- Email: [email protected]
COPD in VA hospitals
clinica/(:OKNEKS’I’ONI:
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COPD
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Vol 5 No I
COPD in VA Hospitals Jesse Roman,
Rafael
MD
Associate Professor of Medicine Director, Division of Pulmonary, Allergy and Critical Care Medicine AtlantaVA Medical Center Emory University School of Medicine Atlanta, Georgia
L. Perez,
MD
Assistant Professor of Medicine Director, Pulmonary Function Laboratory, Long Term Oxygen Therapy, and Pulmonary Rehabilitation Atlanta VA Medical Center Emory University School of Medicine Atlanta, Georgia
The Department of Veterans Affairs (VA) Health Care System is the largest integrated single-payer system in the United States. Its primary mission is to provide primary care, specialized care, and related medical and social support services to veterans. Much time and resources are expended on chronic obstructive pulmonary disease, known as COPD, at VA hospitals and clinics, thereby justifying the development of multifaceted strategies to address this problem. This article discusses the special problems of COPD in veterans who use VA facilities. The article also highlights the contributions of the VA to the research, training, and development of clinical practice guidelines for the management of this pervasive disease and presents the challenges that threaten its role in this area.
HISTORICAL PERSPECTIVE AND DEMOGRAPHICS OF COPD IN VA HOSPITALS The Veterans Administration (VA) Health Care System was created in 1930 by Executive Order 5398 under President Herbert Hoover and renamed the Department of Veterans Affairs when it was elevated to Cabinet status in 1989 during the Reagan administration (1). Today, the VA is the second largest Cabinet department and spends 43% of its $50.6 billion allocation on health care. It has 163 hospitals throughout the United States and Puerto Rico. Additionally, 1103 outpatient clinics, nursing homes, and home-care programs are available to serve the health care needs of the 25.3 million veterans living today. In fact, >4.2 million veterans sought care from the VA in 200 1. Pulmonary diseases are common as primary and comorbid conditions among this population. Chronic obstructive pulmonary disease (COPD) is the most common lung disorder and consumes most of the resources spent on respiratory diseases. The maintenance of the largest home oxygen delivery program, serving 23,000 patients diagnosed with severe COPD, alone cost $26,450,710 in fiscal year 1996 (2).
A review of the VA National Patient Database shows that diagnoses in the domain of COPD (World Health Organization’s International Classijkation of Diseases, Ninth Revision [ICD-91 codes 496,492.8,491.9, and 491.21) make up the fourth most common diagnosis cited on discharge of hospitalized veterans (3). Only hypertension, coronary artery disease, and diabetes are cited more often. More than 126,267 patients were discharged from the VA with a primary or secondary diagnosis of obstructive lung disease in 1996 (3), accounting
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for -33% of all patients admitted to the medical service and -16% of all VA hospital admissions. There are -1 million outpatient visits per year for veterans who carry a diagnosis of COPD, and -two thirds of those visits list the disease as the primary diagnosis. Clearly, COPD is a major health concern in the veteran population served by the VA. A distinctive feature of the VA health care system is that -75% of the national veteran population with disabilities or low income is enrolled in
veterans reported lower levels of health status (reflecting more disease) than a non-VA civilian population (5). The VA Women’s Health Project found that veteran women scored lower on every scale compared with nonveteran women (6). Although these studies did not focus on COPD, they suggest a disproportionate burden of chronic diseases, including COPD, in veterans. The factors that contribute to COPD in veterans are many and multifactorial. The most obvious and significant is smoking. Until recent years, the military and the tobacco industry promoted the availability and use of cheap tobacco products to soldiers and veterans (7). Coupled with socioeconomic differences (8), pressures of group living, stress, and opportunities for smoking breaks (9), military personnel and veterans are at increased risk for tobacco addiction and its detrimental consequences. Data from the Worldwide Survey of Alcohol and Nonmedical Drug Use among Military Personnel, sponsored by the US Department of Defense, and the concurrent National Household Survey on Drug Abuse, sponsored by the National Institute on Drug Abuse, indicate that the prevalence of smoking is -5% higher in military men and women than in civilians (10). The difference in the prevalence of smoking between military and civilian women is even more pronounced, at more than 10%. A large cross-sectional study using the National Health Interview Survey from 1987-88 suggests that military service may be a risk factor for cigarette smoking (7). There were 13,598 veterans and 73,983 nonveterans 220 years in the dataset. Veterans had a greater likelihood of ever smoking, with a prevalence of 74% versus 48% for nonveterans. Prevalence of current smoking among those surveyed was 34% for veterans and 28% for civilians. An interesting finding was that among veterans and nonveterans who began smoking at or after age 18, veterans were about twice as likely to be ever or current smokers. This observation suggested that active military duty increases the likelihood of tobacco use and makes smoking cessation more difficult. However, decreases in smoking rates and prevalence in the military may soon make this observation moot. For example, smoking prevalence in the military was 51% in 1980 but
the system (1). Of VA health care users, 36% are 265 years, compared with 17% of the general population. Seventy percent of these patients have a yearly income of <$20,000, compared with 39% of the general population. This background potentially selects for veterans who already have some impairment from chronic diseases, including COPD, and have restricted access to health care, thus, having a higher incidence of morbidity after enrollment. Strong evidence for a disproportionate burden of COPD in veterans compared with the general population is difficult to access. The results of the 20-year longitudinal Veterans Health Study suggest that veterans have a poor overall health status when compared with the general population. Veterans (1667 men) were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities (4). These veterans received questionnaires of health status including the Medical Outcomes Study Short-Form 36 (SF-36, a short form of functional status assessment), a health examination, clinical assessments, and medical history taking. The VA outpatients were found to have poor health status scores across all measures of the SF-36 compared with scores in nonveterans. In a similar study using the SF-36, 2425
38
dropped to 35% by 1992 (11). Nevertheless, the VA continues to devote many resources to tobaccorelated diseases induced years ago when smoking was much more common among veterans.
