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Chronic obstructive pulmonary disease (COPD)
Spotlight
Chronic obstructive pulmonary disease (COPD) As the global burden of COPD rises, health services must develop strategies to treat exacerbations efficiently and effectively. The ways in which COPD exacerbations
In the USA, hospital admissions for COPD result in over US$ 13 billion in direct combined costs for insurance providers and patients annually, which has led to increased attention on how to improve quality and reduce costs for severe exacerbations. In 2014, the Center for Medicare and Medicaid Services (CMS) incorporated COPD into its Hospital Readmission Reduction Program (HRRP). Readmissions for any reason within 30 days after hospital admission for a COPD exacerbation count towards a hospital’s HRRP penalty programme, which imposes financial penalties to institutions where readmissions for specific conditions exceed the national average. Increased attention is subsequently being paid to improving care coordination within hospitals and the transition from hospital to home for patients admitted to hospital with COPD exacerbations. Some hospitals are exploring standardised inpatient instructions, multidisciplinary teams to coordinate inpatient care and the transition home, and specialised transitions to care clinics that can accommodate patients rapidly after admission for COPD. However, such programmes have met with mixed success and whether they are translatable across health systems is unclear, as is whether the resource investment actually pays off in terms of overall reductions in costs. Further complicating matters is the realisation that factors influencing readmissions may have less to do with care received in the hospital and more to do with the quality of outpatient care, which in many instances is provided by a completely different health system. However, changes to insurer reimbursement structures beyond just the HRRP are incentivising health systems to rapidly merge to be able to provide more global care of patients. Many insurers in the USA are also beginning to incentivise care coordination across providers. Ultimately, only time will tell whether such changes will not only reduce readmissions but also improve overall care quality for patients with COPD.
are handled varies from country to country—some exacerbating patients are admitted to emergency care, while others are treated outside of hospital by
COPD emergency admissions are rising in the UK, and COPD is the second most common cause of emergency admissions. Rates of hospital admission for COPD are generally higher in Scotland, Wales, and Northern Ireland, compared with England, but vary dramatically within regions of the UK (NNCCG data 2012–13). Research from Public Heath England has suggested that short-term hospital admissions might reflect poor care in primary care, and therefore an approach that reduces variability in primary care has merit. Many COPD exacerbations are managed in primary care, and patients are often seen by healthcare professionals who are not doctors, which differs markedly from other countries. Many projects have been proposed and delivered to reduce emergency admissions for COPD. In England, many of these projects are focused on integration of the organisations responsible for care. Scotland, Wales, and Northern Ireland have health boards that are responsible for the funding and delivery of care across boundaries. Integration of primary, secondary, community, urgent, and emergency care is crucial, as is reducing the inequality for patients with COPD in the community. The NHS 5-Year Forward View proposed as the structure for community care in England supports a radical re-design of health care, encouraging all providers to work together to deliver better and more standardised health care. Daryl Freeman, North Norfolk Clinical Commissioning Group, Aylsham, Norwich, UK
MeiLan K Han, University of Michigan, Ann Arbor, MI, USA
COPD remains underdiagnosed and undertreated in Brazil. While the overall prevalence of COPD in the country is not known, we do know that the disease affects approximately 16% of the population of São Paulo. It is estimated that many individuals with COPD still do not have access to bronchodilators, influenza vaccination or smoking cessation advice. Substantial variation exists in healthcare structures in Brazil, reflecting social and regional differences. Less than half of patients with COPD have access to private health insurance (which might not include coverage for medication or oxygen), but most rely on the overcrowded public health system. With some exceptions, the southern and southeastern regions of the country host most of the COPD treatment and specialised care centres. In Brazil, about one in five hospital admissions for respiratory problems are related to a COPD exacerbation. As in many other countries, mild and moderate exacerbations are treated in outpatient clinics and are undertreated or untreated, whereas severe cases are directed to tertiary care in hospitals. There is no standard path for exacerbation management in Brazil, and facilities often try to follow national and international guidelines as much as possible. A rather limited primary care system is one of the bottlenecks of the Brazilian healthcare structure in many regions, and its improvement would greatly increase access to proper pharmacological treatment, pulmonary rehabilitation, and oxygen therapy to patients with COPD. Fabio Pitta, PhD, State University of Londrina, Brazil
18
www.thelancet.com/respiratory Vol 5 January 2017
Spotlight
general practitioners or nurses. The Lancet Respiratory Medicine asked clinicians from around the world to explain how COPD exacerbations are handled in their countries, and the challenges faced by health services
as they try to improve and standardise care of these patients.
