Healthcare professionals comment on the progressive nature of chronic obstructive pulmonary disease and highlight considerations for stratifying patients and navigating through limitations when managing patients.

Transcript

Neil B. Minkoff, MD: The question I was going to ask is: Define the impact on patients’ lives, which I think you’ve all done to a great extent. How bad does it get? How withdrawn do these patients get? How immobile do these patients get, in your experience, as the kind of people who are probably treating some of the most complicated patients?

Byron Thomashow, MD: Most of the time people live with their disease, and most of the time they live with their disease for a very long time. It is usually a gradually progressive disease. There is a subset who tend to be more rapidly progressive. That’s the exception rather than the rule, but we certainly do see that. And point of fact, 1 of the things that has certainly been a concern for many of us for many years is that we have tended to lump all COPD [chronic obstructive pulmonary disease] as the same and have treated it all the same. All COPD is not the same. Just as we have moved, in recent years, away from treating all cancers the same, we need to start moving away from treating all COPD the same.

There are certainly some recent data that have come out from a very large study that both Frank Sciurba and I have been involved in, called COPDGene, that suggests that COPD progresses in different ways. There’s a group that does progress that tends to have more of an emphysematous phenotype, if you will, through the classic gets more and more severe obstruction. But there’s another group that tends to go to a more restricted pattern, and then more rapidly down to progression, that perhaps we need to view in a different fashion. This is all that’s changing in front of us, but I think we all recognize the need to move away from treating and dealing with it all the same.

Neil B. Minkoff, MD: Let me ask a question. Let me bring what you just said over here. Are there ways for you, as a clinician or for you as someone who’s looking at it in an aggregate from the claims point of view, to try to identify who those rapid progressors are versus the slower progressors? And do you stratify their care differently?

Frank C. Sciurba, MD, FCCP: This is actually an important question, but it’s not a question we would target differently right now. Right now, our therapies are not convincingly effective in preventing progression. They’re to optimize a given person’s lung function at a given time and to improve their quality of life. We can affect exacerbations, and I’m sure we’ll get into that in a little bit. But as far as the gradual decline that we know happens in these individuals over time, we’ve not convincingly proven that we have therapies that can affect that.

Byron Thomashow, MD: Although there is some suggestion that if we did it earlier, maybe we could make a difference.

Frank C. Sciurba, MD, FCCP: Certainly with smoking cessation that’s the case.

Byron Thomashow, MD: Yes.

Frank C. Sciurba, MD, FCCP: With the drugs we have early suggestions, but I think we need better therapies.

Neil B. Minkoff, MD: Maria?

Maria Lopes, MD, MS: Yeah, I think we tend to follow guidelines as well as US Preventive Services Task Force measures. Certainly smoking cessation is a huge opportunity. Fifty percent of our chronic conditions are driven by bad behaviors.

Frank C. Sciurba, MD, FCCP: Sure.

Maria Lopes, MD, MS: Smoking cessation is 1 of them. Particularly in this disease, it can make a big impact and have an impact on cancer prevention as well. Going back to the diagnosis, even just making the diagnosis with spirometry you see so much variation. Patients may be labeled and not have the disease or have restrictive lung disease and not have COPD. So getting the right diagnosis in play to hopefully have the right treatment approach that follows is important.

Other opportunities in terms of pulmonary rehab, as a health plan covering pulmonary rehab and how many patients avail themselves to the benefit that exists. And then I also think that clinical inertia, the adherence, even better training with devices, and strategies related to technique and inhalation. Because obviously that matters. The best drug, unless it’s taken appropriately, is not going to have the desired impact. Also, prevention in terms of flu vaccination, pneumococcal vaccines. These are the things on a macro level we tend to be focused on. They impact our rating scores and our quality metrics and have a major impact on cost of care as well.

Byron Thomashow, MD: I think we all agree with everything you just said. I know we’re going to talk a lot more about the medications, but I do want to stress, and I’m sure Frank feels this as well, that pulmonary rehabilitation and exercise programs, in general, are tremendously underutilized in this population. There are some data suggesting that somewhere between 2% and 5% of the 30 million people in this country with COPD ever complete pulmonary rehabilitation. In New York City, where I practice, there may be at most half a dozen pulmonary rehab programs for a population of millions of people. For a therapy that clearly is very effective, that’s really just not acceptable. And it’s gotten progressively worse, actually, since the national reimbursement policy went into place, because the reimbursement rates are just not sustainable. I assume it’s similar in Pittsburgh, Frank?

Frank C. Sciurba, MD, FCCP: One of the problems with pulmonary rehab is that it’s almost never accessible in rural populations, and there are incredible variations even in cities. The Cochrane review on pulmonary rehab said, “We’re not doing this anymore because it’s convincingly effective in improving quality of life and exercise tolerance. So just do it.” Unfortunately, it’s not being done—3% to 5%, as Byron said.

Byron Thomashow, MD: Frank mentioned rural America. There are a tremendous amount of data that have come present in recent years that reveal that people who live in rural America are at far greater risk of having COPD and progressive COPD than those who even live in an urban environment. It’s an area that is really difficult because that’s an area where the number of practicing pulmonologists is frighteningly small. And the number of rehab programs is even smaller.