randomized multicenter clinical trials. One example of this is a high-impact study published in 1999 by Niewoehner and colleagues (12) who examined the efficacy of systemic glucocorticoids in the treatment of patients hospitalized with exacerbations of COPD. This double-blind, randomized trial included participants from 25 VA medical centers and demonstrated increased rates of treatment failure in patients receiving placebo compared with patients receiving systemic glucocorticoids. Furthermore, the study showed that systemic glucocorticoids were associated with shorter hospital stays and higher forced expiratory volume in 1 second (FEV,) than that demonstrated by the placebo group by the first day of enrollment; a 2-week regimen was found to be as effective as an g-week regimen. Sponsored by the same program, Smith et al (13) studied patients from 9 VA medical centers to examine the factors predicting nonelective hospital readmissions. Of the 1378 patients, 23.3% were readmitted within 90 days. Notably, a diagnosis of COPD, among other factors, predicted readmission. In a related study, Fan and colleagues (14) examined whether a brief, self-administered COPD-specific quality-of-life questionnaire could accurately predict hospitalizations and death. Patients (n = 24,458) enrolled in primary care clinics from 7 VA medical centers completed the health inventory; 5503 patients reported having chronic lung disease. During the next 12 months, 18% of all patients were hospitalized, 4.3% (141) for COPD exacerbations. A diagnosis of COPD with low physical function was found to be a good predictor of recurrent hospitalizations and death when adjusted for age and other variables. VA research is also placing an emphasis on testing global strategies of health care delivery. Hughes et al ( 15) showed that although more expensive (6% higher mean cost per person), a team-managed, home-based primary care intervention improved most health-related quality-of-life measures and patient satisfaction and reduced hospital readmissions at 6 months. Other studies have focused on previously unidentified predictors of clinical outcome in COPD. For example, Kim et al (16) examined the relationship between functional status and comorbid anxiety and depression, and the relationship
COPD RESEARCH IN VA HOSPITALS The high concentration of patients with COPD in VA hospitals, together with the existence of a solid research program, has made the VA a rich source for clinical, epidemiologic, and basic science research in COPD. The VA research program funds individual grants, career development grants, special research initiatives, centers of excellence, and health service research centers, with >$350 million expended each year. Current work at the VA related to COPD spans diverse areas, ranging from studies dissecting the cellular and molecular mechanisms of tobacco-related lung dysfunction to investigations testing the role of distinct therapies in the treatment of COPD. More recently, attention has been given to health services-related research designed to investigate the impact of specific approaches on quality of life, patient and caregiver satisfaction, and cost control. These types of studies have provided important insight into the mechanisms that lead to the pathophysiology of COPD. However, their greatest impact has been in the area of patient care delivery and is best represented by studies sponsored by the US Department of Veterans Affairs Cooperative Studies Program. Support from this program has provided resources and united investigators from many VA hospitals to address important questions in 39
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between utilization of health care resources and psychopathology in elderly veterans with COPD. They found that anxiety and depression contributed significantly to the overall variance in functional status of COPD patients, and that these were independent of COPD severity. In another study, the impact of cognitive behavioral therapy for elderly patients with COPD was assessed (17). In this study, 20% to 40% of patients with COPD were found to have high levels of anxiety and depression. When compared with controls, the group receiving specialized cognitive behavioral therapy showed less depression and anxiety. Gastroesophageal reflux is another factor studied by VA researchers. For years it has been suspected that gastroesophageal reflux aggravates symptoms in patients with obstructive lung diseases such as asthma and COPD. Mokhlesi et al (18) investigated the prevalence of gastroesophageal reflux symptoms in patients with COPD and the association of these symptoms with the severity of airway obstruction in a prospective questionnairebased, cross-sectional analytic survey. The subjects were recruited from pulmonary and general medicine clinics at a VA hospital. Compared with patients with no respiratory symptoms or diagnosis of asthma or COPD, the COPD subjects had significant gastroesophageal reflux symptoms (ie, heartburn, regurgitation once or more per week), chronic cough, and dysphagia. Twenty-six percent of patients with COPD and gastroesophageal symptoms reported respiratory symptoms associated with reflux events. Although pulmonary function test results were similar among COPD patients with or without gastroesophageal reflux symptoms, significant reflux symptoms were more prevalent among COPD patients with FEV, < 50% of predicted values. Also, an increased number of COPD patients used antireflux medications compared with controls. In a related study, Good-Fratturelli et al ( 19) performed a retrospective study in 78 men with COPD referred for modified barium swallow studies. They found that nearly 85% of subjects showed evidence of some degree of dysphagia, with 44% showing laryngeal penetrations or aspirations. Osteoporosis is another problem not often
