Dr. MeiLan from University of Michigan and Medical Director of Women’s Respiratory Health Program, in a recent interview to the Lancet journal published on May 13, 2016, highlighted how the health care services for COPD are being reviewed for more effective and efficacy based system development.
She explained the significance of a well coordinated system and how all the theoretical talk becomes irrelevant when actual management of daily care of a patient gets affected due to multiple practical issues and many intricacies of the United States health care system. The disjoined healthcare efforts towards COPD management, needs careful restructuring and integration to maximize benefits.
Chronic Obstructive Pulmonary Disease is the third leading cause of death in United States today with an estimated number of 28.9 million affected individuals. People with severe form of the disease (chronic deterioration of lungs and their function) become restricted in terms of physical activity due to easy distress it can cause.
The Lancet Respiratory Medicine Commission, which took a year to develop, pulls together multiple perspectives involved and vital to coordinate and improve COPD care in United States, like respiratory physicians, general physicians, patients, nurses, patient organizations and the health organization managers among others.
The eport published by the commission found that people with chronic cases of the disease face challenges while accessing health care services as treatment costs are generally out of reach for many patients and hospitals providing those services are not in accordance with theorized standards of care.
Twenty eight experts from the field of respiratory medicine and research contributed to the study led by Dr MeiLan Han. Dr Han explained that the disease disproportionately affects some of the most vulnerable people in the society like older adults and people from lower socio-economic backgrounds.
“As a physician, I can discuss best treatments with my patients, only to later find out it isn’t covered by their insurance, or the co-pay is simply too high”, said Dr Han.
Usually treated with pulmonary rehabilitation and inhalers (to which access has been increased in recent years), the patients often can’t comply with the treatment prescribed. Insurance copayments can often be as high as $ 75 or more per drug. This situation can often result into patients skipping medications, not taking complete dosages, or not coming to collect their refills.
The report finds that out of total prescribed drugs only half are actually taken by the patients diagnosed with COPD. The patients have generally found the pulmonary rehabilitation to be quite beneficial, but geographical inconvenience, scarcity of treatment centers, and varying insurance coverage has limited their usage.
Annually 1.5 million emergency hospital visits, 700,000 hospital stays and 10 million physician visits are in reference with COPD. One in five hospital admissions for the disease ends up in readmission within a month. Only 1 in three hospital admissions offered patients the recommended treatments.
The report while discussing the recent requirements by Medicare which focus on reducing the rates of hospital re-admissions,advises to rather work on improved diagnosis, treatment access, and facilities outside the hospital to provide support to COPD patients.
COPD treated as a low priority disease is mainly due to absence of written protocols for inpatients, as it has been seen for other disease too. The report calls for more research to developing new treatments and more allocation of funds as it is the fourteenth most funded research category by the NIH, despite being the third largest cause of deaths in America.
COPD And USPSTF Recommendations For Screening
There is no cure for the disease currently available but patients diagnosed with acute condition can be helped by slowing the progression of the disease and management of the symptoms. This vitalizes the importance of screening, early diagnosis and prevention management of the disease.
However, USPS Task force just this month published its statement regarding COPD screening recommendations based on a systematic review of the scientific literature and research studies, in the form of an evidence report.
The Taskforce recommended that the patients showing no symptoms of the disease should not be screened for COPD. Previously in 2008 the task force had also recommended against the usage of spirometry to diagnose asymptomatic COPD patients (Grade D).
The 2016 report on which these recommendations were based found that the screening had no net benefit and was associated with large opportunity costs. Smoking Cessation was recommended as a potential treatment. This recommendation is in line with the ones made by the UK National Screening Committee, and the American College of Physicians and the European Respiratory Society for a consortium after a review of scientific publications.
The UKreview found that there was no accurate test present to detect early COPD and the best prevention strategy and treatment for the disease is to stop smoking, consistent with the Taskforce’s recommendations.
Eight key questions were considered and answered to reach these USPSTF recommendations using data from thirty three studies represented by forty eight published articles:
- Does screening the asymptomatic adults for COPD with pre-bronchodilator screening spirometry improve quality of life, and reduce mortality and morbidity?
- Can questionnaire be used to identify high risk asymptomatic adults likely to test positive if screened?
- Can screening pulmonary function tests be used to effectively identify patients with COPD?
- What adverse effects are there of using prescreening questionnaires and screening pulmonary function tests?
- Do identifying asymptomatic adults improve delivery and uptake of targeted preventive services? Does screening for COPD increase smoking cessation and relevant immunization rates?
- What are the adverse effects of COPD screening and targeted preventive services in the population?
- Does the treatment for asymptomatic adults identified with mild to moderate disease through screening, improve quality of life, and reduce mortality and morbidity?
- What are the adverse effects of COPD treatments?
There was no direct evidence of effectiveness comparison between COPD screening and no screening on patient health outcomes. No direct evidence was available to access the pro and cons of screening asymptomatic adults for the disease using either questionnaires or screening pulmonary function tests.
Some indirect evidence did suggest that the COPD questionnaires had overall moderate performance for the disease detection. Among patients with mild to moderate conditions, the evidence of benefit of pharmacotherapy for decreasing episode of exacerbations was modest.
COPD Screening, Diagnosis, And Management
The current criterion for a positive COPD diagnosis entails a forced expiratory volume in 1 second to forced vital capacity ratio of less than 0.70 that can be denoted by (FEV1/FVC). The Severity of the COPD is analyzed by the percentage of predicted post-bronchodilator FEV1 value, according to which it can be pinned down into following categories:
80% or more is mild
50% to 79% is moderate
30% to 49% is severe
Less than 30% is very severe
It should be noted that the standardized methods used for the COPD screening includes: post-bronchodilator spirometry, that is a simple test used for monitoring the airways obstruction in the lungs. It is carried out by a device known as spirometer i.e. a small machine attached by a cable to a mouthpiece which detects the amount of air you breathe out in one forced breath according to NHS, UK.
