Caring for Patients With COPD

Deciphering the fourth leading cause of death and the seventh leading cause of loss of disability for older adults.

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Chronic obstructive pulmonary disease (COPD) is incapacitating at advanced stages and often leads to the death of the patient. By 2030, it is expected to be the fourth leading cause of death and the seventh leading cause of loss of disability adjusted life years (DALYs).1

Until the year 2000, few epidemiological studies had addressed COPD, and those that were undertaken mostly targeted the population aged over 40 years. A meta-analysis of studies published up to 2004 estimated COPD prevalence among over 40-year-olds to be 10%;2 however, heterogeneity in the case definitions makes for inter-study comparisons difficult. In the latest update of the Global initiative for Obstructive Lung Disease (GOLD), prevalence, again, is directly linked to tobacco smoking, occupational environments and outdoor pollution.3

Comorbidity is present in one third of the adult population and its prevalence increases with age, eventually affecting 60% of the population aged 55 to 74 years.4,5 COPD often coexists with other diseases, and this comorbidity is a key prognostic factor of the consequences of COPD. Some of these diseases occur regardless of COPD, some are related by virtue of having a common cause and others share risk factors with COPD.3

For instance, inflammation brought about by smoking can be a common route for a series of diseases, such as ischemic heart disease, heart failure, osteoporosis, anemia, cancer, depression and diabetes.6 COPD-associated comorbidity contributes to symptoms, often determines the quality of life, incrementally increases healthcare costs and has a negative impact on the mortality of patients suffering with COPD.7,8,9

COPD in the Recent Literature
Clinical research efforts tend to target isolated and acute manifestations of disease. Chronic care, on the other hand, is geared to managing individual diseases via "disease management programs". The clinical practice guidelines that underpin these models, likewise, focus on isolated diseases.10 Stratification of COPD patients takes into account the level of obstruction, but does not usually consider the burden of comorbidity, notwithstanding its implications.

The common co-existence of diverse comorbidities with COPD can be partly explained by their shared risk factor (i.e., cigarette smoking). However, the fact that the association between COPD and cardiovascular disease in the youngest cohort of patients was high in never-smokers suggests that smoking itself is an insufficient explanation. It is believed that many of these comorbidities can be attributed to systemic inflammation.11 How to address that underlying condition is a topic of ongoing research.

Clinical research into comorbidity is a relatively new field; population, hospital and primary healthcare studies are some recent examples. Most of these studies, however, have analyzed the association between COPD and several isolated diseases - and a few of them have analyzed COPD's association to larger groups of chronic diseases. COPD is also thought to be a disease suffered by elderly people, with comorbidities more common among older patients. An unintended consequence of this link becomes a key point when studying comorbidity. One must distinguish clearly if these diseases are independent or if they are associated more frequently with COPD than in general population.12

What About Spirometry?
It is unclear if primary care physicians are following guidelines or using other patient characteristics and factors to determine when to perform spirometry in patients at risk for COPD. It is also unclear to what degree a diagnosis of COPD is accurately reflected by spirometry results.

In a retrospective cohort study, Chicago researchers examined characteristics associated with spirometry usage in primary care for patients with increased risk for COPD and the accuracy of COPD diagnosis in patients with spirometry. The medical records of all primary care physician visits prior to the time of inclusion were reviewed. Data on patient demographics, comorbidities, respiratory medication use, presence of symptoms, history of tobacco use and pulmonary function tests were extracted. A cohort that met the following criteria was identified: ≥35 years of age; ≥ 2 primary care visits in an internal medicine clinic in 2007; at least one respiratory or smoking cessation medication, or diagnosis of COPD, shortness of breath or dyspnea in 2007. From these parameters, a total 1052 patients were identified.