considered in COPD patients, particularly if they are men. Iqbal et al (20) studied the incidence of osteoporosis in a cohort of male veterans with chronic lung disease. Although the study did not focus exclusively on COPD patients, many of the subjects carried a diagnosis of COPD. The researchers found that compared with subjects without lung disease attending a hypertension clinic in the same VA hospital, osteoporosis was 5 times more likely in patients with chronic lung disease. Although the prevalence of osteoporosis was higher (ninefold) after chronic glucocorticoid therapy, patients with chronic lung disease who had never been treated with glucocorticoids still had a substantial (fourfold) risk of osteoporosis. Chronic inhaled glucocorticoid therapy offered no protection from bone loss compared with oral glucocorticoids. Other studies have addressed the role of antibiotics in the treatment of acute COPD exacerbations (21), the reliability and usefulness of dyspnea scales (22), and the role of ambulatory oximetry monitoring to determine the need for long-term oxygen therapy (23). These and many other studies conducted at the VA have begun to shape our understanding of COPD, unveiled important factors that contribute to patients’ deterioration, and revealed the effectiveness of specific strategies for management, ranging from new drug regimens to treatment interventions that address COPD patients globally. COPD EDUCATION AND TRAINING IN VA HOSPITALS With more than 8 1,000 trainees (28,493 residents and fellows, 17,582 medical students, 16,649 nursing students, and 18,391 associated health residents and students) in various areas of health care delivery passing through the hallways of VA hospitals every year, the VA is one of the most important sources for education in COPD in this country. It is no coincidence that VA hospitals are often affiliated with institutions involved in higher education, and the VA’s impact on the education of the next generation of practitioners should not be overlooked. The VA has established initiatives for the education of trainees as well as patients. Its most aggressive educational initiative in COPD to date
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has been to partner with the Department of Defense (DOD) to generate the VA/DOD Clinical Practice Guidelines Working Group in 1999. From this partnership originated a document called
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persistent, albeit decreasing, perception that health care delivery and training in the VA are suboptimal; and the somewhat rigid nature of the VA’s infrastructure that prevents the swift and expedient mobilization of resources to tackle new problems. The VA will need to confront these challenges head on by: Strengthening its affiliation with universities to continue its educational programs while maintaining its ability for self-determination and independence. Universities, on the other hand, need to openly acknowledge the important services provided by the VA and its key role in their overall patient care and research and teaching enterprises. Maintaining a strong research program that encourages investigator-initiated research while simultaneously creating initiatives to drive the discovery of novel research strategies that address COPD pathogenesis. Engaging in research designed to identify efficient, low-cost strategies for health care delivery and seeking assistance from private and related health care organizations that have tested and implemented such strategies. Developing fruitful collaborations with large professional organizations that are involved in the study and management of COPD, such as the American Thoracic Society, the American College of Chest Physicians, the American Lung Association, and the National Institutes of Health. Designing simple, effective protocols to facilitate the interaction between VA investigators and industry to accelerate the development of novel therapies for the treatment of COPD. Seeking professional assistance to develop public relations initiatives that educate the public about COPD, its causes and consequences, and inform them about the high-quality research, educational, and health care delivery programs offered by the VA.
Management of Chronic Obstructive Pulmonary Disease, a comprehensive clinical practice guideline for COPD management (24). This guideline consists of a core module that outlines the diagnostic approach to COPD and 6 modules of specific interventions and practices for the management of the disease. Thirteen algorithms describe decision points in the areas of acute exacerbation, long-term oxygen therapy, air travel, and even insomnia, among others. These guidelines parallel those developed by other large professional organizations. FUTURE CHALLENGES COPD is a common problem in veterans. Veterans who seek care in the VA system have a lower income level and show a lower overall health status than the general population. These factors account for a disproportionate burden of COPD in VA hospitals and clinics throughout the United States. To address this problem, the VA has engaged in the development of research-based, educational, health care delivery and physician practice guideline programs that serve as models for other organizations. Today, the VA faces increasing fiscal and logistic challenges that threaten its stability and leading role in health care delivery, research, and education. These challenges include the ever-increasing cost of health care; the increasing reliance of patients and their relatives on legal action to deal with painful losses related to COPD and its consequences; the
DISCLAIMER The opinions expressed by the authors do not necessarily reflect those of the US Department of Veterans Affairs. REFERENCES 1. Dept of Veterans Affairs Office of Public Affairs. 41
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Media Relations Fact Sheet. Washington,
DC: Dept of Veterans Affairs; March 2002. http:/www.va.gov/about-va. 2. Veterans Administration National Center for Cost Containment. National Home Oxygen Program. FY 95. Washington, DC: Dept of Veterans Affairs. August 1996. 3. Veterans Integrated Service Network Support Service Center (VSSC). Dept of Veterans Affairs. http:www.klfmenu.med.va.gov. 4. Kazis LE, Miller DR, Clark J, et al. Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med. 1998;158: 626-632. 5. Kazis LE, Ren XS, Lee A, et al. Health status in VA patients: results from the Veterans Health Study. Am J Med Qual. 1999; l4:28-38. 6. Skinner KM, Furey J. The focus on women veterans who use Veterans Administration health care: the Veterans Administration Women’s Health Project. Mil Med. 1998;163:761-766. 7. Klevens RM, Giovino GA, Peddicord JP, et al. The association between veteran status and cigarette-smoking behaviors. Am J Prev Med. 1995; I 1: 245-250. 8. Centers for Disease Control and Prevention. Reducing the health consequences of smoking: 25 years of progress - a report of the Surgeon General, 1989. Rockville, Md: US Dept of Health and Human Services, Public Health Service; 1989. DHHS publication. 9. Cronan TA, Conway TL. Is the Navy attracting or creating smokers? Mil Med. 1988;153: 175-178. 10. Bray RM, Marsden ME, Peterson MR. Standardized comparisons of the use of alcohol, drugs, and cigarettes among military personnel and civilians. Am J Public Health. 1991;81:865-869. I I. Bray RM, Marsden ME, Guess LL, Herbold JR. Prevalence, trends, and correlates of alcohol use, nonmedical drug use, and tobacco use among U.S. military personnel. Mil Med. 1989; 154: I- 1 1. 12. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340:1941-1947. 13. Smith DM, Giobbie-Hurder A, Weinberger M, et al. Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
