COPD: Better Health Care Through Improved Diagnosis, Treatment and Pulmonary Rehab

Statistics paint a stark reality of chronic obstructive pulmonary disease (COPD), which is now the fourth leading cause of death in the United States, claiming more than 130,000 lives each year. Of the top 10 leading causes of death in the United States, COPD is the only one with increasing incidence, and it is on track to become the third leading cause of death by the year 2015.

 There are now more than 12 million Americans who have already been diagnosed with COPD, and it is estimated that another 12-14 million Americans, mostly baby boomers, will be diagnosed during the next five to seven years.

Recently, a major COPD patient activist group, EFFORTS (, has joined with both the American Lung Association (ALA) and the American Thoracic Society (ATS) to petition Congress to allocate $6 million in the federal budget for fiscal 2009 to authorize the Centers for Disease Control & Prevention (CDC) to launch a COPD-specific program. Such a program would enable the CDC to expand critical surveillance activities while creating a nationwide action plan to address the prevention, early diagnosis, treatment and long-term disease management of this deadly malady.

Other organizations, such as the National Heart, Lung and Blood Institute (NHLBI) have begun similar public awareness programs to focus attention on the growing issues and costs associated with the diagnosis and treatment of COPD.

Key to the success of these initiatives will be to direct dollars toward established public access channels, while at the same time providing primary care physicians with better tools to diagnosis and manage COPD. It has been estimated that as many as 70 percent of cigarette smokers visit a primary care physician each year for a non-respiratory medical problem. Accordingly, it makes sense to provide primary care physicians with the knowledge and tools needed to easily and quickly assess the pulmonary status of patients at risk for COPD. It is hoped that by training primary care physicians to be aware of and to recognize certain risk factors, such as chronic exposure to direct or secondhand cigarette smoke or airborne occupational contaminants, as well as more obvious signs and symptoms, such as chronic cough and/or shortness of breath, early detection would be much more likely.
Patients presenting with such risk factors and/or symptoms should, in turn, undergo spirometry to confirm the diagnosis. The goal is to begin treatment earlier in the disease process before there is progression to a more advanced stage, where there is often a less than positive response to treatment. This comprehensive approach has been used with a great deal of success in the management of other chronic diseases.

Fortunately, treatment options for COPD patients have been improving steadily. The 2007 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines for COPD Management represent an excellent framework to not only stage the severity of a particular patient’s disease, but to also determine which treatment interventions would be best given a particular patient’s established severity level.

The GOLD Guidelines also make a strong case for pulmonary rehabilitation as a standard intervention for COPD patients with disease severity levels II (moderate) through IV (very severe). Therefore, it was most propitious that the recently enacted Medicare Improvements for Patients and Providers Act of 2008 finally directs the Centers for Medicare & Medicaid Services (CMS) to develop — by Jan, 01, 2010 — a national, uniform coverage policy for pulmonary rehabilitation provided to Medicare beneficiaries.

This long-overdue legislative breakthrough comes at a time when the benefits of pulmonary rehabilitation continue to be extolled in peer-reviewed medical journals from around the world. For example, in 2001, Finnerty and Keeping reported in CHEST the results of a six-week, randomized controlled trial of outpatient pulmonary rehabilitation that showed significant improvement in the quality of life in patients with moderate to severe COPD. In 2005, Porszasz and colleagues from the Biomedical Research Institute at Harbor-UCLA Medical Center Rehabilitation Clinical Trials Center in Torrance, Calif., also writing in CHEST, demonstrated that exercise training in patients with severe COPD dramatically improves submaximal exercise endurance.

In a more robust undertaking in 2006, Lacasse and colleagues, from Hospital Laval in Quebec, reported an updated Cochrane review of 31 randomized controlled trials (RCTs) of pulmonary rehabilitation that led the authors to conclude: “rehabilitation relieves dyspnea and fatigue, improves emotional function and enhances patients’ sense of control over their condition.” The researchers further added that the improvements were moderately large and clinically significant. Lastly, the 2007 evidence-based clinical practice guidelines, published jointly in CHEST by the American College of Chest Physicians (ACCP) and the American Association for Cardiovascular and Pulmonary Rehabilitation (AACVPR), included an introductory paragraph stating that “based on a growing body of scientific evidence, pulmonary rehabilitation has emerged as a recommended standard of care for patients with chronic lung disease.”
That there are significant clinical benefits to be derived from participation in a formal pulmonary rehabilitation program can no longer be questioned. Pulmonary rehabilitation has other benefits as well, including contributing to a reduction in the hospital readmission rate of COPD patients from acute exacerbations.

Repeat readmissions due to acute exacerbations are expensive, and we often fail to recognize and appreciate the negative impact of readmissions on an acute hospital’s bottom line. The Medicare reimbursement rate for DRG #088, acute exacerbation of COPD, is well below Medicare’s own 2006 cost estimate of $24,000 for each hospitalization. Moreover, frequent rehospitalizations due to acute exacerbations of COPD also are considered a significant risk factor for death.

Some have questioned whether pulmonary rehabilitation is beneficial for those with moderate disease, suggesting that the program should be reserved for those with severe to very severe disease. However, Steele and colleagues from the Veterans Affairs Puget Sound Health Care System in Seattle presented a paper at the 2008 ATS Conference in Toronto in which they found that “more temporal benefits with regard to exercise capacity and quality of life will accrue if COPD patients are referred earlier in their disease process.” These findings further underscore the importance and advantages of early detection and diagnosis.

While the news about pulmonary rehabilitation is certainly welcome, there are other issues that continue to have a less than positive impact on COPD patients. Specifically, in some sectors of our health care system, the use of long-term oxygen therapy (LTOT) to reduce the cardiovascular ravages of untreated chronic arterial hypoxemia is becoming increasingly viewed as a commodity treatment option. This is a dangerous trend, especially since the scientific basis for the clinical, physiological and psychological benefits of LTOT has been well established in the peer-review medical literature. Simply stated, properly prescribed and used LTOT is a maintenance medication for COPD symptom control, and in that regard, is no different than scheduled, twice-daily dosing of long-acting bronchodilators for the control of bronchoconstriction.

Supplemental oxygen is also a vitally important component of pulmonary rehabilitation. Many COPD patients enrolled in a formal program are physically unable to continue participation without an ambulatory oxygen system that is effective and easy to use. As mentioned, low flow supplemental oxygen is a controller medication for COPD patients, and as such, the oxygen needs of COPD patients must be routinely assessed and prescribed with the thought of improving outcomes and reducing health care costs. If coverage and reimbursement levels for LTOT are driven down to the lowest common denominator by third-party payors, including Medicare, the potential impact in reducing recidivism, improving clinical outcomes and improving the quality of life for COPD patients will be severely undermined.
While there is no question that the U.S. health care system is in desperate need of a fix, wholesale and often indiscriminate funding cuts are not the answer. Rather, in the final analysis, it will be better health care, not cheaper health care, that will save both lives and money. Our patients deserve no less.

This article originally appeared in the Respiratory Management Sept/Oct 2008 issue of HME Business.


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