American College of Physicians (ACP), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and European Respiratory authority (ERS) have previously given their recommendations for effective diagnosis and management of COPD, in a statement in 2009, which includes:
- Use of spirometry to diagnose airflow obstruction in patients with respiratory symptoms, is recommended by ACP, ATS, ERS, and ACCP. (Strong recommendation with moderate quality evidence)
- Spirometry should not be used in patients without the symptoms. (Strong recommendation with moderate quality evidence)
- For stable patients with the symptoms and FEV between sixty to eighty percent, ACP, ACCP, ATS, and ETS suggests use of inhaled bronchodilators (weak recommendation with low quality evidence)
- For stable patients with the symptoms and FEV less than sixty percent, ACP, ACCP, ATS, and ETS suggests use of inhaled bronchodilators (strong recommendation with moderate quality evidence)
- Monotherapy either long acting inhaled anticholinergics or long acting inhaled beta agonists for symptomatic patients with FEV less than sixty percent is recommended. The specific monotherapy should be dependent upon patients’ choice. (Strong recommendation with moderate quality evidence)
- Combination of inhaled therapies, like long acting inhaled anticholinergics or long acting inhaled beta agonists for symptomatic patients with FEV less than sixty percent and stable COPD, is recommended. (weak recommendation with low quality evidence)
- Pulmonary rehabilitation for symptomatic patients with FEV less than fifty percent is recommended. (strong recommendation with moderate quality evidence)
- Pulmonary rehabilitation for symptomatic or exercise limited patients with FEV more than fifty percent is recommended. (weak recommendation with low quality evidence)
- Continuous oxygen therapy in patients with COPD with severe hypoxemia is recommended. (strong recommendation with moderate quality evidence)
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Obstructive Pulmonary Disease (COPD) often commonly referred to as chronic bronchitis and emphysema, makes it difficult to breathe and is often characterized by rough cough and sputum production. The condition typically becomes worse over time and presents itself as an obstructive lung disease with long term poor airflow.
The disease is has very high morbidity (disease) and mortality (death) rates. In United States more than 6.5 percent of adults of age twenty five and above report a physician diagnosis of COPD including emphysema and chronic bronchitis.
Emphysema and chronic bronchitis are two different types of COPD which is the result of more permanent complications over the time.
Emphysema, however, involves gradual destruction of alveoli sacs of lungs, which hinders breathing and restrict the flow of oxygen to the body cells as that is the main role of alveoli; exchange of gases in lungs. The disease can over time destroy the alveoli and limit the elasticity of the pulmonary airways. This results in patients experiencing shortness of breath and trouble breathing.
Chronic bronchitis is the opposite of emphysema but with similar symptoms which make it difficult to tell them both apart. Bronchitis causes the lungs to become inflamed. It affects windpipe, passageways in the lungs as a result of infection or severe irritation. The disease is found in both acute and chronic forms. The body normally reacts to the condition by inducing severe coughing to clear the airways.
In United States the prevalence of COPD varies between 3.1 to 9.3 percent in adults aged more than eighteen years, depending upon the state they are in. annually the disease is reported in 7.8 percent women and 5.8 percent men and prevalence varies according to ethnic origin.
The Strongest Risk Factor For COPD Is Smoking
Cigarette smoking is the most common cause of COPD, in addition to the long-term exposure to other lung irritants such as air pollution or chemical fumes. Out of the people who smoke 20 percent will get COPD an out of lifelong smokers nearly half will get the disease.
The currently diagnosed COPD patients in United States are eighty to ninety five percent smokers or previous smokers. The chances of developing the disease increase with total smoke exposure. In non smokers diagnosed with the disease twenty percent are exposed to second hand smoke. Women are more susceptible to the effects of smoking and the ones who smoke during pregnancy increase the risk of COPD in their children.
It is recommended to avoid exposure to cigarette smoke and other toxic fumes. The smokers are advised to stop the tobacco use by availing smoking cessation counseling along with other behavioral and pharmacological therapies.
Moreover, USPSTF recommends that healthcare professionals should ask all adults including pregnant women about the tobacco usage and should provide interventions along with creating awareness through brief counseling sessions, to prevent initiation of tobacco use even for adolescents.
Other causes of the disease can be environmental pollution, occupational exposures such as workplace dust, chemical and fumes along with genetic makeup of an individual. The disease is seen to be more common in people with relatives with COPD who smoke than unrelated smokers of tobacco. The alpha 1-antitrypsin (AAT) is the only current inherited risk factor which is responsible for 1 to 5 percent of the cases and the risk factor is present in three to four people per 10,000.
US Preventive Services Task Force (USPSTF)
USPSTF created in 1984 is a panel of independent and volunteer national experts from the field of prevention and evidence based medicine. The panel makes recommendations for clinical preventive services like counseling, screenings and preventive medications to improve health of all Americans. The recommendations are evidence based and are often published through peer reviewed journals or the official website for the Taskforce. The team writes yearly reports to be submitted to congress, identifying critical gaps in research related to health prevention services, their recommendations to fill those gaps, and highlighting priority areas for the research.
Each set of recommendations is awarded letter grades like A, B, C, or D, based on the strength of the evidence after conducting research and systematic reviews on available literature. The recommendations are made only for people who have no symptoms or signs of the specific condition or disease under study and only address primary healthcare services.
Agency for Healthcare Research and Quality (AHRQ) is authorized by the congress to assemble the Taskforce and to provide administrative, scientific, and dissemination support to it, since 1998.