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Readmissions. J Clin Epidemiol. 2000;53: 1113-1118. Fan VS, Curtis JR, Tu SP, et al. Using quality of life to predict hospitalization and mortality in patients with obstructive lung diseases. Chest. 2002;122: 4299436. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000; 284:2877-2885. Kim HF, Kunik ME, Molinari VA, et al. Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics. 2000;41:46547 1. Kunik ME, Braun U, Stanley MA, et al. One session cognitive behavioural therapy for elderly patients with chronic obstructive pulmonary disease. Psycho1Med. 2001;3 1:7 17-723. Mokhlesi B, Morris AL, Huang CF, et al. Increased prevalence of gastroesophageal reflux symptoms in patients with COPD. Chest. 2001; 119:1043-1048. Good-Fratturelli MD, Curlee RF, Holle JL. Prevalence and nature of dysphagia in VA patients with COPD referred for videofluoroscopic and swallow examination. J Common Disord. 2000;33: 93-l 10. Iqbal F, Michaelson J, Thaler L, et al. Declining bone mass in men with chronic pulmonary disease: contribution of glucocorticoid treatment, body mass index, and gonadal function. Chest. 1999; 116: 1616-1624. Adams SG, Melo J, Luther M, et al. Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest. 2000; 117:1345-1352. Kendrick KR, Baxi SC, Smith RM. Usefulness of the modified 0- 10 Borg scale in assessing the degree of dyspnea in patients with COPD and asthma. J Emerg Nut-s. 2000;26:216-222. Pilling J, Cutaia M. Ambulatory oximetry monitoring in patients with severe COPD: a preliminary study. Chest. 1999;116:314-321. VA/DOD Clinical Practice Guideline Working Group. Management of Chronic Obstructive Pulmonary Disease. Washington, DC: Office of Quality and Performance; August 1999. Publication 1OQ-CPG/ COPD-00. Available at: http://www.oqp.med.va.gov/cpg/COPD/ COPD-base.htm.
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ADVISORY BOARD How did the tobacco industry promote smoking to soldiers and veterans and when and how was it halted?
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ly published VA Western New York Healthcare System article (N Engl J Med. I 2002;347:465), which found a correlation between the acquisition of new strains of bacteria and COPD exacerbations.
PEREZ It took about 20 years after the original Surgeon General’s report on the dangers of smoking to remove tobacco products from military rations, commissaries, and VA hospital canteens. The military was a savory target of the tobacco industry where concentrations of young and long-term customers were to be found. Cigarettes were provided to soldiers and sailors in K- and C-rations during both World Wars and the Korean and Vietnam wars. Cigarette advertising touting patriotism showed young men and women in uniform enjoying cigarettes. An additional incentive was the discounted price of cigarettes sold in the military commissaries.
ROMAN Sehti and colleagues conducted a prospective study that included molecular typing of sputum isolates of several bacterial strains commonly found in COPD patients. They observed that new strains of bacteria detected during clinic visits were associated with a COPD exacerbation twice as often as in patients without an exacerbation (33% vs 15.4%). Furthermore, they found that the isolation of a new strain of H influenzae, M catarrhalis, or S pneumoniae was associated with a significantly increased risk of an exacerbation. As the authors concluded, these observations support a causative role of bacteria in exacerbations of COPD. However, it raises many questions that will have to be addressed. For example, is the acquisition of new strains directly responsible for the COPD exacerbations, or is the inflammatory state elicited during an exacerbation contributing to airway colonization with new strains? Are new strains acquired due to current antibiotherapy strategies? Is the acquisition of new strains predictive of increased exacerbations?
ADVISORY BOARD Describe smoking cessation programs implemented by the VA and comment on their efficacy. PEREZ There is no national VA guideline or policy related to smoking cessation. Each VA Medical Center implements its own smoking cessation program, usually through the Mental Health Service Line. A psychologist, physician, or other health practitioner with expertise in smoking cessation techniques manages the program. In Atlanta, our lo-year-old program uses a combination of counseling and nicotine replacement therapy and has resulted in an abstinence rate of about 30% after 5 years. This is par with most smoking cessation programs in this country. ADVISORY BOARD What are the clinical implications
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ADVISORY BOARD What were the home-based primary care interventions implemented by Hughes et al that improved quality-of-life measures? ROMAN In general, the interventions were designed to facilitate communication between the hospital staff and the primary care doctors and to provide access to physicians when needed. They included
of the recent-
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the establishment of a primary care manager position, 24-hour contact for patients, prior approval of hospital readmissions, and home-based primary care team participation in discharge planning. ADVISORY
BOARD
Does effective management of gastroesophageal refiux improve pulmonary symptoms or function in patients with COPD? ROMAN The association between gastroesophageal reflux and COPD is not well established. Although many believe that treatment of gastroesophageal reflux can improve or prevent COPD exacerbations, there is not much evidence to support this belief. On the contrary, in 1998, Boerce et al published data sug-
gesting that in asthma and COPD patients with severe airway hyperresponsiveness, treatment with omeprazole had no beneficial effect on pulmonary parameters despite its significant effect on acid reflux when compared with placebo. In a more intriguing study, Orr et al (1992) were unable to document a bronchoconstrictive reflex in response to distal esophageal acidification in 12 patients with COPD. These and other studies suggest that further investigations are needed to confirm a role for gastroesophageal reflux in COPD exacerbation, and the effects, if any, of antireflux therapy on COPD exacerbations. Until new data are collected, I continue to offer antireflux therapy to patients with manifest symptoms and diffkult-to-treat COPD where gastroesophageal reflux is documented.
