COPD: An Individualized Approach to Medication and Delivery - Episode 5
Peter Salgo, MD: We’ve been talking about patient education. Let’s take a step back. We’ve got to educate doctors.
Byron Thomashow, MD: Providers.
Peter Salgo, MD: You’ve got the 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines, and you’ve got updates, right? What are the updates, first of all? And then, we’ve got to discuss how to bring this information to doctors’ and providers’ attention.
Antonio Anzueto, MD: They called for an update for COPD. I clearly understand that in the primary care setting, you are receiving many, many other guidelines—many other recommendations. So, the intent of this is, how can we simplify it for you? We emphasize to make a diagnosis with spirometry, and then ask about exacerbations and symptoms. Your therapy should be driven by symptoms and the risk of exacerbations.
We now understand the severity of the disease and know that the main decision-making tool, for deciding how you want to treat patients, is going to be driven by certain factors. If you have a person who has been in a hospital 2 or 3 times because of an exacerbation, it has to be very different from the individual who hasn’t had an exacerbation but has started to have symptoms. “I have cough every day.” “I have limitations.” The emphasis of the revised document has been to look at patients, ask about symptoms, and ask about exacerbations. That will help you to guide therapy.
Peter Salgo, MD: How does that differ? Before, was it suggested to look at the spirometry and go by the numbers?
Antonio Anzueto, MD: Right. Then, based on the spirometry, the patient would fall into a group. “This is what you should be doing.” Now we say, “Do your spirometry, but you have to make a diagnosis.” Put that aside for a minute and ask the patient, “Have you been in the hospital? Have you required antibiotics, and how many times within the last year? How are your symptoms? How limited are you?”
Peter Salgo, MD: So, the implication here, if I hear you right, is that the spirometry wasn’t tracking symptoms as well as we would like. Is that fair?
Byron Thomashow, MD: Very poorly, actually.
Peter Salgo, MD: Very poorly. So, why spirometry in the first place?
Byron Thomashow, MD: To make a diagnosis. I think that is important. It’s not only the underdiagnosis. It’s the overdiagnosis. There are a lot of people who carry a COPD diagnosis who don’t have COPD at all. They’re potentially getting treated. So, I think we do need to define it.
I just want to come back, for a second, to your comment about the team approach. How to develop that, as Barbara says, is complicated. There is something happening now, though, that potentially allows us to begin to look at this. That’s the readmission issue, right?
Hospitals are being penalized if their readmission rates in 30 days are greater than the national average. The first 3 core measures were acute myocardial infarction, congestive heart failure, and pneumonia. Several years ago, COPD and hip and knee replacement were added. So, hospitals that have readmission rates greater than the national average are penalized. That puts a significant financial burden on hospitals. It’s up to 1%, 2%, 3%, not just for the core measures, but for all Medicare hospitalizations. Many hospitals are now looking at that. It’s not just length-of-stay issues. It’s the readmission issues. Many hospitals have begun to develop programs that include more of a team approach, to try to prevent that from happening.
Peter Salgo, MD: But you know what hospitals say, right? “We get sicker patients. Our patients come back because ours are sicker.” That doesn’t fly.
Barbara P. Yawn, MD, MSc, FAAFP: No, it doesn’t fly because it’s not true.
Peter Salgo, MD: What a good reason not to fly.
Barbara P. Yawn, MD, MSc, FAAFP: Yes, amazing. The other thing is, we need to expand those programs. What percentage of COPD patients are actually in the hospital every year? Now, in your academic practice, it may be higher than it is in the primary care practice.
Byron Thomashow, MD: It’s still very small.
Barbara P. Yawn, MD, MSc, FAAFP: So, that may apply to 5% of my COPD patients. How do we expand and enhance that? The other thing I wanted to comment on is, you moved on to the GOLD guidelines. Primary care should love the new GOLD guidelines. We really haven’t ever done spirometry, repeatedly, to guide therapy. Now, you’re moving in with the GOLD guidelines, which should be right back into our wheelhouse.
Peter Salgo, MD: It’s validating all that you’ve been doing.
Barbara P. Yawn, MD, MSc, FAAFP: Something like that. We need to look at the patient. Decide what your patient needs, based on what you see right in front of you. What are their symptoms? What have they had to change in their life? Have they been to the hospital? Have they been to the emergency department? Have they had that crazy chronic or acute bronchitis diagnosed 3 times in the last 2 years? Again, this should be very comfortable for primary care physicians. Once they think of the possibility of COPD, they go ahead and make the diagnosis with the spirometry. We’re now back to the bread and butter of primary care. Ask the patient what’s going on. Look at the patient. Make a decision about therapy.
Antonio Anzueto, MD: Byron mentioned the issues of hospitalizations and readmissions. We looked at this in our institution. It turns out that half of the people who are admitted with COPD have never had a spirometry. And the ones who had a spirometry were normal. This guy was admitted 5 times, and we were like, “Gosh, you know, this guy has been admitted.” The guy had a 100% normal spirometry. What happened was, they put a diagnosis in the chart and nobody changed it.
Peter Salgo, MD: It self-propagated after a while.
Byron Thomashow, MD: The other thing about the readmissions is, for whatever the index causes, they’re almost always related to one of the comorbidities. Almost always, comorbidities play a role.
Barbara P. Yawn, MD, MSc, FAAFP: You put them in the hospital. You put them on oral steroids. Their diabetes is totally out of control. They end up back in the hospital, a week later, for their diabetes.
Transcript edited for clarity.