Laura Feetham, Aaron van Dorn
According to epidemiological studies conducted in Russia, the prevalence of COPD based on spirometry in patients with respiratory symptoms was estimated at 21·8% of adults. COPD mortality has increased in recent years, and according to official statistics of the Russian heath ministry, 45 000 patients with COPD died in Russia in 2015. COPD in Russia is treated according to national guidelines that comply with the GOLD initiative. Most patients with COPD who acquire medical help for any reason in the primary healthcare system are symptomatic (average CAT score 22·3, SD 7·6) and belong to GOLD B (22·4%) or GOLD D (74·3%) groups. Moreover, most patients who acquired help for any reason (58·5%) have frequent COPD exacerbations. Prevalence of group D COPD and frequent exacerbations is higher than in observational studies conducted in other countries. Aside from smoking, a possible reason for this is high proportions of incorrectly treated patients, for example, 24·5% of frequent exacerbators were treated with short-acting bronchodilators alone in 2014. A specific feature of Russian national guidelines is inclusion of an original, nationally produced, new generation anticholinergic; troventolum (methiodide tropine ester d, l- (2-hydroxymethyl-2phenylbutyric acid), which is not present in other national guidelines. Russian health-care infrastructure is experiencing a period of reforms that will increase the role of primary health care in the treatment of lung diseases. The Russian National Respiratory Society is planning special educational programs for primary care professionals to improve their knowledge of COPD, and address regional differences in primary care. Increased public awareness of COPD will help to improve treatment. An important step in this direction is entry of Russia into the WHO initiative on noncommunicable diseases, and COPD morbidity and mortality could be reduced by greater implementation of antismoking programmes and pulmonary rehabilitation. Alexander Chuchalin and Zaurbek Aisanov, Pulmonary Research Institute, Moscow, Russia
In Sweden, specific asthma–COPD units in primary care centres exist as a complement to the general practitioners´ surgery. These units are organised around an university educated asthma–COPD nurse, who cooperates with the patient and the responsible doctor. The asthma–COPD unit should have access to a physiotherapist, a dietitian, an occupational therapist, and a welfare officer. In an approved asthma–COPD clinic, the nurse must have at least 1·5 hours per week and 1000 listed persons allocated to asthma and COPD care. Spirometers and asthma-COPD units with an asthma-COPD nurse are available in most primary health-care centres in Sweden that should provide free smoking cessation programs The criteria of an approved asthma–COPD unit are, however, far from satisfied in many units. Many nurses cannot spend the stipulated time in the asthma–COPD unit and spirometry is not performed as frequently as needed, despite the fact that the equipment is available. There are not enough physiotherapists available to cover the need for COPD rehabilitation. In Sweden, most COPD patients are managed in primary care. Unclear diagnosis, young age, respiratory failure, low FEV1, malnutrition, and need for extensive rehabilitation should make the general practitioner consider referral to a respiratory specialist. Swedish COPD guidelines were published in 2015 by the National Board of Health and Welfare and from the Medical Products Agency. In these guidelines, the goals are defined but, although the work on establishing well-functioning asthma–COPD clinics has been in progress for many years, the goals are far from reached. Measures must be taken to educate more health care professionals in order to meet the need of approved asthma–COPD clinics and carry on implementation of the guidelines. Kjell Larsson, Karolinska Institutet, Stockholm, Sweden
Admission rates to hospital for COPD exacerbations in New Zealand are nearly the highest in the Organisation for Economic Co-operation and Development (OECD), approximately 4 times higher than countries such as France, and 60% more than the OECD average. This is not due to higher prevalence of the disease, but is probably due to the use of ambulance services and emergency departments as first point of contact for many patients with COPD during exacerbations, in spite of the exacerbation itself being mild. A number of reasons have been proposed including ease of access to emergency health services, financial barriers (emergency visits are free whereas being seen in primary care attracts a charge), and standardised ambulance and emergency department responses to exacerbations which lead to admission rates of 85% of people with COPD presenting to the emergency department (compared with 50% of patients with asthma). The 2011 earthquake in Christchurch (and associated loss of hospital beds) led to the need to explore different models of care, including ambulance diversion to primary care settings such as GP practices and after-hours GP-manned assessment and treatment units (using agreed assessment and triage criteria). This increased the use of community nursing and medical support, and enhanced early discharge programmes. Underpinning this strategy was a commitment to a shared care view of the medical record (both electronic and patient-held management plans), including details of the patient’s baseline status and wishes, to allow accurate triage; and agreed communication and support pathways between community and specialist services. This led to significantly more care of COPD exacerbations being undertaken in community settings, with overall reduction of 35% in bed days occupied by patients with COPD. These learnings are being disseminated and rolled out by other health boards throughout New Zealand. Michael Epton