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COPD in VA Hospitals Jesse Roman,
Rafael
MD
Associate Professor of Medicine Director, Division of Pulmonary, Allergy and Critical Care Medicine AtlantaVA Medical Center Emory University School of Medicine Atlanta, Georgia
L. Perez,
MD
Assistant Professor of Medicine Director, Pulmonary Function Laboratory, Long Term Oxygen Therapy, and Pulmonary Rehabilitation Atlanta VA Medical Center Emory University School of Medicine Atlanta, Georgia
The Department of Veterans Affairs (VA) Health Care System is the largest integrated single-payer system in the United States. Its primary mission is to provide primary care, specialized care, and related medical and social support services to veterans. Much time and resources are expended on chronic obstructive pulmonary disease, known as COPD, at VA hospitals and clinics, thereby justifying the development of multifaceted strategies to address this problem. This article discusses the special problems of COPD in veterans who use VA facilities. The article also highlights the contributions of the VA to the research, training, and development of clinical practice guidelines for the management of this pervasive disease and presents the challenges that threaten its role in this area.
HISTORICAL PERSPECTIVE AND DEMOGRAPHICS OF COPD IN VA HOSPITALS The Veterans Administration (VA) Health Care System was created in 1930 by Executive Order 5398 under President Herbert Hoover and renamed the Department of Veterans Affairs when it was elevated to Cabinet status in 1989 during the Reagan administration (1). Today, the VA is the second largest Cabinet department and spends 43% of its $50.6 billion allocation on health care. It has 163 hospitals throughout the United States and Puerto Rico. Additionally, 1103 outpatient clinics, nursing homes, and home-care programs are available to serve the health care needs of the 25.3 million veterans living today. In fact, >4.2 million veterans sought care from the VA in 200 1. Pulmonary diseases are common as primary and comorbid conditions among this population. Chronic obstructive pulmonary disease (COPD) is the most common lung disorder and consumes most of the resources spent on respiratory diseases. The maintenance of the largest home oxygen delivery program, serving 23,000 patients diagnosed with severe COPD, alone cost $26,450,710 in fiscal year 1996 (2).
A review of the VA National Patient Database shows that diagnoses in the domain of COPD (World Health Organization’s International Classijkation of Diseases, Ninth Revision [ICD-91 codes 496,492.8,491.9, and 491.21) make up the fourth most common diagnosis cited on discharge of hospitalized veterans (3). Only hypertension, coronary artery disease, and diabetes are cited more often. More than 126,267 patients were discharged from the VA with a primary or secondary diagnosis of obstructive lung disease in 1996 (3), accounting
37
for -33% of all patients admitted to the medical service and -16% of all VA hospital admissions. There are -1 million outpatient visits per year for veterans who carry a diagnosis of COPD, and -two thirds of those visits list the disease as the primary diagnosis. Clearly, COPD is a major health concern in the veteran population served by the VA. A distinctive feature of the VA health care system is that -75% of the national veteran population with disabilities or low income is enrolled in
veterans reported lower levels of health status (reflecting more disease) than a non-VA civilian population (5). The VA Women’s Health Project found that veteran women scored lower on every scale compared with nonveteran women (6). Although these studies did not focus on COPD, they suggest a disproportionate burden of chronic diseases, including COPD, in veterans. The factors that contribute to COPD in veterans are many and multifactorial. The most obvious and significant is smoking. Until recent years, the military and the tobacco industry promoted the availability and use of cheap tobacco products to soldiers and veterans (7). Coupled with socioeconomic differences (8), pressures of group living, stress, and opportunities for smoking breaks (9), military personnel and veterans are at increased risk for tobacco addiction and its detrimental consequences. Data from the Worldwide Survey of Alcohol and Nonmedical Drug Use among Military Personnel, sponsored by the US Department of Defense, and the concurrent National Household Survey on Drug Abuse, sponsored by the National Institute on Drug Abuse, indicate that the prevalence of smoking is -5% higher in military men and women than in civilians (10). The difference in the prevalence of smoking between military and civilian women is even more pronounced, at more than 10%. A large cross-sectional study using the National Health Interview Survey from 1987-88 suggests that military service may be a risk factor for cigarette smoking (7). There were 13,598 veterans and 73,983 nonveterans 220 years in the dataset. Veterans had a greater likelihood of ever smoking, with a prevalence of 74% versus 48% for nonveterans. Prevalence of current smoking among those surveyed was 34% for veterans and 28% for civilians. An interesting finding was that among veterans and nonveterans who began smoking at or after age 18, veterans were about twice as likely to be ever or current smokers. This observation suggested that active military duty increases the likelihood of tobacco use and makes smoking cessation more difficult. However, decreases in smoking rates and prevalence in the military may soon make this observation moot. For example, smoking prevalence in the military was 51% in 1980 but
the system (1). Of VA health care users, 36% are 265 years, compared with 17% of the general population. Seventy percent of these patients have a yearly income of <$20,000, compared with 39% of the general population. This background potentially selects for veterans who already have some impairment from chronic diseases, including COPD, and have restricted access to health care, thus, having a higher incidence of morbidity after enrollment. Strong evidence for a disproportionate burden of COPD in veterans compared with the general population is difficult to access. The results of the 20-year longitudinal Veterans Health Study suggest that veterans have a poor overall health status when compared with the general population. Veterans (1667 men) were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities (4). These veterans received questionnaires of health status including the Medical Outcomes Study Short-Form 36 (SF-36, a short form of functional status assessment), a health examination, clinical assessments, and medical history taking. The VA outpatients were found to have poor health status scores across all measures of the SF-36 compared with scores in nonveterans. In a similar study using the SF-36, 2425
38
dropped to 35% by 1992 (11). Nevertheless, the VA continues to devote many resources to tobaccorelated diseases induced years ago when smoking was much more common among veterans.
