Troubling new evidence from the CDC raises questions about how COPD is not being adequately diagnosed and treated in many patients.
Time to brush up on national guidelines for treating chronic obstructive pulmonary disease (COPD). Not only will quality initiatives now being implemented under health care reform penalize doctors and hospitals for poor care for COPD patients, but there is substantial evidence that such patients aren’t currently receiving quality care.
The latest data come from the CDC. Researchers used data from the 2007 and 2009 North Carolina COPD Behavioral Risk Factor Surveillance System (BRFSS) survey to assess the level of care patients with COPD received. They found that just 43% of respondents with COPD said they’d seen a doctor in the past 12 months, while 15% had visited the emergency department (ED) or been admitted to the hospital for COPD symptoms.1
As the researchers wrote: “These results indicate that many adults with COPD might not have had adequate diagnostic spirometry, and many who might benefit from daily medications, such as long-acting bronchodilators and inhaled corticosteroids, are not taking them.”
• Despite recommendations that spirometry be used as a component of diagnosis, just 59% of those 18 to 44 had had received this test in 2007 for their diagnosis, although that number improved in 2009 to 71%. This was much higher (92%) among older people in whom COPD was diagnosed. While spirometry should also be used to track COPD progression, just 39% of patients who were not receiving COPD medication had undergone a breathing test in the past year.
• About a third of those surveyed reported that cost prevented them from seeking medical care, compared with 17% of those without COPD. Other obstacles were poor or fair health status (46% of those with COPD vs 16% of those without) and moderate or severe disability (37% of those with COPD vs 9.1% of those without).
• More than two-thirds (70.7%) said dyspnea affected their quality of life.
• In 2007, barely half of respondents (48.1%) reported that they used at least one daily medication for COPD, even though guidelines call for nearly all patients with COPD to be using at least a bronchodilator.2 Even among those who had been admitted to a hospital, just 48% were taking daily COPD medications.
• In 2009, nearly a third of patients (70% of those who had been seen in the ED and 38% of those who had been hospitalized) said that prednisone had been prescribed for them. The drug is recommended only during extreme COPD exacerbations, not for routine therapy. 2
This study confirms other evidence of undertreatment in COPD. A study by Make et al3 published in January 2012 identified similar problems in 19 health plans involving 42,565 patients with commercial insurance and 8507 Medicare patients. Maintenance therapy had not been prescribed for 71% of Medicare patients and 66% of commercially insured patients. Even patients with severe COPD were undertreated; maintenance therapy had not been prescribed for 59% of commercially insured and 69% of Medicare patients. In addition, few smokers had received any smoking cessation interventions, and less than a quarter (16.6% commercial and 23.5% Medicare) had received a flu shot.3
Other studies find that up to half of primary care physicians are not familiar with COPD guidelines.4
These studies have significant implications, not only for the quality of care provided to patients with COPD, but for the financial health of physician practices. New Medicare guidelines will penalize hospitals for preventable readmissions related to COPD, putting more pressure on physicians to provide guideline-recommended, evidence-based care. In addition, Medicare quality criteria for physicians call for all patients with COPD to receive bronchodilator therapy and spirometry evaluation.
1. Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease and associated health-care resource use-North Carolina, 2007 and 2009. MMWR. 2012;61:143-146
2. Global Strategy for Diagnosis, Management, and Prevention of COPD. Updated December 2011. Available at: http://www.goldcopd.org/. Accessed February 16, 2012.
3. Make B, Dutro MP, Paulose-Ram R, et al. Undertreatment of COPD: a retrospective analysis of US managed care and Medicare patients. Int J COPD. 2012;7:1-9.
4. Rutschmann OT, Janssens JP, Vermeulen B, Sarasin FP. Knowledge of guidelines for the management of COPD: a survey of primary care physicians. Respir Med. 2004;98:932-937.