely useful allowing any accelerated decline in lung function to be highlighted – (a loss of 500 ml or more over 5 years will select out those patients with rapidly progressing disease who may need specialist referral and investigation).
For continuity of patient care software packages should ideally allow patient spirometry results to be exported to other electronic records systems or to associated health professionals such as hospital respiratory physicians and out- patient clinics for review where required.
Smoking is a key contributory factor in disease management of COPD and smoking cessation. Coaching and metric supported consultation is imperative to obtain maximum result and improved quit rates.
All GP’s and PA’ should encourage patients to quit smoking and refer to a specialist smoking cessation service or toan in house program if appropriately trained in smoking cessation.
Exhaled carbon monoxide monitors prove invaluable in measuring the level of exhaled Carbon Monoxide and Carboxyhaemoglobin levels to visually aid and guide the patients to the amount of carbon monoxide in their lungs.
Other useful tools to encourage smokers to consider stopping include “Lung Age” – available on many spirometers or other smaller COPD screening devices. Lung Age is calculated against the patients FEV1 a decline in FEV1 directly correlates to an increase in Lung Age – patients will have an increased Lung Age compared to their chronological age and can appreciate the damage smoking is causing to their lungs.
In the video below Dr Bradley Eli from Sleep Treatment Specialists in Encinitas CA demonstrates the use of the Pulmolife device to collect FEV1 data in order to evaluate lung function preceding treating a patient for Obstructive Sleep Apnea. This device also generates a Lung age calculation which helps with smoking cessation consultation.
In order to meet the demands of the strategy and the current guidelines it is imperative that healthcare professionals have the tools to perform this role effectively. Not all spirometers are the same and the task can be made easier by choosing a spirometer that fulfills the above requirements, and selecting complimentary devices such as pulse oximeters, Lung Age meters and carbon monoxide monitors to ensure you have the tools for the job.
- American Lung Association: Lung and Health Diseases: Retrieved From http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/learn-about-copd
- CDC Leading causes of death: Retrieved From http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
- British Lung Foundation 2011
- Consultation on a strategy for services for Chronic obstructive Pulmonary disease (COPD) in England – DoH
- NICE COPD Guidelines – Management of chronic obstructive pulmonary disease in adults in primary and secondary care.
- NICE Clinical Guidance 12 June 2010.
- ATS/ERS Task Force: Standardisation of Lung Function Testing, Standardisation of Spirometry M.R. Miller et al.Eur Resp. J. 2005; 26: 319-338.https://www.thoracic.org/statements/resources/copd/copdexecsum.pdf