www.thelancet.com/respiratory Vol 5 January 2017
19
Chronic obstructive pulmonary disease (COPD) As the global burden of COPD rises, health services must develop strategies to treat exacerbations efficiently and effectively. The ways in which COPD exacerbations
In the USA, hospital admissions for COPD result in over US$ 13 billion in direct combined costs for insurance providers and patients annually, which has led to increased attention on how to improve quality and reduce costs for severe exacerbations. In 2014, the Center for Medicare and Medicaid Services (CMS) incorporated COPD into its Hospital Readmission Reduction Program (HRRP). Readmissions for any reason within 30 days after hospital admission for a COPD exacerbation count towards a hospital’s HRRP penalty programme, which imposes financial penalties to institutions where readmissions for specific conditions exceed the national average. Increased attention is subsequently being paid to improving care coordination within hospitals and the transition from hospital to home for patients admitted to hospital with COPD exacerbations. Some hospitals are exploring standardised inpatient instructions, multidisciplinary teams to coordinate inpatient care and the transition home, and specialised transitions to care clinics that can accommodate patients rapidly after admission for COPD. However, such programmes have met with mixed success and whether they are translatable across health systems is unclear, as is whether the resource investment actually pays off in terms of overall reductions in costs. Further complicating matters is the realisation that factors influencing readmissions may have less to do with care received in the hospital and more to do with the quality of outpatient care, which in many instances is provided by a completely different health system. However, changes to insurer reimbursement structures beyond just the HRRP are incentivising health systems to rapidly merge to be able to provide more global care of patients. Many insurers in the USA are also beginning to incentivise care coordination across providers. Ultimately, only time will tell whether such changes will not only reduce readmissions but also improve overall care quality for patients with COPD.
are handled varies from country to country—some exacerbating patients are admitted to emergency care, while others are treated outside of hospital by
COPD emergency admissions are rising in the UK, and COPD is the second most common cause of emergency admissions. Rates of hospital admission for COPD are generally higher in Scotland, Wales, and Northern Ireland, compared with England, but vary dramatically within regions of the UK (NNCCG data 2012–13). Research from Public Heath England has suggested that short-term hospital admissions might reflect poor care in primary care, and therefore an approach that reduces variability in primary care has merit. Many COPD exacerbations are managed in primary care, and patients are often seen by healthcare professionals who are not doctors, which differs markedly from other countries. Many projects have been proposed and delivered to reduce emergency admissions for COPD. In England, many of these projects are focused on integration of the organisations responsible for care. Scotland, Wales, and Northern Ireland have health boards that are responsible for the funding and delivery of care across boundaries. Integration of primary, secondary, community, urgent, and emergency care is crucial, as is reducing the inequality for patients with COPD in the community. The NHS 5-Year Forward View proposed as the structure for community care in England supports a radical re-design of health care, encouraging all providers to work together to deliver better and more standardised health care. Daryl Freeman, North Norfolk Clinical Commissioning Group, Aylsham, Norwich, UK
MeiLan K Han, University of Michigan, Ann Arbor, MI, USA
COPD remains underdiagnosed and undertreated in Brazil. While the overall prevalence of COPD in the country is not known, we do know that the disease affects approximately 16% of the population of São Paulo. It is estimated that many individuals with COPD still do not have access to bronchodilators, influenza vaccination or smoking cessation advice. Substantial variation exists in healthcare structures in Brazil, reflecting social and regional differences. Less than half of patients with COPD have access to private health insurance (which might not include coverage for medication or oxygen), but most rely on the overcrowded public health system. With some exceptions, the southern and southeastern regions of the country host most of the COPD treatment and specialised care centres. In Brazil, about one in five hospital admissions for respiratory problems are related to a COPD exacerbation. As in many other countries, mild and moderate exacerbations are treated in outpatient clinics and are undertreated or untreated, whereas severe cases are directed to tertiary care in hospitals. There is no standard path for exacerbation management in Brazil, and facilities often try to follow national and international guidelines as much as possible. A rather limited primary care system is one of the bottlenecks of the Brazilian healthcare structure in many regions, and its improvement would greatly increase access to proper pharmacological treatment, pulmonary rehabilitation, and oxygen therapy to patients with COPD. Fabio Pitta, PhD, State University of Londrina, Brazil
18
www.thelancet.com/respiratory Vol 5 January 2017
Spotlight
general practitioners or nurses. The Lancet Respiratory Medicine asked clinicians from around the world to explain how COPD exacerbations are handled in their countries, and the challenges faced by health services
as they try to improve and standardise care of these patients.
