Collaborative Care for the COPD Patient:

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• Collaborative Care for the COPD Patient
• The Physicians Perspective

Sushmita Pamidi, MD, FRCPC Respirology
Fellow Department of Medicine, Division of
Respirology London Health Sciences Centre,
London October 2008
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Conflict of Interest

• None!

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COPD Impact

• A leading cause of morbidity and mortality
• Significant co-morbidities
• Economic and social burden
• Underreported and Underdiagnosed

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Is There Room to Improve?

• Preventable and Treatable
• CTS Guidelines, GOLD
• Therapies exist that improve morbidity and
  mortality
• Multiple guidelines set standards for quality of
  care
• However, COPD patients receive recommended care
  only 58 of time

Mularski, Chest 2006
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Barriers to Optimal Treatment
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Underdiagnosis

• Underrecognition of symptoms by patients and
  physicians
• Underutilization of spirometry
• Competing co-morbidities
• Smokers avoiding health care

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Adherence

• The extent to which a persons behaviour
  coincides with medical or health advice (Haynes,
  1979)
• Non-adherence is common and contributes to
  decreased health outcomes
• Adherence to COPD treatment is low (lt50)
• Adherence can improve when patients have a
  greater understanding of their illness and the
  options of managing their illness

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Bourbeau, Thorax 2008
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Resource Limitations

• GPs are often left managing the vast majority of
  COPD patients by themselves
• Insufficient resources and time for patient
  education and self-management training ?
  requires complex and comprehensive management
• Significant co-morbidities

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The typical 30-minute consult

• 65 M, lives alone
• CC SOB
• PMHX
• COPD, FEV1 1.2 L/ or 54 predicted, DLCO 60
  predicted
• Hypertension
• Smoker 70 pack year history
• On Tiotropium, Salbutamol

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The typical 30-minute consult

• HPI
• Identified Issues
• SOBOE limited exercise capacity and therefore
  ADLs
• Frequent exacerbations and pneumonias (2/year x
  2 years)
• Low BMI (21)
• Deconditioning prefers to limit activity to
  avoid SOB
• Anxiety
• Smoking tried quitting twice, but
  unsuccessful
• Inappropriate use of inhalers and suboptimal
  therapy

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Management Goals

• Prevent disease progression
• Symptom management and exercise tolerance
• Prevention of exacerbations
• Education
• Adherence (cost?)
• Self-management skills

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An Ideal Management Plan

• Medication review Add LABA/ICS
• Discuss adherence to treatment and cost issues
• Ensure proper technique and use of inhalers
• Smoking cessation
• Encourage exercise program, consider pulmonary
  rehab
• Counsel on diet and significance of weight loss,
  refer to dietician
• Discuss anxiety and depression
• Action plan for exacerbations (eg. vaccinations,
  antibiotics, etc.)

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The Collaborative Team

• Patient
• Physician
• Pharmacist
• Nurse Educator
• Physiotherapist
• Occupational Therapist

• Dietician
• Social Worker
• Psychologist

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Role of the Family Physician

• GPs have a challenging job in the management of
  COPD patients!
• Need early intervention and management
• Need more structured systems to implement care
  for COPD and other chronic respiratory illnesses
• Ex. multidisciplinary care plan

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The Patient

• Imperative that the patient is an active
  collaborator in their own health care management
• Need a patient-centered approach to management
• Acknowledge patients role in medical
  decision-making
• Describes relationship between patient and
  health-care provider as a partnership

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Education

• Needs to be individualized
• Pharmacist medications, inhaler technique
• Self-management programs have shown to reduce
  resource utilization
• Smoking cessation
• Support of case manager

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Self-Management Intervention

• Living Well with COPD
• Self-Management Program Booklet
• Breathing and coughing techniques
• Relaxation exercises
• Inhalation techniques
• Plan of action for acute exacerbation
• Healthy lifestyle
• Exercise
• Teaching for 1 hr/week for 7 weeks
• Program supervised by health professional
• Follow-up with weekly phone calls for 8 weeks
  then monthly

Bourbeau, Arch Int Med, 2003
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Exercise and Pulmonary Rehabilitation

• Formal pulmonary rehabilitation
• Home exercise programs
• Regular walking
• Adherence is often an issue
• Maintenance after intervention
• Help patients understand importance of
  self-monitoring of activity (ex. Daily activity
  diaries)
• Help patient overcome barriers to being active

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Boxall, Journal of Cardiopulmonary
Rehabilitation, 2005
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Tackling Depression/Anxiety

• Prevalent!
• 30-50
• Team psychologist if available
• Stigma related to discussing anxiety and
  depression ? Need to be able to recognize
  symptoms
• Psychopharmacology
• Pulmonary rehabilitation

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Key Points

• Refer early to COPD education/exercise program
  (ex. COLD)
• Patients will have more knowledge and can use
  resources earlier
• If there is no program close-by, then refer to
  individual health care professionals to meet
  needs of patient (i.e. dietician,
  physiotherapist)
• Make use of community resources
• Need repetition, self-care plans, education
  resources

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Thank you!

• Questions?