Dyspnea on exertion (Adjusted odds ratio (AOR) 1.52 [95% CI 1.06-2.18]) and chronic cough (AOR 1.71 [1.07-2.72]) were the only chronic symptoms associated with use of spirometry. Current (AOR 1.54 [0.99-2.40]) or past smoking (AOR 1.09 [0.72-1.65]) status were not associated with use of spirometry. Of the 159 patients with a diagnosis of COPD, 93 (58.5%) met GOLD criteria and 81 (50.9%) met lower limit of normal (LLN) criteria for COPD. They concluded that allopathic and osteopathic family physicians (FPs) use spirometry more often among patients with symptoms suggestive of COPD but not more often among patients with current or past tobacco use. For patients who had a spirometry and a diagnosis of COPD, primary care physicians were accurate in their diagnosis only half of the time.13

Holistic & Multdisciplinary Treatment
The assessment of COPD is required to determine the severity of the disease, its impact on the health status and the risk of future events - such as exacerbations, hospital admissions or death - and this is essential to guide therapy. COPD is treated with inhaled bronchodilators, inhaled corticosteroids, oral theophylline and oral phosphodiesterase-4 inhibitor. Non-pharmacological treatment of COPD includes smoking cessation, pulmonary rehabilitation and nutritional support.14 Lung volume reduction surgery and lung transplantation are advised in select severe patients.15 Global strategy for the diagnosis, management and prevention of COPD guidelines recommend influenza and pneumococcal vaccinations.16

So, therein lies the challenge . despite a well-recognized burden of disabling physical symptoms compounded by comorbidities, psychological distress and social isolation, the needs of people with severe COPD have yet to be optimally managed in the primary care setting.

