Utilization of Treatment Guidelines for COPD

An overview of treatment algorithms for chronic obstructive pulmonary disease and implications for standardized therapy versus a personalized approach.


Neil B. Minkoff, MD: Let me raise what seems to me to be somewhat of a conundrum. I talk to specialists and subspecialists, like yourselves, and there’s a tremendous amount of concern about the patient not being treated as a patient and their goals not being adjusted to. Yet when I go to any of the fancy buildings in Washington with 3-letter acronyms that want to measure healthcare and so on, everything comes back to how closely you followed the guideline, right? And so the plans, the payers—many of them have adopted either the goals or the COPD [chronic obstructive pulmonary disease] Foundation treatment guidelines because that’s what they have to fall back on and that’s what they’re being pushed to use…

I’m going to ask you, Maria, how you’re using those algorithms. And then, where do we need to follow the algorithms for a basic patient, and when do we know to veer away from them? Because we’re having this sort of head butting between personalizing therapy and standardizing therapy, and both are actually quite strong movements.

Maria Lopes, MD, MS: And also, the payer is usually not in the role of practicing medicine. And this may have been tied to the formulary—what drugs are available, how onerous we create barriers in terms of using certain drugs or not. But I think the point is a good one. As a payer, this is a disease that has incredible importance in terms of the implications for total cost of care. For the most part, wanting to have access to agents and classes of agents that, according to the guidelines, should be used—and, if anything, generics are on the lowest tier. We want patients to use them.

But to the extent that there’s clinical inertia, that’s where hopefully data [help] to assist in closing gaps in care or being able to provide meaningful and actionable data to clinicians. They could see that even though they wrote the prescription, that patient never picked it up. Or they’re using the wrong combinations or more rescue inhalers, etc. The payer is an incredible position with data to be able to look at not only variations in care but also gaps in care that hopefully have a meaningful impact on how we can not only personalize but perhaps keep people out of the hospital or ER [emergency department].

Byron Thomashow, MD: Let me just follow up on that, Maria, because I find it very interesting. Part of the problem, as we mentioned before, is that patients with chronic diseases like COPD have so many other comorbid conditions.

Maria Lopes, MD, MS: Yes.

Neil B. Minkoff, MD: Correct.

Byron Thomashow, MD: So it’s not at all unusual for a patient with COPD to have 5, 6, 7 other conditions and to be on 10 to 15 different medications. Anyone who believes that those patients take 10 or 15 different medicines are drinking something. It just doesn’t happen. Even if you’ve got a drug plan, once you start adding 5, 10, 15 different drugs with your co-pays, you’re talking about hundreds and hundreds of dollars a month. It’s an impact with all the things we do in medicine, but it’s particularly an impact in patients who have COPD because of what Frank said from the beginning: People frequently will cut back on their activity level. It’s the reason why there are a lot of data suggesting that even though we have medicines that oftentimes can help, only 30% of people refill a prescription for many of these medicines, because there’s a cost issue as you start adding these 15 different drugs. It’s 1 of the major differences between asthma, for example, and COPD. There are many, but most young asthmatics just have asthma. Most COPD patients, as they go along, have multiple other issues with multiple other medicines. I don’t have a simple answer to that, but it is a problem.

Neil B. Minkoff, MD: So let me ask you a question about trying to pull this together. We, as payers, and a lot of provider organizations spend their time bringing the GOLD [Global Initiative for Chronic Obstructive Lung Disease] guidelines, as an example, out to their primary care doctors and so on. When do you deviate from those? And is it based on exacerbations? Is it based on symptoms? Is it based on patient to patient? How do you decide when the deviation from the algorithm is justified?

Frank C. Sciurba, MD, FCCP: One good thing about the COPD-based guidelines—both with the COPD Foundation that Byron has a heavy hand in and the GOLD guidelines—is they actually do have components of personalized medicine in those. So they do acknowledge that 1 size doesn’t fit all. They’re also not just based on the traditional definer of disease severity, FEV1 [forced expiratory volume in 1 second]. They acknowledge symptoms and exacerbation frequency, and they stratify different therapies based on those. And so those guidelines do allow for some granularity.

As specialists, we don’t worship the guidelines. We recognize there’s even more granularity and make decisions that—I mean, I don’t know when I follow or I don’t follow the guidelines, because as a specialist, I think the guidelines are thoughtful. They help guide therapy, but I feel that there needs to be more flexibility. And so I don’t make a decision to follow or not follow the guidelines. I treat the patient in front of me. The reality is that my treatment is consistent with the guidelines, but there are some variations, I think, as a specialist.

Byron Thomashow, MD: What Frank said is probably true with most of us. I think the problem is complicated because, for example, if you look at GOLD, and you can make a strong argument that GOLD is the most important program in the COPD world over the last several decades—they deserve a tremendous amount of credit from moving away from FEV1 alone to include issues like exacerbations and symptoms, and I think they provide a wealth of information—I think their impact has predominantly been on the academic world—on clinical research trials in academic centers—with much less of an impact in the primary care world, where I suspect most people don’t know what GOLD is. And that’s problematic when most of your people live in primary care.

I know we’re going to be talking more about the medications that are available. And there are medicines that are available, but I think the data are suggesting that in the primary care world, most of these people are being treated with a combination of a long-acting beta-agonist and inhaled corticosteroid as if they have a variation of asthma. That’s probably not the best approach.

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