Laura Feetham, Aaron van Dorn
According to epidemiological studies conducted in Russia, the prevalence of COPD based on spirometry in patients with respiratory symptoms was estimated at 21·8% of adults. COPD mortality has increased in recent years, and according to official statistics of the Russian heath ministry, 45 000 patients with COPD died in Russia in 2015. COPD in Russia is treated according to national guidelines that comply with the GOLD initiative. Most patients with COPD who acquire medical help for any reason in the primary healthcare system are symptomatic (average CAT score 22·3, SD 7·6) and belong to GOLD B (22·4%) or GOLD D (74·3%) groups. Moreover, most patients who acquired help for any reason (58·5%) have frequent COPD exacerbations. Prevalence of group D COPD and frequent exacerbations is higher than in observational studies conducted in other countries. Aside from smoking, a possible reason for this is high proportions of incorrectly treated patients, for example, 24·5% of frequent exacerbators were treated with short-acting bronchodilators alone in 2014. A specific feature of Russian national guidelines is inclusion of an original, nationally produced, new generation anticholinergic; troventolum (methiodide tropine ester d, l- (2-hydroxymethyl-2phenylbutyric acid), which is not present in other national guidelines. Russian health-care infrastructure is experiencing a period of reforms that will increase the role of primary health care in the treatment of lung diseases. The Russian National Respiratory Society is planning special educational programs for primary care professionals to improve their knowledge of COPD, and address regional differences in primary care. Increased public awareness of COPD will help to improve treatment. An important step in this direction is entry of Russia into the WHO initiative on noncommunicable diseases, and COPD morbidity and mortality could be reduced by greater implementation of antismoking programmes and pulmonary rehabilitation. Alexander Chuchalin and Zaurbek Aisanov, Pulmonary Research Institute, Moscow, Russia
In Sweden, specific asthma–COPD units in primary care centres exist as a complement to the general practitioners´ surgery. These units are organised around an university educated asthma–COPD nurse, who cooperates with the patient and the responsible doctor. The asthma–COPD unit should have access to a physiotherapist, a dietitian, an occupational therapist, and a welfare officer. In an approved asthma–COPD clinic, the nurse must have at least 1·5 hours per week and 1000 listed persons allocated to asthma and COPD care. Spirometers and asthma-COPD units with an asthma-COPD nurse are available in most primary health-care centres in Sweden that should provide free smoking cessation programs The criteria of an approved asthma–COPD unit are, however, far from satisfied in many units. Many nurses cannot spend the stipulated time in the asthma–COPD unit and spirometry is not performed as frequently as needed, despite the fact that the equipment is available. There are not enough physiotherapists available to cover the need for COPD rehabilitation. In Sweden, most COPD patients are managed in primary care. Unclear diagnosis, young age, respiratory failure, low FEV1, malnutrition, and need for extensive rehabilitation should make the general practitioner consider referral to a respiratory specialist. Swedish COPD guidelines were published in 2015 by the National Board of Health and Welfare and from the Medical Products Agency. In these guidelines, the goals are defined but, although the work on establishing well-functioning asthma–COPD clinics has been in progress for many years, the goals are far from reached. Measures must be taken to educate more health care professionals in order to meet the need of approved asthma–COPD clinics and carry on implementation of the guidelines. Kjell Larsson, Karolinska Institutet, Stockholm, Sweden
Admission rates to hospital for COPD exacerbations in New Zealand are nearly the highest in the Organisation for Economic Co-operation and Development (OECD), approximately 4 times higher than countries such as France, and 60% more than the OECD average. This is not due to higher prevalence of the disease, but is probably due to the use of ambulance services and emergency departments as first point of contact for many patients with COPD during exacerbations, in spite of the exacerbation itself being mild. A number of reasons have been proposed including ease of access to emergency health services, financial barriers (emergency visits are free whereas being seen in primary care attracts a charge), and standardised ambulance and emergency department responses to exacerbations which lead to admission rates of 85% of people with COPD presenting to the emergency department (compared with 50% of patients with asthma). The 2011 earthquake in Christchurch (and associated loss of hospital beds) led to the need to explore different models of care, including ambulance diversion to primary care settings such as GP practices and after-hours GP-manned assessment and treatment units (using agreed assessment and triage criteria). This increased the use of community nursing and medical support, and enhanced early discharge programmes. Underpinning this strategy was a commitment to a shared care view of the medical record (both electronic and patient-held management plans), including details of the patient’s baseline status and wishes, to allow accurate triage; and agreed communication and support pathways between community and specialist services. This led to significantly more care of COPD exacerbations being undertaken in community settings, with overall reduction of 35% in bed days occupied by patients with COPD. These learnings are being disseminated and rolled out by other health boards throughout New Zealand. Michael Epton
www.thelancet.com/respiratory Vol 5 January 2017
19