A new meta analysis speculates whether specialists or primary care physicians are the best clinicians to diagnose, treat, and manage COPD.
Craig Riley, MD
Chronic obstructive pulmonary disease (COPD) is complicated. As such, it requires more intensive and specialized treatment than previously thought, according to a new literature review.
A team of investigators from the University of Pittsburgh conducted a meta-analysis of the current literature in order to synthesize the discussion about the current diagnosis and treatments for COPD. They wrote that 30 million adults in the US have COPD, and most of these patients have been diagnosed by a primary care physician—despite the complicated and specialized nature of the disease.
Ultimately, the investigators found 90 applicable studies from 3 databases. Of those, 26 were clinical trials, 21 were meta-analyses themselves, 25 were observational studies and 18 included guidelines and other reports.
The study authors wrote that the primary risk factor for COPD diagnosis is tobacco smoke, though other exposure to inhaled particles such as indoor cooking or smoke from wood and other fuels could play a role, too.
“In this review article, Frank Sciurba, MD, and I summarize recent advances in the ambulatory care of patients with COPD,” Craig Riley, MD, told MD Magazine®. “I think there are 3 important takeaway points that we emphasized that many primary care practitioners may not routinely consider.”
First, Riley explained, many patients are diagnosed without the use of spirometry, despite its requirement for a COPD diagnosis.
“An inordinately large number of patients are either diagnosed presumptively without spirometry (and may not have COPD) or are diagnosed with other conditions (and may not have them) despite having exposures and symptoms consistent with possible COPD,” Riley said. “In both cases, incorrect diagnoses lead to incorrect and ineffective treatments.”
Riley added that a patient’s misuse of inhaler devices for COPD pharmacotherapy is both incredibly common and oftentimes unnoticed by healthcare providers.
“Having a basic understanding of how inhaler devices work will allow providers to screen patients for proper use; if a patient is unable to adequately get their medication into their lungs, they will not see a benefit and are at higher risk of clinical deterioration,” he said.
Additionally, the study authors believe that as clinicians are better able to screen for and correct improper inhaler use practices, it could lead to improved disease control. In time, it could also reduce healthcare costs.
Decreasing and withdrawing from inhaler use should also be considered, they said, especially in patients who are able to maintain stability of 2 years or longer without a moderate to severe exacerbation of symptoms.
Finally, Riley and colleagues suggested that pulmonary rehabilitation has a greater comparative benefit on COPD symptoms, hospitalizations, and death than pharmacotherapies. He said it was “unfortunate” that a majority of COPD patients are never made aware of these pulmonary rehabilitation programs—as little as 5% of patients.
These programs combine strength and endurance training with educational, nutritional and psychosocial support. They aim to improve cardiovascular fitness, physical activity levels, and symptoms in COPD patients.
A patient would typically attend these program sessions 2-3 times per week. Medicare coverage allows for a maximum of 36 sessions although an additional 36 sessions over a lifetime are available if deemed medically necessary, the study authors explained.
“Greater availability and utilization of pulmonary rehabilitation has the potential to improve quality of life, decrease hospitalization costs and has been suggested to improve mortality following hospitalization,” Riley said.
The study, “Diagnosis and Outpatient Management of Chronic Obstructive Pulmonary Disease,” was published in JAMA.