COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 1

COPD: Current Clinical and Economic Burden

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Prior to diving into a discussion on best practices for managing chronic obstructive pulmonary disease, stakeholders in health care remark on the prevalence and impact of the disease in the United States.


Neil Minkoff, MD: Hello, and welcome to the American Journal of Managed Care® program, “COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcome.” I’m Dr Neil Minkoff, the founder of FountainHead HealthCare.

Joining me today in this important discussion are some of my colleagues: Dr Bradley Drummond, associate professor of medicine in the Division of Pulmonary Diseases at the University of North Carolina School of Medicine; Mr Michael Hess, respiratory therapist and the chronic lung disease coordinator for the Western Michigan University School of Medicine; Dr Maria Lopes, a former chief medical officer of Magellan Rx, EmblemHealth, at Horizon Blue Cross/Blue Shield; and Dr Donald Mahler, the emeritus professor of medicine, Division of Pulmonology at the Geisel School of Medicine at Dartmouth University.

Today, this panel of experts will provide an overview of existing treatment options, practical considerations for drug and device selection, the role of peak inspiratory flow to evaluate treatment, recent guideline recommendations, and approaches for health care decision-makers and clinicians for individualized management of COPD [chronic obstructive pulmonary disease] based on patient characteristics and limitations.

With that, I’ll try to begin. To get us level set and to make sure we’re all on the same page, let’s start with an understanding of the clinical burden of COPD in the United States: the key drivers, what the patients are experiencing, and what pushes health care utilization. Dr. Drummond, could you lead us, please?

M. Bradley Drummond, MD, MHS: Sure. Thanks, Dr Minkoff. We really can’t underestimate the burden of COPD in the United States. It’s estimated that 16 million US adults have COPD and that’s likely an underestimate given the underdiagnosis of COPD, as it requires spirometry testing. Potentially, upward of 24 million individuals in the United States have COPD. It’s the fourth leading cause of death in the US. To put a face to that, that’s the equivalent of 1 Airbus A380 crashing every single day in the United States, so it’s an important disease to focus on.

It’s estimated that there’s about $5 billion in annualized medical expenditures related to COPD in the US, and those with COPD have about 2 times the health care cost of those without COPD.

When we think about what drives this health care utilization, there are 2 components to the COPD disease. The first is the burden of respiratory symptoms, and the second is what we call the acute exacerbation of COPD. Let’s talk about the symptoms first.

Patients with COPD experience regular shortness of breath, cough, phlegm, and wheezing. This can impact to their daily life and their work productivity. It leads to frequent outpatient health care encounters and drives the need for additional inhaled medical therapies. It also can impact other comorbidities, like depression and cardiovascular disease, so the symptom burden is an important driver of the clinical burden of COPD.

Related to that are what we call acute exacerbations of COPD. In COPD, there are normal day-to-day fluctuations of respiratory symptoms. But there are episodes of acute sudden worsening, which are called exacerbations, and this may be worsening of cough, shortness of breath, or wheeze. It may be driven by a trigger such as viral infections, or unknown triggers, and this often leads to escalation of care with antibiotics and steroids. These can occur in the outpatient setting, require emergency department [ED] evaluation, or even hospitalization.

Exacerbations matter. An individual who’s hospitalized with an exacerbation has a 25% chance of being dead in the next year. For those who require additional, what we call noninvasive ventilations, so a mask to help improve their airflow, 40% of those could be dead in a year. This is a substantial signal of disease morbidity in COPD, and it’s associated with significant health care costs. When we think about these factors—symptoms, exacerbations, and impact on comorbidities—these really help drive our understanding of the clinical burden of COPD in the United States.

Neil Minkoff, MD: You raised an interesting point near the end that I wanted to follow up on: how these things are also impacting cost. It’s always such an important part of what we do, to try to be stewards of cost and try to be conscious of that. Dr Lopes, could you talk a little bit about, from your experience in the payer world, what has been an economic burden of COPD and how COPD drives health care spending?

Maria Lopes, MD, MS: Absolutely. Dr Drummond explained so many good points: the relationship between exacerbations, ED visits, hospitalization, and also the use of DME [durable medical equipment]. Some of these patients, particularly later stage, are on oxygen. Obviously, many of them have comorbidities, and this can impact sleep, anxiety, depression, and cardiovascular risk. If you have COPD on top of other comorbidities, you’re at even higher risk of ending up in the ER or hospitalized.

Of course, now we’re worried about COVID-19 [coronavirus disease 2019] and respiratory infections. That only compounds the issues around total cost of care. When we think about total cost, we think of the outpatient component, and we think about the inpatient component. The single biggest driver of repeat hospitalizations is if you’ve already had a hospitalization related to respiratory issues in the past 6 to 12 months. So, certainly a lot of focus. I think COPD is actually second only to heart failure with respect to 30-day readmission. Certainly for payers, COPD is very high on the radar in terms of everything we can do to stabilize, educate, focus on health care management, and how we can improve the care delivery for these patients.

This activity is supported by an educational grant from Boehringer Ingelheim.