WORLD COPD DAY
November 20, 2013
Raising COPD Awareness Worldwide
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Chronic Obstructive Pulmonary Disease
(COPD): Improving Fiscal and Health
Impact through Accountable Care
Guy W. Soo Hoo, MD, MPH
Pulmonary and Critical Care Section
West Los Angeles VA Healthcare Center
Los Angeles, CA
WORLD COPD DAY 2013: It’s not too late
How many people have COPD?
Worldwide, one in 10 adults over age 40 may have COPD.
COPD is most common in countries where cigarette smoking
has been, or still is, very widespread.
How many lives are lost to COPD?
Worldwide, nearly 3 million people die from COPD every year.
According to a report commissioned by the World Bank, COPD
is the third leading cause of death worldwide, surpassed only
by heart attack and stroke.
In the United States in 2005, the direct costs of COPD were
$21.8 billion and the indirect costs totaled $17 billion.
World COPD Day 2013 is organized by the Global Initiative
for Chronic Obstructive Lung Disease (www.goldcopd.org).
COPD: perceptions of disease
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COPD is a disease of smokers
COPD is a disease of men
COPD is a disease of elderly adults
COPD only affects the lungs
COPD is diagnosed too late for any treatment
COPD results an progressive decline
COPD results in permanent disability
COPD is unmanageable
COPD is untreatable
Death rates of major cardiopulmonary diseases
Pauwels R, Rabe K:. Lancet 2004; 304: 613-20
Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPD
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COPD, a common preventable and treatable
disease, is characterized by persistent airflow
limitation that is usually progressive and
associated with an enhanced chronic
inflammatory response in the airways and the
lung to noxious particles or gases.
Exacerbations and comorbidities contribute to
the overall severity in individual patients.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Petty T. Chest 2002: 1219(S):116S
Prevalence of COPD in the US 2007-2009
Most people with COPD are < 75 years of age
Most undiagnosed patients with COPD are < 65 years of age
Akinbami L , Liu X. NCHS Data brief; 2011 (6): 1-8
Prevalence of COPD in the US 2007-2009
There are more women with COPD than men
COPD in more common among women than men
Akinbami L , Liu X. NCHS Data brief; 2011 (6): 1-8
Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
 A clinical diagnosis of COPD should be
considered in any patient who has dyspnea,
chronic cough or sputum production, and a
history of exposure to risk factors for the
disease.
 Spirometry is required to make the diagnosis;
the presence of a post-bronchodilator FEV1/FVC
< 0.70 confirms the presence of persistent
airflow limitation and thus of COPD.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations
Combine these assessments for the
purpose of improving management of COPD
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of Airflow
Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild
FEV1 > 80% predicted
GOLD 2: Moderate
50% < FEV1 < 80% predicted
GOLD 3: Severe
30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Modified Medical Research Council
(mMRC) Dyspnea Scale
Grade
Description
0
Not troubled with breathlessness except with strenuous exercise
1
Troubled by shortness of breath when hurrying on the level or walking up
a slight hill
2
Walks slower than people of the same age on the level because of
breathlessness or has to stop for breath when walking at own pace on the
level
3
Stops for breath after walking about 100 yards or after a few minutes on
the level
4
Too breathless to leave the house or breathless when dressing or
undressing
Mahler D et al. Chest 1988; 93: 580
Global Strategy for Diagnosis, Management and Prevention
of COPD
Combined Assessment of
COPD
When assessing risk, choose the highest risk
according to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)
Patient
Characteristic
Spirometric
Classification
Exacerbations mMRC
per year
A
Low Risk
Less Symptoms
GOLD 1-2
≤1
0-1
< 10
B
Low Risk
More Symptoms
GOLD 1-2
≤1
>2
≥ 10
C
High Risk
Less Symptoms
GOLD 3-4
>2
0-1
< 10
D
High Risk
More Symptoms
GOLD 3-4
>2
>2
© 2013 Global Initiative for Chronic Obstructive Lung Disease
CAT
≥ 10
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Goals of Therapy
 Relieve symptoms
 Improve exercise tolerance
 Improve health status
Reduce
symptoms
 Prevent disease progression
 Prevent and treat exacerbations
 Reduce mortality
Reduce
risk
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Key Points
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Identification and reduction of exposure to risk factors
are important steps in prevention and treatment.
Individualized assessment of symptoms, airflow
limitation, and future risk of exacerbations should be
incorporated into the management strategy.
All COPD patients benefit from rehabilitation and
maintenance of physical activity.
Pharmacologic therapy is used to reduce symptoms,
reduce frequency and severity of exacerbations, and
improve health status and exercise tolerance.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
The natural history of lung function:
smoker and non-smokers
Smoking cessation decreases the decline in lung function
Fletcher C, Peto R. BMJ 1997; 1: 1645-8
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: All COPD Patients
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Avoidance of risk factors
- smoking cessation
- reduction of indoor pollution
- reduction of occupational exposure
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Influenza vaccination
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Options in COPD management
• Increasing options for treatment
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Medications
Oxygen therapy
Preventive vaccinations
Pulmonary rehabilitation
Surgical options
Lung transplantation
• Biomarkers and genes (ECLIPSE, COPD Gene,
SPIROMICS)
• Targeted therapy
COPD: World COPD Day 2013
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COPD is a disease of inhaled irritants
COPD is a disease of men and women
COPD is a disease of working adults
COPD is a systemic disease
COPD diagnosis important for treatment
COPD progression is variable
COPD patients are functional
COPD is manageable
COPD is treatable
Patient Protection and Affordable Care Act
(PPACA); Affordable Care Act
Enacted 2010; Upheld 2012
• Most significant overhaul of US healthcare system
since Medicare and Medicaide (1965)
• Goals of legislation
• Increase quality and affordability of health insurance
• Lower uninsured rate, expanding insurance coverage
• Minimum standards, eliminate exclusion from pre-existing
conditions
• Reforms by shifting system towards quality over quantitiy
• Expanding Medicaid and establishing state based
health insurance exchanges
Health care providers
Heath care plans
Accountable care
organizations
What is the impact on COPD?
It’s not too late
The changing face of COPD
Under-diagnosis and unfamiliarity with COPD
Public not aware of
“COPD”, ~ 15% aware
Diagnosis on query
COPD 23%
Emphysema 26%
Chronic bronchitis 36%
Only about half of
patients with COPD
diagnosed
Mannino, D et al MMWR 2002: 51: 1-16; Rennard S, et al. Eur Resp J 2002;20: 799-805
How do you
know you
have COPD?