Here are some important COPD facts to help family medicine physicians better understand the condition and its impact:
  • COPD is the third leading cause of death in America, claiming the lives of 124,477 Americans in 2007.17
  • This is the eight consecutive year in which women have exceeded men in the number of deaths attributable to COPD. In 2007, almost 64,000 females died compared to almost 60,000 males.18
  • Smoking is the primary risk factor for COPD. Approximately 85 to 90% of COPD deaths are caused by smoking. Female smokers are nearly 13 times as likely to die from COPD as women who have never smoked. Male smokers are nearly 12 times as likely to die from COPD as men who have never smoked.19 Any current or former smoker over age 40 or never-smoker with a family history of COPD, emphysema or chronic bronchitis, those with exposure to occupational or environmental pollutants and those with a chronic cough, sputum production or breathlessness, should seek testing for COPD with spirometry.20
  • Other risk factors of COPD include exposure to air pollution, second-hand smoke and occupational dusts and chemicals, heredity, a history of childhood respiratory infections and socioeconomic status.21 Particulate matter from cigarette smoke and air pollution, including smoke from poorly ventilated wood stoves and the burning of biomass, are related to lung damage.22
  • Occupational exposure to certain industrial pollutants also increases the risk for COPD. One study found that the percentage of COPD attributed to work was estimated as 19.2% overall and 31.1% among never smokers.23
  • In 2008, 13.1 million U.S. adults (aged 18 and over) were estimated to have COPD.24 However, close to 24 million U.S. adults have evidence of impaired lung function, indicating an under diagnosis of COPD.25
  • An estimated 672,000 hospital discharges were reported in 2006 - a discharge rate of 22.5 per 100,000 population. COPD is an important cause of hospitalization in our aged population. Approximately 64% of discharges were in the 65 years and older population in 2006.26
  • A Lung Association survey revealed that half of all COPD patients (51%) say their condition limits their ability to work. It also limits them in normal physical exertion (70%), household chores (56%), social activities (53%), sleeping (50%) and family activities (46%).27
  • In 2010, the cost to the nation for COPD was projected to be approximately $49.9 billion, including $29.5 billion in direct healthcare expenditures, $8 billion in indirect morbidity costs and $12.4 billion in indirect mortality costs.28
  1. Mathers CD, Loncar D: Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006, 3:e442. 
  2. Halbert RJ, Natoli JL, Gano A, Badamgarv E, Buist AS, Manino DM: Global burden of COPD: systematic review and meta-analysis. Eur Respir J 2006, 28:523-532. 
  3. Global initiative for chronic Obstructive Lung Disease: Global strategies for diagnosis, management, and prevention of chronic obstructive pulmonary disease - 2013 Update. http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf
  4. Fortin M, Lapointe LA, Hudon C, Vanasse A: Multimorbidity is common to family practice. Is it commonly researched? Can Fam Physician 2005, 51:244-250. 
  5. Laux G, Kuehlein T, Rosemann T, Szecsenyi J: Co- and multimorbidity patterns in primary care based on episodes of care: results from the German CONTENT project. BMC Health Serv Res 2008, 8:14-21. 
  6. Bornes PJ, Celli BR: Systemic manifestations and comorbidities of COPD. Eur Respir J 2009, 33:1165-1185. 
  7. Yeo J, Karimova G, Bansal S: Co-morbidity in older patients with COPD -- its impact on health service utilization and quality of life, a community study. Age Ageing 2006, 35:33-37. 
  8. Menzin J, Boulanger L, Marton J, Guadagno L, Dastani H, Dirani R, et al:The economic burden of chronic obstructive pulmonary disease (COPD) in a U.S. medicare population. Respir Med 2008, 102:1248-1256. 
  9. Sin DD, Anthonisen NR, Soriano JB, Agusti AG: Mortality in COPD: role of comorbidities. Eur Respir J 2006, 28:1245-1257. 
  10. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW: Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. Implications for pay for performance. JAMA 2005, 294:716-724. 
  11. Fabbri LM, Rabe KF. From COPD to chronic systemic inflammatory syndrome? Lancet. 2007;370:797-799. 
  12. Van den Akker M, Buntinx F, Metsemakers JFM, Roos S, Knottnerus JA: Multimorbidity in general practice: prevalence, incidence and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol 1998, 51:367-375. 
  13. Joo MJ, Au DH, Fitzgibbon ML, McKell J, Lee TA. Determinants of spirometry use and accuracy of COPD diagnosis in primary care. J Gen Intern Med. 2011 Nov;26(11):1272-7. doi: 10.1007/s11606-011-1770-1. Epub 2011 Jun 29. 
  14. Breunig IM, Shaya FT, Scharf SM. Delivering cost-effective care for COPD in the USA: recent progress and current challenges. Expert Rev Pharmacoecon Outcomes Res. 2012 Dec;12(6):725-31 
  15. Arango E, Espinosa D, Illana J, et al. Lung volume reduction surgery after lung transplantation for emphysema-chronic obstructive pulmonary disease. Transplant Proc. 2012 Sep;44(7):2115-7 
  16. Sehatzadeh S. Influenza and pneumococcal vaccinations for patients with chronic obstructive pulmonary disease (COPD): an evidence-based review. Ont Health Technol Assess Ser. 2012;12(3):1-64. Epub 2012 Mar 1 
  17. Centers for Disease Control and Prevention. National Center for Health Statistics. 
  18. Final Vital Statistics Report. Deaths: Final Data for 2007. Vol. 58, No. 19, May 2010. 
  19. U.S. Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General, 2004. 
  20. Celli BR, MacNee W, et al. Standards for the Diagnosis and Treatment of Patients with COPD: A Summary of the ATS/ERS Position Paper. European Respiratory Journal. 2004; 23:932-46. 
  21. Global Initiative for Chronic Obstructive Pulmonary Disease. Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Updated 2007. Accessed on June 10, 2009. 
  22. U.S Environmental Protection Agency. Air & Radiation: Six Common Pollutants; Particulate Matter, Health and Environment. May 9, 2008. Accessed on June 10, 2009. 
  23. Hnizdo E, Sullivan, PA, Bang KM and Wagner G. Association between COPD and Employment by Industry and Occupation in the US Population: A Study of Data from the Third National Health and Nutrition Examination Survey. American Journal of Epidemiology. 2002; 156:738-45. 
  24. Centers for Disease Control and Prevention. National Center for Health Statistics: National Health Interview Survey Raw Data, 2008. Analysis performed by American Lung Association Research and Program Services using SPSS and SUDAAN software. 
  25. Centers for Disease Control and Prevention. Chronic Obstructive Pulmonary Disease Surveillance - United States, 1971-2000. Morbidity and Mortality Weekly Report. August 2, 2002; 51(SS06):1-16. 
  26. Centers for Disease Control and Prevention. National Center for Health Statistics. National Hospital Discharge Survey, 1979-2006. 2006 Unpublished Data. 
  27. Confronting COPD in America, 2000. Schulman, Ronca and Bucuvalas, Inc. (SRBI) Funded by Glaxo Smith Kline. 
  28. U.S. Department of Health and Human Services. National Institutes of Health. National Heart Lung and Blood Institute. Morbidity and Mortality: 2009 Chartbook on Cardiovascular, Lung and Blood Diseases.
Ken Korber is the education director for the American College of Osteopathic Family Physicians (ACOFP) and the COPD Alliance.


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