Optimal Management of COPD: Escalation and De-escalation of Therapy

Treatment pathways, including escalation and de-escalation of therapy, for patients with COPD are explored by a panel of medical experts.

Jeffrey D. Dunn, PharmD, MBA: How long are you typically waiting to consider escalating or de-escalating therapy?

Reynold Panettieri Jr, MD: I tend to escalate pretty [early] in the process to meet goals. I’m impatient, and I also love to [eliminate] drugs quickly and move on to the next group of drugs. But I engage the patient and tell them what the metrics are for me to think this therapy is successful and then stay to those milestones. It’s hard to generalize, but I’m going to add drugs quickly to get them to their personal best. Then once they’re at their personal best for a period of time—3, 6, 9, or 12 months—I consider peeling back medicine, but only if I got to their personal best.

Jeffrey D. Dunn, PharmD, MBA: Courtney, if somebody is doing well, what does an appropriate follow-up look like in terms of timing and conversation?

Courtney Crim, MD: If the [patient] has pretty much met their goals and is not significantly symptomatic, and we’ve reached the goal that they were seeking, then I may have them come back in 6 months and see how they’re doing. If they’re particularly stable at that in time on their regimen and they’re using their inhalers correctly—because that’s something important to assess at every visit—that would be a circumstance in which I might consider de-escalating their therapy. But it depends on why I escalated.

For example, if a reason for escalating is exacerbations, if a [patient] was having either no or 1 exacerbation per year and they started having 2 or 3, and I stepped them up, adding the inhaled corticosteroid, it’s going to take a year or so for me to be [confident] that the therapy is affecting exacerbations. Whereas, on the other hand, if it was dyspnea, exercise limitation, or things of that particular nature, I’ll be able to get a signal much sooner than that. Where they are and the main issue with the therapy that was implemented will determine how often I’ll follow them to see if we reach the plateau and whether we need to step up or down.

…When a patient presents, depending on how severe my perception is of their complaint, whether it’s shortness of breath or what have you, I may have them come back sooner than if they didn’t appear to be that sick. It’s empiric. Are they sick? Are they sick-sick? Are they sick-sick-sick? That would determine the frequency that I’d have them come back and follow up.

Jeffrey D. Dunn, PharmD, MBA: Even if they aren’t having exacerbations, these patients need fairly frequent intervention. A lot of that goes into what we’ve been talking about separately. It’s all of the other stuff too.

Courtney Crim, MD: Correct. That’s what I’m saying. If I’m stepping up because of exacerbations, I recognize that if I want to decrease their risk of exacerbations, that end point will take time for follow-up, compared with dyspnea or exercise limitation.

Jeffrey D. Dunn, PharmD, MBA: Excellent. I’m going to ask a big question, and this can go a lot of different ways….How does appropriate guideline-based disease state management impact quality metrics in COPD [chronic obstructive pulmonary disease]? I’m sure you have to meet certain metrics, whether they’re regulatory based, payer based, or facility based. How does that factor into what you do?

Mike Hess, MPH, RRT, RPFT: There’s probably going to be some variation on that depending on the system that you’re in. There are certain payment models under Medicare, where as long as you’re prescribing things that are associated with guideline-based, evidence-based practice, then you’re meeting those benchmarks. But there are other issues as well. Patient satisfaction is a huge issue. As a respiratory therapist, I’ve found that when [patients] can’t breathe, they aren’t very happy. But when you can help them breathe better, they’re a little happier.

It’s tough because everybody is going to define those metrics a bit differently. When I was in primary care, we had metrics based on whether we were talking about tobacco cessation, prescribing things appropriately, recommending those prescriptions, or patient satisfaction. I don’t mean [for this] to sound like too much of a cop-out, but it’s a very vague question based on your practice setting.

Jeffrey D. Dunn, PharmD, MBA: That’s fair. In my experience, a lot of those metrics are operation based. They aren’t outcome based.

Mike Hess, MPH, RRT, RPFT: Exactly.

Jeffrey D. Dunn, PharmD, MBA: It would be nice if we could measure outcomes rather than just ask questions. That makes sense to me. Do you have any comments from a different perspective around quality metrics?

Reynold Panettieri Jr, MD: I thought Mike did a great job. You define metrics accordingly. There are health care utilization metrics, how many times [patients] are in the ED [emergency department], how many are hospitalized, and how many are in the ICU [intensive care unit]. You want to avoid those. The other aspect here is population health, which is a whole different metric. We don’t know the value proposition there, but the greatest value proposition is to prevent smoking and smoking cessation. It depends on which god you pray to. Is it going to be utilization or population health and wellness? Then there’s something in between.

Jeffrey D. Dunn, PharmD, MBA: I love that comment because formularies are population tools as well. There’s a disconnect between making pharmaceutical decisions vs making care management decisions when we’re talking about individual patients. These things don’t always fit across the entire spectrum. I appreciate those comments.

Transcript edited for clarity.

CH LogoCenter for Biosimilars Logo