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Effective Management of COPD in Primary Care: Challenges and Opportunities
November 30, 2018

Effective Management of COPD in Primary Care: Challenges and Opportunities

Sanjay Sethi, MD, FACP is a professor in the Department of Medicine at the University of Buffalo at the State University of New York (SUNY) in Buffalo, New York. He is chief of the Division of Pulmonary/Critical Care/Sleep Medicine, assistant vice president for Health Sciences and director of the Clinical Research office at the University at Buffalo. He is a staff physician in Pulmonary/Critical Care/Sleep Medicine at the Western New York Veterans Administration HealthCare System in Buffalo. Dr Sethi is board certified in internal medicine, pulmonary disease, and critical care medicine and was recently named one of the top 5 COPD Specialists in the USA by Expertscape.
Almost 16 million Americans have chronic obstructive pulmonary disease (COPD).1 For many of these individuals, simple activities, such as walking or climbing stairs, leaves them breathless, making their lives a daily struggle.2 Primary care providers are the main point of contact for COPD patients, providing about 80% of their care.3 Most of the patients they treat present with symptomatic disease–the most common symptoms being shortness of breath, productive cough, fatigue, and limited exercise tolerance.4 Primary care providers’ main focus is to provide treatment to reduce patients’ symptoms and improve their quality of life.5,6

In treating COPD, it is important for primary care providers to grasp the complexity of the disease.7 No 2 COPD cases are alike; both the symptoms and the disease course vary by patient.7 Therefore, clinicians should tailor treatment to address individual patients’ symptoms, rather than managing all COPD patients the same. Clinicians also must recognize other key barriers to effective management of COPD. The following are some of the most common challenges in primary care: correctly identifying/diagnosing COPD; improving patient adherence to treatment; and reducing the risk of acute exacerbations. By meeting these challenges head-on, primary care doctors have an opportunity to reduce the potential for unnecessary or sub-optimal care while improving patient outcomes.8

Identifying and Diagnosing COPD

A major challenge facing primary care providers is diagnostic confusion between COPD and asthma.9 Both are complex, chronic conditions that cause obstructed airflow,9 and both share many of the same symptoms, such as shortness of breath and chronic cough.10 Spirometry testing is widely used in primary care to help clinicians diagnose either condition.4 However, a diagnosis based solely on spirometry may be erroneous, as partial reversibility of airflow obstruction with bronchodilator therapy is often seen in COPD and does not reliably distinguish between COPD and asthma.11 For a more accurate diagnosis, spirometry results should be combined with physical exam findings and a careful medical history that considers the patient’s age, onset and progression of symptoms and social and occupational risk factors. For example, some of the primary features of COPD include onset after age 40, persistent symptoms, and heavy exposure to risk factors, such as tobacco smoke or biomass fuels.4,11

Improving Patient Adherence and Treatment Outcomes

Inhaled bronchodilators are central to COPD treatment.12 It is becoming evident that certain patients may struggle to reach optimal peak inspiratory flow (PIF) with some inhalers.13 As a result, both the mode of delivery and the type of inhaler device are important considerations in COPD treatment.13 Device selection should be informed by the patient’s needs, preferences, and abilities.7,13 For instance, patients who find it hard to reach optimal PIF may benefit from an inhaler that requires less inspiratory effort to activate.14 Primary care practices should use multiple educational and training methods (eg, verbal, visual, demonstration) to instruct patients on proper inhaler technique. Instruction and review should be repeated at every office visit to ensure effective inhalation and drug delivery to optimize therapeutic outcomes.8,13

Reducing COPD Exacerbation Risk

Primary care providers’ main focus is to reduce their COPD patients’ symptom burden and associated comorbidities.4 Exacerbations – a sudden worsening, or flare-up, of symptoms7 – place a huge burden on some patients, as complications from these acute events can cause progressive airflow obstruction and lead to lengthy hospitalizations or even death.15 However, it is important to note that “frequent exacerbators” (ie, patients with 2 or more exacerbations requiring additional therapy and/or one hospitalization in the previous 12 months) are a small subset of COPD patients in primary care.9 In fact, the most severe and hard-to-treat COPD patients – ie, those who tend to experience frequent exacerbations and hospitalizations – mostly receive specialist care from pulmonologists.16

