Meilan King Han, MD, a professor of internal medicine at the University of Michigan, discusses how her practice has altered patient care to adapt to the ongoing pandemic and challenges patients with chronic obstructive pulmonary disease (COPD) and providers face when dealing with a highly contagious airborne respiratory virus.
As coronavirus disease 2019 (COVD-19) deaths and cases continue to climb in the United States, patients with conditions that can exacerbate COVID-19 severity, such as chronic obstructive pulmonary disease (COPD), have had to adjust to transitions in care delivery and maintenance.
Although the prevalence of comorbid COPD among those hospitalized with COVID-19 is lower than that of the general population, patients with COPD are 3 times more likely to die from a COVID-19 infection.
In an effort to protect these patients, telemedicine utilization has become paramount to ensuring individuals receive quality and timely care while adhering to pandemic guidelines.
However, as Meilan King Han, MD, a professor of internal medicine in the Division of Pulmonary and Critical Care at the University of Michigan explained, because patients with COPD knew they were at increased risk of COVID-19 complications, many experienced fewer exacerbations over the course of the pandemic due to less exposure from external triggers.
In an interview with The American Journal of Managed Care®(AJMC®) Han laid out how her practice has altered patient care to adapt to the ongoing pandemic and elaborated on challenges patients with COPD and their providers face when dealing with a highly contagious airborne respiratory virus.
Han is a physician and researcher with a focus on chronic lung disease and COPD. She is also a national volunteer spokesperson for the American Lung Association.
The following interview has been edited for length and clarity.
AJMC®: The CDC classified individuals with COPD as being at a higher risk of experiencing more severe COVID-19 symptoms. Nearly a year into this pandemic, what do we know about how these 2 conditions interact?
Han: I think it's really interesting because one thing that has happened is that many patients with COPD got the message that they were at increased risk and have been doing, I would say overall, a fairly good job of staying at home. What I would say, on the ground, at least in my own practice, as well as with talking to other physicians around the country, is that one odd thing that we're seeing is that patients with COPD in general are having fewer exacerbations of their disease than we would normally see. We know that in normal times, exacerbations would be due to things like normal colds, and other non-COVID-19 viruses. The interesting thing is that overall, we're seeing patients having fewer exacerbations simply because they're heeding the CDC guidance and staying at home.
Now, this does not mean that no one is getting sick. I have more recently seen several of my patients with both things like COPD as well as asthma become sick with COVID-19. The studies really do indicate that patients who are either older—which COPD patients tend to be, we know that the prevalence increases with age—as well as have underlying conditions such as COPD, truly are at increased risk for poorer outcomes. Certainly, I've had some of my own clinic patients, unfortunately, do poorly when they've contracted COVID-19. For every patient, there's still a wide range of disease severity, even within the group of patients who have COPD. But we know that as a group, they are at increased risk for more severe COVID-19.
AJMC®: What extra pressures or challenges do patients with COPD face during a pandemic that is wrought by a respiratory virus?
Han: We're seeing tons of challenges. One of them is just attaining regular medical care. Many patients with COPD live in rural areas, and they also tend to be, as a group, more socioeconomically disadvantaged. They're also afraid. What this means is that in a pandemic they're less willing to travel. They may not be able, for instance, to get someone to drive them because of the risk of that, and so they're having a harder time making it to in-person appointments when that's an option. They're also having a harder time doing virtual visits, because I'm finding a lot of them don't have the appropriate technical equipment that would require. We still are allowed to do phone visits, but it's unclear how long that those will continue to be reimbursed for.
I will also say, I've had one patient in particular that I did a video visit with who then was admitted to the hospital not long afterwards. And I wondered whether if I'd actually seen her, I would have realized perhaps how sick she was. But it's just difficult, even with video, to not be in the same room with a patient and observe how they're breathing and to listen to them and talk to them and watch them walk around. It's just not the same overall experience.
The other thing I'm finding a challenge is even how to do things like patient education. Normally, my nurses would go into the patients' rooms and would review inhaler techniques with them. We've never really tested this system out virtually. Like I said, many of my patients don't even have video as an option, so that's getting harder and harder.
The other problem that we've noticed is that many of the pulmonary rehabilitation centers closed during the pandemic. Many of them are back open, and are taking significant precautions, but these are intended to be shared spaces. Rehab is often performed in groups. So, getting patients in pulmonary rehabilitation has been hard.
Other things that have been challenging include things like some of the treatments that many of our patients receive. Things like nebulizers, which are aerosol generating procedures, can be challenging, because if a patient has COVID-19, they could be aerosolizing COVID-19 particles to anyone that they might be sharing a home with, for instance. We had developed specific guidance for patients if they already become infected about trying to isolate when using nebulizers. The same thing goes for continuous positive airway pressure (CPAP) machines. Those also can generate aerosols and spread virus. So, if you have an actively infected patient they need to be sleeping alone, for instance, when using the CPAP machine. I think almost every aspect of life for COPD patients has been affected by the pandemic.
