Amid fresh evidence that the quality of care provided to people with obstructive lung diseases such as asthma and chronic obstructive pulmonary disease (COPD) is inadequate,1 the medical community has made new calls for system-level changes that could help providers with the dizzying number of tests and procedures that national guidelines recommend.
The help is certainly needed. Not only is quality of life at stake for the patients and families affected by these illnesses, but the complications associated with inadequate care cost the country dearly: More than $50 billion is spent annually on COPD-related complications with an additional $50 billion spent on indirect costs, according to the Centers for Disease Control and Prevention.
If there is good news, it is that some experts believe that chronic conditions such as COPD are beginning to receive the attention they deserve from healthcare organizations and providers. Further, there is now a solid base of research to rely upon when making treatment decisions. What still needs work is dissemination of best-practice information and new ideas on how to translate this information into clinical practice.
The latest research about the care provided to patients with COPD and asthma comes from a RAND Corporation study published in the December 2006 CHEST, which suggests that patients receive only 55% of recommended care. It’s a disturbing figure, but not particularly surprising, according to Richard Mularski, MD, MSHS, FCCP, the lead author of the study and a clinical investigator at Kaiser Permanente’s Center for Health Research in Oakland, CA. “These deficits are not different than what we find in nearly every other chronic condition, with the amount of [recommended] care that Americans receive for disease management somewhere in the mid-50s,” he says.
More intriguing, however, are differences investigators found between the care provided to patients with asthma versus COPD. For example, although investigators found that routine care of asthma was quite good, fewer than 50% of patients with exacerbations from the disease received recommended interventions. However, in the case of COPD, investigators observed the opposite: Care providers were doing a good job of treating exacerbations of COPD according to recommended care, but adherence to routine management was only 46%.
Mularski speculates that one reason why routine care of asthma has improved in recent years may be because the disease has received high-profile attention by researchers, healthcare organizations, and parents. “For 20 years, the [United States] has worked though a number of mechanisms to improve the routine care of asthma,” he says. “We haven’t seen any targeted efforts with regard to COPD—at least not up to this point.”
Guidelines reflect scientific evidence
One organization that is attempting to change this picture—not just in the United States, but worldwide—is the Global Initiative for Chronic Obstructive Lung Disease (GOLD). In fact, the group has just unveiled updated clinical guidelines for the diagnosis, management, and prevention of COPD, and it is taking steps to make clinicians aware of new changes in the recommendations and to assist them in translating those changes into practice.2
A new concept reflected in the updated guidelines is the elimination of the “at risk” category from the spirometric classification system of disease severity for COPD outlined in the first GOLD guidelines, published in 2001. This was done because investigators found no scientific evidence that people who have symptoms of COPD actually go on to develop the disease. “The concept is that before you even start thinking ‘COPD’ [the patient] probably should have some sort of alteration in lung function,” says Suzanne Hurd, PhD, GOLD’s scientific director. “If you have a patient who is a smoker and he [or she] is coughing, that is not normal. And you should at least consider that this is a patient you should follow. But we are not saying this patient has COPD.”
The amended spirometric classification of disease severity outlined in the guidelines includes four stages, ranging from mild to very severe.
Comorbidities are important
The guidelines also emphasize—more strongly than in their first iteration—that providers need to pay close attention to treating the whole patient and not just the COPD. “Throughout the report, we recognize that when providers are treating COPD or thinking about COPD, they should also be very aware of all of the other extra systemic effects—the comorbid conditions,” says Hurd. “There is even some indication that people with COPD may be at increased risk for some of these other diseases such as heart disease and osteoporosis.”
Further, in a slight modification of the definition of COPD outlined in the guidelines, the terms “preventable” and “treatable” have been added in an effort to stress to providers that there are options to prevent and treat this disease.
However, because cigarette smoking is the primary cause of the disease in this country, there has always been a tendency among providers to blame the patient. “That attitude and way of thinking has prevailed for many, many years, and so that may explain why even today some PCPs, who are very busy people—they have between five and 10 minutes for every patient they see—do not pay the attention they should to this condition,” says Claude Lenfant, MD, former director of the National Heart, Lung, and Blood Institute.
In general, however, Lenfant and Mularski agree that the chief underlying reasons for poor adherence to recommended care are not related to providers, but to system failures. “Especially for many of these routine diagnostics that might be recommended, you really need to change the way that healthcare is delivered in this country and come up with systems that approach this through a multidisciplinary focus—and not rely on individual providers to try and remember to do everything within a busy 15-minute visit, but rather to have many of these things happen automatically, like we see in the airline industry, for example,” says Mularski.
Reimbursement changes needed
The deployment of electronic medical records and decision-support technology should ultimately close some of these gaps. But Hurd emphasizes that changes in reimbursement policies are needed as well. “There is a lot of interest in trying to get payers to [reimburse] for rehabilitation for COPD as well as to pay for smoking cessation, neither of which are well covered,” she says. “Until someone pays for those kinds of things, it is going to be very difficult for physicians to encourage active participation in well-established programs that can help patients—especially those early in the course of their disease.”
A second issue that needs much attention—in terms of reimbursement and provider training—is lung function testing. Hurd says that physicians and medical students need to understand the importance of lung function in a medical examination. “This is woefully poor in this country, and that in many ways depends on not only who is going to pay for doing the test, but also on [who is going to pay] for interpreting the results,” she adds.
Despite the many problems that clearly need to be addressed, Lenfant is optimistic about the prospects for quality improvement (QI) in COPD care. “We are in the middle of an evolutionary period here, which is eventually going to do a lot of good for patients,” he says. “And my prediction is that in five years, we will have a very different picture of this condition.” v
1Mularski R, Asch S. Shrank W, et al. “The Quality of Obstructive Lung Disease Care for Adults in the United States as Measured by Adherence to Recommended Processes.” CHEST 2006; 130: 1844–1850.
2Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Copyright 2006 MCR Vision, Inc.
Editor’s note: The GOLD clinical guidelines for COPD can be accessed at www.goldcopd.org.