randomized multicenter clinical trials. One example of this is a high-impact study published in 1999 by Niewoehner and colleagues (12) who examined the efficacy of systemic glucocorticoids in the treatment of patients hospitalized with exacerbations of COPD. This double-blind, randomized trial included participants from 25 VA medical centers and demonstrated increased rates of treatment failure in patients receiving placebo compared with patients receiving systemic glucocorticoids. Furthermore, the study showed that systemic glucocorticoids were associated with shorter hospital stays and higher forced expiratory volume in 1 second (FEV,) than that demonstrated by the placebo group by the first day of enrollment; a 2-week regimen was found to be as effective as an g-week regimen. Sponsored by the same program, Smith et al (13) studied patients from 9 VA medical centers to examine the factors predicting nonelective hospital readmissions. Of the 1378 patients, 23.3% were readmitted within 90 days. Notably, a diagnosis of COPD, among other factors, predicted readmission. In a related study, Fan and colleagues (14) examined whether a brief, self-administered COPD-specific quality-of-life questionnaire could accurately predict hospitalizations and death. Patients (n = 24,458) enrolled in primary care clinics from 7 VA medical centers completed the health inventory; 5503 patients reported having chronic lung disease. During the next 12 months, 18% of all patients were hospitalized, 4.3% (141) for COPD exacerbations. A diagnosis of COPD with low physical function was found to be a good predictor of recurrent hospitalizations and death when adjusted for age and other variables. VA research is also placing an emphasis on testing global strategies of health care delivery. Hughes et al ( 15) showed that although more expensive (6% higher mean cost per person), a team-managed, home-based primary care intervention improved most health-related quality-of-life measures and patient satisfaction and reduced hospital readmissions at 6 months. Other studies have focused on previously unidentified predictors of clinical outcome in COPD. For example, Kim et al (16) examined the relationship between functional status and comorbid anxiety and depression, and the relationship
COPD RESEARCH IN VA HOSPITALS The high concentration of patients with COPD in VA hospitals, together with the existence of a solid research program, has made the VA a rich source for clinical, epidemiologic, and basic science research in COPD. The VA research program funds individual grants, career development grants, special research initiatives, centers of excellence, and health service research centers, with >$350 million expended each year. Current work at the VA related to COPD spans diverse areas, ranging from studies dissecting the cellular and molecular mechanisms of tobacco-related lung dysfunction to investigations testing the role of distinct therapies in the treatment of COPD. More recently, attention has been given to health services-related research designed to investigate the impact of specific approaches on quality of life, patient and caregiver satisfaction, and cost control. These types of studies have provided important insight into the mechanisms that lead to the pathophysiology of COPD. However, their greatest impact has been in the area of patient care delivery and is best represented by studies sponsored by the US Department of Veterans Affairs Cooperative Studies Program. Support from this program has provided resources and united investigators from many VA hospitals to address important questions in 39
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between utilization of health care resources and psychopathology in elderly veterans with COPD. They found that anxiety and depression contributed significantly to the overall variance in functional status of COPD patients, and that these were independent of COPD severity. In another study, the impact of cognitive behavioral therapy for elderly patients with COPD was assessed (17). In this study, 20% to 40% of patients with COPD were found to have high levels of anxiety and depression. When compared with controls, the group receiving specialized cognitive behavioral therapy showed less depression and anxiety. Gastroesophageal reflux is another factor studied by VA researchers. For years it has been suspected that gastroesophageal reflux aggravates symptoms in patients with obstructive lung diseases such as asthma and COPD. Mokhlesi et al (18) investigated the prevalence of gastroesophageal reflux symptoms in patients with COPD and the association of these symptoms with the severity of airway obstruction in a prospective questionnairebased, cross-sectional analytic survey. The subjects were recruited from pulmonary and general medicine clinics at a VA hospital. Compared with patients with no respiratory symptoms or diagnosis of asthma or COPD, the COPD subjects had significant gastroesophageal reflux symptoms (ie, heartburn, regurgitation once or more per week), chronic cough, and dysphagia. Twenty-six percent of patients with COPD and gastroesophageal symptoms reported respiratory symptoms associated with reflux events. Although pulmonary function test results were similar among COPD patients with or without gastroesophageal reflux symptoms, significant reflux symptoms were more prevalent among COPD patients with FEV, < 50% of predicted values. Also, an increased number of COPD patients used antireflux medications compared with controls. In a related study, Good-Fratturelli et al ( 19) performed a retrospective study in 78 men with COPD referred for modified barium swallow studies. They found that nearly 85% of subjects showed evidence of some degree of dysphagia, with 44% showing laryngeal penetrations or aspirations. Osteoporosis is another problem not often