AJMC®: In your practice how has the pandemic altered care? Are you doing predominantly telehealth visits or phone visits with patients?
Han: I've been doing a mix depending on how bad the surge is. In Michigan, where I live, the surge was really bad in the spring, and at that point, the hospital encouraged us to move to almost all virtual visits. Things were much better in Michigan over the summer. I was able to get many of my patients back in for in-person visits and check their spirometry and tried to get issues sorted out in person.
We're now in the middle of a second surge. I have re-transitioned many of my visits back to virtual and we're kind of doing a mix. One thing that's been really challenging is just even doing pulmonary function testing on patients because this is also an aerosol generating procedure. Health systems have taken 1 of 2 approaches. Either they will test for COVID-19 first, or they will not test but the technicians and therapists that are doing pulmonary function testing have to wear full personal protective equipment (PPE) and will try to even do those in a negative pressure room if it's available. Even bringing people in when things were better was still more cumbersome than it typically would be.
Right now, I'm doing a mixture both in-person and virtual. The question on all my patients' minds right now is "When can I get the vaccine?" As we know the government and CDC have recommended currently individuals over 65 and individuals with conditions that would put them at increased risk [of COVID-19 complications should be vaccinated]. I think the majority of COPD patients would fall into that group that really should be prioritized for vaccination.
In Michigan and at Michigan Medicine, they started rolling that [protocol] out and scheduling this week, but then put a halt on it because we did not get a shipment of vaccine that we were expecting. I'm kind of just sitting here waiting to see what's going to happen with that. I know that at a national level, we've been told there's plenty of vaccines, but Michigan did not get an expected shipment this week. I really have yet to see any of my COPD patients receive the vaccine yet.
AJMC®: Are most of your patients eager to get the vaccine or are you confronting any hesitancy?
Han: I would say the majority of patients are eager to get the vaccine and are trying to sign up in as many places as they can think of; if they've seen physicians at 2 health systems, they're signing up with both health systems. They're signing up with multiple pharmacies. I have received some patients that have concerns. Patients, for instance, that might be on immunosuppressive medications, or have had other specific questions. Some younger patients, not my COPD patients, have had concerns or they may have seen in the media, for instance, things about pregnancy. But I would say for the most part, my COPD patients have been quite eager to be vaccinated.
AJMC®: How do you think the pandemic will affect treatment paradigms moving forward? Do you think there will be any long-term impacts?
Han: I do, and I'm hoping that they're for the better. I know that getting into the health system for care has always been a challenge for COPD patients, even outside the pandemic. I'm hoping that we can make at least some version of virtual [care] work for patients and figure out how to do that.
But in order to do so we've got to solve some of the technology problems. We need to figure out how to better deliver patient education virtually. We also need to figure out how better to deliver pulmonary rehabilitation, I think in a virtual format. Certainly, there are pulmonary rehab programs that are virtual that exist but trying to figure out how to help patients access that has been a challenge. Another thing that we've seen is, there are portable spirometers that are available. There are companies that manufacture these. They exist and the platforms exist to get these into the hands of patients, but how to bill for them, how to monitor, how to use that information, how to get that information into the electronic medical record, such as EPIC that we're on at the University of Michigan, and I think many health systems are on, those details have not yet been sorted out.
I think this is an opportunity to try to figure out all of these issues, such that we can better deliver care in a way that patients most need it in the future. Interestingly, before the pandemic The University of Michigan had as a goal to transition roughly 30% to 35% of all patient visits to virtual…just to increase access. I would envision that, in the future, I will have better ability to provide care virtually for patients, including patient education and rehab and mobile spirometry, if that makes sense for the patient.
But I don't think this means in-person visits will go away. I think in the future, we will probably be looking at a hybrid approach where patients might do virtual visits, for instance, alternating with in-person visits or perhaps, doing urgent add-on visits virtually if that's the most convenient for both the patient and the provider. My hope is that this will sort of improve options to optimize patient care moving forward because we've been forced to figure out how to deliver care in different ways during the pandemic.
AJMC®: Is there anything that we haven't covered that you would like to discuss, or do you have any final thoughts you'd like to share?
Han: The best final wrap-up thought would be just encouraging patients who do have COPD to get vaccinated as soon as they are able. I have no reason at this point to believe that the vaccines are not safe or effective in the patient population that we're discussing. And I am strongly recommending that all of my COPD patients get the vaccine as soon as they can.