Nevertheless, primary care providers should assess their patients’ exacerbation status at every visit by monitoring the frequency with which patients require medical intervention for increased COPD symptoms. If a patient meets the criteria for frequent exacerbation, care providers should carefully assess both the patient’s adherence practices and the effectiveness of current therapy, and prescribe additional treatment or refer to specialist care as indicated.8

Best Practices in COPD Management

Ultimately, the treatment of COPD is a shared responsibility between the patient and the primary care provider – from the point of diagnosis and throughout the treatment journey. The following primary care best practices may facilitate a successful doctor-patient partnership and enhance COPD treatment outcomes:4
  • Support patients in their efforts to self-manage COPD by encouraging smoking cessation and healthy lifestyle behaviors
  • Provide routine patient monitoring, including spirometry, to identify and address any change in symptoms, manage the risk of acute exacerbations, and assess ongoing treatment goals
  • Promote medication adherence by demonstrating and training on correct inhaler technique


References:

 
  1. Wheaton AG, Cunningham, TJ, Ford ES, Croft JB. Employment and activity limitations among adults with chronic obstructive pulmonary disease—United States, 2013. MMWR. 2015:64 (11):290-295. Available at: https://www.cdc.gov/copd/basics-about.html#ref2. Accessed on September 4, 2018.
  2. American Lung Association. Lung Health and Diseases: Chronic Obstructive Pulmonary Disease (COPD). http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/. Accessed on August 15, 2018.
  3. Perez X, Wisnivesky JP, Lurslurchachai L, et al. Barriers to adherence to COPD guidelines among primary care providers. Respir Med. 2012;106:374-381.
  4. American Academy of Family Physicians. COPD and Asthma: Differential Diagnosis. 2016. https://www.aafp.org/dam/AAFP/documents/journals/fpm/COPD-Asthma.pdf. Accessed on August 16, 2018.
  5. Spyratos D, Chloros D, Sichletidis L. Diagnosis of chronic obstructive pulmonary disease in the primary care setting. Hippokratia. 2012;16(1):17-22.
  6. van Boven JF, Ryan D, Eakin MN, et al; Respiratory Effectiveness Group. Enhancing respiratory medication adherence: the role of health care professionals and cost-effectiveness considerations. J Allergy Clin Immunol Pract. 2016;4(5):835-846.
  7. American Thoracic Society. Patient Information Series: Exacerbation of COPD. Am J Respir Crit Care Med. 2014;189:11-12. https://www.thoracic.org/patients/patient-resources/resources/copd-exacerbation-ecopd.pdf. Accessed on August 15, 2018.
  8. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. https://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed on August 17, 2018. 
  9. Buhl R, Criée C-P, Kardos P, et al. A year in the life of German patients with COPD: the DACCORD observational study. Int J COPD. 2016;11:1639-1646.
  10. Buist AS. Similarities and differences between asthma and chronic obstructive pulmonary disease: treatment and early outcomes. Eur Respir J. 2003;21(suppl 39):S30-S35.
  11. D’Urzo AD, Tamari I, Bouchard J, et al. New spirometry interpretation algorithm: Primary Care Respiratory Alliance of Canada approach. Can Fam Physician. 2011;57:1148-1152.
  12. Cazzola M, Page C. Long-acting bronchodilators in COPD: where are we now and where are we going? Breathe. 2014;10(2):111-120.
  13. Yawn BP, Colice GL, Hodder R. Practical aspects of inhaler use in the management of chronic obstructive pulmonary disease in the primary care setting. Int J COPD. 2012;7:495-502.
  14. Roberts CM, Gungor G, Parker M, et al. Impact of a patient-specific co-designed COPD care scorecard on COPD care quality: a quasi-experimental study. NPJ Prim Care Respir Med. 2015;25,15017; doi:10.1038/npjpcrm.2015.17.
  15. Mapel DW, Dalal AD, Johnson PT, et al. Application of the new GOLD COPD staging system to a US primary care cohort, with comparison to physician and patient impressions of severity. Int J COPD. 2015;10:1477-1486.
  16. Tinkelman DG, Price DB, Nordyke RJ, et al. Misdiagnosis of COPD and asthma in primary care patients 40 years of age and over. J Asthma. 2006;43(1):75-80.


 
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