considered in COPD patients, particularly if they are men. Iqbal et al (20) studied the incidence of osteoporosis in a cohort of male veterans with chronic lung disease. Although the study did not focus exclusively on COPD patients, many of the subjects carried a diagnosis of COPD. The researchers found that compared with subjects without lung disease attending a hypertension clinic in the same VA hospital, osteoporosis was 5 times more likely in patients with chronic lung disease. Although the prevalence of osteoporosis was higher (ninefold) after chronic glucocorticoid therapy, patients with chronic lung disease who had never been treated with glucocorticoids still had a substantial (fourfold) risk of osteoporosis. Chronic inhaled glucocorticoid therapy offered no protection from bone loss compared with oral glucocorticoids. Other studies have addressed the role of antibiotics in the treatment of acute COPD exacerbations (21), the reliability and usefulness of dyspnea scales (22), and the role of ambulatory oximetry monitoring to determine the need for long-term oxygen therapy (23). These and many other studies conducted at the VA have begun to shape our understanding of COPD, unveiled important factors that contribute to patients’ deterioration, and revealed the effectiveness of specific strategies for management, ranging from new drug regimens to treatment interventions that address COPD patients globally. COPD EDUCATION AND TRAINING IN VA HOSPITALS With more than 8 1,000 trainees (28,493 residents and fellows, 17,582 medical students, 16,649 nursing students, and 18,391 associated health residents and students) in various areas of health care delivery passing through the hallways of VA hospitals every year, the VA is one of the most important sources for education in COPD in this country. It is no coincidence that VA hospitals are often affiliated with institutions involved in higher education, and the VA’s impact on the education of the next generation of practitioners should not be overlooked. The VA has established initiatives for the education of trainees as well as patients. Its most aggressive educational initiative in COPD to date
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persistent, albeit decreasing, perception that health care delivery and training in the VA are suboptimal; and the somewhat rigid nature of the VA’s infrastructure that prevents the swift and expedient mobilization of resources to tackle new problems. The VA will need to confront these challenges head on by: Strengthening its affiliation with universities to continue its educational programs while maintaining its ability for self-determination and independence. Universities, on the other hand, need to openly acknowledge the important services provided by the VA and its key role in their overall patient care and research and teaching enterprises. Maintaining a strong research program that encourages investigator-initiated research while simultaneously creating initiatives to drive the discovery of novel research strategies that address COPD pathogenesis. Engaging in research designed to identify efficient, low-cost strategies for health care delivery and seeking assistance from private and related health care organizations that have tested and implemented such strategies. Developing fruitful collaborations with large professional organizations that are involved in the study and management of COPD, such as the American Thoracic Society, the American College of Chest Physicians, the American Lung Association, and the National Institutes of Health. Designing simple, effective protocols to facilitate the interaction between VA investigators and industry to accelerate the development of novel therapies for the treatment of COPD. Seeking professional assistance to develop public relations initiatives that educate the public about COPD, its causes and consequences, and inform them about the high-quality research, educational, and health care delivery programs offered by the VA.
Management of Chronic Obstructive Pulmonary Disease, a comprehensive clinical practice guideline for COPD management (24). This guideline consists of a core module that outlines the diagnostic approach to COPD and 6 modules of specific interventions and practices for the management of the disease. Thirteen algorithms describe decision points in the areas of acute exacerbation, long-term oxygen therapy, air travel, and even insomnia, among others. These guidelines parallel those developed by other large professional organizations. FUTURE CHALLENGES COPD is a common problem in veterans. Veterans who seek care in the VA system have a lower income level and show a lower overall health status than the general population. These factors account for a disproportionate burden of COPD in VA hospitals and clinics throughout the United States. To address this problem, the VA has engaged in the development of research-based, educational, health care delivery and physician practice guideline programs that serve as models for other organizations. Today, the VA faces increasing fiscal and logistic challenges that threaten its stability and leading role in health care delivery, research, and education. These challenges include the ever-increasing cost of health care; the increasing reliance of patients and their relatives on legal action to deal with painful losses related to COPD and its consequences; the
DISCLAIMER The opinions expressed by the authors do not necessarily reflect those of the US Department of Veterans Affairs. REFERENCES 1. Dept of Veterans Affairs Office of Public Affairs. 41
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Media Relations Fact Sheet. Washington,
DC: Dept of Veterans Affairs; March 2002. http:/www.va.gov/about-va. 2. Veterans Administration National Center for Cost Containment. National Home Oxygen Program. FY 95. Washington, DC: Dept of Veterans Affairs. August 1996. 3. Veterans Integrated Service Network Support Service Center (VSSC). Dept of Veterans Affairs. http:www.klfmenu.med.va.gov. 4. Kazis LE, Miller DR, Clark J, et al. Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med. 1998;158: 626-632. 5. Kazis LE, Ren XS, Lee A, et al. Health status in VA patients: results from the Veterans Health Study. Am J Med Qual. 1999; l4:28-38. 6. Skinner KM, Furey J. The focus on women veterans who use Veterans Administration health care: the Veterans Administration Women’s Health Project. Mil Med. 1998;163:761-766. 7. Klevens RM, Giovino GA, Peddicord JP, et al. The association between veteran status and cigarette-smoking behaviors. Am J Prev Med. 1995; I 1: 245-250. 8. Centers for Disease Control and Prevention. Reducing the health consequences of smoking: 25 years of progress - a report of the Surgeon General, 1989. Rockville, Md: US Dept of Health and Human Services, Public Health Service; 1989. DHHS publication. 9. Cronan TA, Conway TL. Is the Navy attracting or creating smokers? Mil Med. 1988;153: 175-178. 10. Bray RM, Marsden ME, Peterson MR. Standardized comparisons of the use of alcohol, drugs, and cigarettes among military personnel and civilians. Am J Public Health. 1991;81:865-869. I I. Bray RM, Marsden ME, Guess LL, Herbold JR. Prevalence, trends, and correlates of alcohol use, nonmedical drug use, and tobacco use among U.S. military personnel. Mil Med. 1989; 154: I- 1 1. 12. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med. 1999;340:1941-1947. 13. Smith DM, Giobbie-Hurder A, Weinberger M, et al. Predicting non-elective hospital readmissions: a multi-site study. Department of Veterans Affairs Cooperative Study Group on Primary Care and
