COPD Projected to be Third Leading Cause of Death by 2020

Boston—Chronic obstructive pulmonary disease (COPD) is the leading cause of morbidity and mortality worldwide, and by 2020, COPD will be the third leading cause of mortality, according to a satellite symposium presented at the AMCP meeting. The session was supported by educational grants from AstraZeneca and Boehringer Ingelheim.

Neil MacIntyre, MD, professor, Duke University Medical Center, opened the session by acknowledging the increasing economic burden of COPD management, with an estimated $29.5 billion in direct US costs and an estimated $20.4 billion in indirect US costs. The increasing mortality of COPD is mainly attributed to smoking habits.

The diagnosis of COPD typically occurs after exposure to risk factors and symptom onset. In the United States and Western Europe, smoking is the big culprit of COPD development, though in third world countries, indoor cooking is a large facilitator. Symptoms that present with COPD include sputum, cough, dyspnea, and wheezing. These factors often lead clinicians to conduct a spirometry test, which is the oldest clinical test still in use today, originating in 1946. However, spirometry is often underutilized and COPD is commonly underdiagnosed, according to the presentation.

Dr. MacIntyre said the GOLD [The Global Initiative for Chronic Obstructive Lung Disease] guidelines (www.goldcopd.org) should be followed and call for a combined assessment that includes 3 components: (1) spirometry to assess the degree of airflow limitations; (2) symptom assessment; and (3) risk of exacerbations.

Though rates of conditions such as coronary heart disease, stroke, and other cardiovascular diseases have decreased since 1965, the rate of COPD has continued to increase. “It is going up, and it is going up a lot,” said Dr. MacIntyre. He said the increased rate can be attributed to the extensive smoking habits in the 1960s and 1970s. Symptoms do not usually present until the lung capacity reaches 50%, so individuals who smoked decades ago are just now being diagnosed. Though smoking rates have decreased in recent years, Dr. MacIntyre said it will take many more decades before this decline is seen in COPD rates.

Dr. MacIntyre said hospital care accounts for the biggest cost contributor for this disease state, followed by prescription medications and physician services. Because hospital rates are a significant cost driver, Dr. MacIntyre said the Centers for Medicare & Medicaid Services (CMS) is making COPD a big focus in order to reduce exacerbations and hospital readmissions.

Current classes of treatment options for COPD include anticholinergics, short-acting agents, long-acting agents, combination bronchodilators, inhaled corticosteroids, and phosphodiesterase 4 inhibitors. “Triple therapy is coming [and is] likely to be very expensive,” said Dr. MacIntyre.

In addition to treatment and oxygen, Dr. MacIntyre stressed the need for an action plan for patients. “This is not pushed as hard as it can be,” he said. Action plans are a useful tool for patients so they are prepared and hospital readmissions can be avoided. Patients should be able to understand the complex medication regimens and have clinical support structures in place, such as a hotline to call with questions or a healthcare provider point person to contact. Medication adherence and understanding will lead to fewer hospitalizations, said Dr. MacIntyre.

Ben Hamlin, MPH, director, performance measurement, National Committee for Quality Assurance (NCQA), reiterated the importance of managing COPD rehospitalizations, noting that 1 in 11 patients with COPD are readmitted within 30 days of discharge, and approximately 10% of emergency department visits for COPD exacerbations are near-fatal events. “For the CMS and [the Department of Health and Human Services], these statistics raise a lot of concern,” said Dr. Hamlin.
As part of the NCQA, Dr. Hamlin discussed the Healthcare Effectiveness Data and Information Set (HEDIS®) measures for COPD. He said performance rates indicate that there is much room for improvement in both early
diagnosis and management following COPD exacerbations. Dr. Hamlin said new measures are underway. “Quality measurement is in a transitional phase,” said Dr. Hamlin, but he was hopeful that new measures would be published soon to encourage better data collection on COPD.

Eric Cannon, PharmD, FAMCP, chief of pharmacy, SelectHealth, concluded the session by agreeing that better measurement and data collection is needed for COPD, indicating the need for a standardized approach to care.

The objectives of better COPD management, put forth by the GOLD guidelines, include:
• Prevent disease progression
• Relieve symptoms
• Improve exercise tolerance
• Improve health status
• Prevent and treat exacerbations
• Prevent and treat complications
• Reduce mortality
• Minimize side effects from treatment

He highlighted the components needed for a disease management program that would include:
• Member identification process
• Evidence-based practice guidelines
• Risk stratification and matching of interventions with need
• Collaborative practice model integrating physician and support staff
• Self-management education program for patients
• Routine reporting and feedback processes, including the patient, physicians, and health plan
• Information technology, including the use of the Internet and distance measuring
• Methodology for process and outcomes measurement

Dr. Cannon also said there needs to be a better division of management responsibilities among various healthcare providers.—Kerri Fitzgerald