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Readmissions. J Clin Epidemiol. 2000;53: 1113-1118. Fan VS, Curtis JR, Tu SP, et al. Using quality of life to predict hospitalization and mortality in patients with obstructive lung diseases. Chest. 2002;122: 4299436. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000; 284:2877-2885. Kim HF, Kunik ME, Molinari VA, et al. Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics. 2000;41:46547 1. Kunik ME, Braun U, Stanley MA, et al. One session cognitive behavioural therapy for elderly patients with chronic obstructive pulmonary disease. Psycho1Med. 2001;3 1:7 17-723. Mokhlesi B, Morris AL, Huang CF, et al. Increased prevalence of gastroesophageal reflux symptoms in patients with COPD. Chest. 2001; 119:1043-1048. Good-Fratturelli MD, Curlee RF, Holle JL. Prevalence and nature of dysphagia in VA patients with COPD referred for videofluoroscopic and swallow examination. J Common Disord. 2000;33: 93-l 10. Iqbal F, Michaelson J, Thaler L, et al. Declining bone mass in men with chronic pulmonary disease: contribution of glucocorticoid treatment, body mass index, and gonadal function. Chest. 1999; 116: 1616-1624. Adams SG, Melo J, Luther M, et al. Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest. 2000; 117:1345-1352. Kendrick KR, Baxi SC, Smith RM. Usefulness of the modified 0- 10 Borg scale in assessing the degree of dyspnea in patients with COPD and asthma. J Emerg Nut-s. 2000;26:216-222. Pilling J, Cutaia M. Ambulatory oximetry monitoring in patients with severe COPD: a preliminary study. Chest. 1999;116:314-321. VA/DOD Clinical Practice Guideline Working Group. Management of Chronic Obstructive Pulmonary Disease. Washington, DC: Office of Quality and Performance; August 1999. Publication 1OQ-CPG/ COPD-00. Available at: http://www.oqp.med.va.gov/cpg/COPD/ COPD-base.htm.
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ADVISORY BOARD How did the tobacco industry promote smoking to soldiers and veterans and when and how was it halted?
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ly published VA Western New York Healthcare System article (N Engl J Med. I 2002;347:465), which found a correlation between the acquisition of new strains of bacteria and COPD exacerbations.
PEREZ It took about 20 years after the original Surgeon General’s report on the dangers of smoking to remove tobacco products from military rations, commissaries, and VA hospital canteens. The military was a savory target of the tobacco industry where concentrations of young and long-term customers were to be found. Cigarettes were provided to soldiers and sailors in K- and C-rations during both World Wars and the Korean and Vietnam wars. Cigarette advertising touting patriotism showed young men and women in uniform enjoying cigarettes. An additional incentive was the discounted price of cigarettes sold in the military commissaries.
ROMAN Sehti and colleagues conducted a prospective study that included molecular typing of sputum isolates of several bacterial strains commonly found in COPD patients. They observed that new strains of bacteria detected during clinic visits were associated with a COPD exacerbation twice as often as in patients without an exacerbation (33% vs 15.4%). Furthermore, they found that the isolation of a new strain of H influenzae, M catarrhalis, or S pneumoniae was associated with a significantly increased risk of an exacerbation. As the authors concluded, these observations support a causative role of bacteria in exacerbations of COPD. However, it raises many questions that will have to be addressed. For example, is the acquisition of new strains directly responsible for the COPD exacerbations, or is the inflammatory state elicited during an exacerbation contributing to airway colonization with new strains? Are new strains acquired due to current antibiotherapy strategies? Is the acquisition of new strains predictive of increased exacerbations?
ADVISORY BOARD Describe smoking cessation programs implemented by the VA and comment on their efficacy. PEREZ There is no national VA guideline or policy related to smoking cessation. Each VA Medical Center implements its own smoking cessation program, usually through the Mental Health Service Line. A psychologist, physician, or other health practitioner with expertise in smoking cessation techniques manages the program. In Atlanta, our lo-year-old program uses a combination of counseling and nicotine replacement therapy and has resulted in an abstinence rate of about 30% after 5 years. This is par with most smoking cessation programs in this country. ADVISORY BOARD What are the clinical implications
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ADVISORY BOARD What were the home-based primary care interventions implemented by Hughes et al that improved quality-of-life measures? ROMAN In general, the interventions were designed to facilitate communication between the hospital staff and the primary care doctors and to provide access to physicians when needed. They included
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the establishment of a primary care manager position, 24-hour contact for patients, prior approval of hospital readmissions, and home-based primary care team participation in discharge planning. ADVISORY
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Does effective management of gastroesophageal refiux improve pulmonary symptoms or function in patients with COPD? ROMAN The association between gastroesophageal reflux and COPD is not well established. Although many believe that treatment of gastroesophageal reflux can improve or prevent COPD exacerbations, there is not much evidence to support this belief. On the contrary, in 1998, Boerce et al published data sug-
gesting that in asthma and COPD patients with severe airway hyperresponsiveness, treatment with omeprazole had no beneficial effect on pulmonary parameters despite its significant effect on acid reflux when compared with placebo. In a more intriguing study, Orr et al (1992) were unable to document a bronchoconstrictive reflex in response to distal esophageal acidification in 12 patients with COPD. These and other studies suggest that further investigations are needed to confirm a role for gastroesophageal reflux in COPD exacerbation, and the effects, if any, of antireflux therapy on COPD exacerbations. Until new data are collected, I continue to offer antireflux therapy to patients with manifest symptoms and diffkult-to-treat COPD where gastroesophageal reflux is documented.