Exploring the GeneralistSubspecialist Interface
Higher quality caring for patients
with asthma and COPD
Mark Linzer MD
Disclosures and Objectives
• No financial support for the talk
• Learning Objectives: to better understand
– National scene for generalists and specialists
– ASP Workforce Committee
– Literature on outcomes for patients with
respiratory disorders
– Proposed practice patterns for managing
patients with asthma and COPD
Overlecturing and Underteaching
• J Willis Hurst, recent Archives (Arch Intern Med.
2004;164:1605-9; thanks to Tom McCarthy)
• Most lectures are a waste of time
• Teach interactively; engage the listeners’
brains.
• Teach based upon patient problems
3 cases
• 70 year old man with HBP, BPH and mildmoderate, well controlled COPD initially managed
by pulmonary consultant, now by me. Referred
back ’95, stable sx on ICS, FEV1 78% predicted,
FEV1/FVC 68%. Meds include albuterol, theo,
fluticasone. Last hospital stay >10 yrs ago.
– Does he need periodic pulmonary consultation?
– How am I (and he) doing?
Case 2
• 60 yr old woman with HBP, sinusitis, asthma,
sleep apnea (desats to low 80s, now on O2), gout,
alcohol use, seen by me, allergist and pulmonary
specialist. Takes the right meds (Advair, flonase,
albuterol). BMD nl. On exam, wt. 200, clear
lungs, resolving SI after recent Rx by allergy with
steroids and Abx. FEV1 77%; FEV1/FVC 63%.
– Does she need the allergist? Does she need the sleep
specialist?
– Does she need me?
Case 3
• 30 yr old male: dyslipidemia, hypothyroid,
GERD, HBP and RAD presents 6/04 with
severe asthma attack (went to ER, sent
home on oral steroids). Followed for
several yrs on Advair, albuterol, Flonase,
PPI. One hospital stay 10/03 for asthma
exacerbation after chemical exposure. He
does not have an allergist.
– Does he (did he) need one?
The national scene
• ACGIM (Assn Chiefs in GIM) and SGIM joined
ASP (Assn Subspecialty Professors) in 2003.
• Agreement: 2 generalist Council reps; name
change; annual meeting with chairs (APM); article
each year in AJM; new committee on generalistspecialist interactions (Workforce Comm.)
• For first time, generalists and specialists sit
together and discuss policy.
ASP Workforce Committee
• 3-4 generalists, 4 specialists
• Charge: discuss models for management of
chronic illness
• Co-Chairs: ML and Bob Myerburg, Chief,
Cardiology, Miami. Both sit on Executive
Committee.
• Agreement: no turf battles. What is best for
the patient will guide our recommendations.
Questions for the Workforce Committee*
•
•
•
•
•
•
When to refer (from GIM to SSIM)?
When to refer back (from SSIM to GIM)?
What are communication issues?
What are educational issues for GIM?
What are workforce implications?
Where are new data required?
– *Linzer M. SGIM Forum. 2004;27(5):2,8
Illnesses to address first
•
•
•
•
•
•
•
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Diabetes
CAD
HTN
Atrial fibrillation
Chronic renal disease
RA and O.A.
RAD and COPD
Inflammatory bowel disease and Irritable Bowel
Questions
• What do you think of bringing generalists
and specialists together for these purposes?
• What additional questions might you ask of
the committee?
• Any strategic suggestions?
Practice pattern grids
•
•
•
•
When to refer
When and how to co-manage
When to refer back
Education and communication issues
RAD: NAEPP guidelines
(www.nhlbi.nih.gov)
•
•
•
•
All patients: SA beta agonists (minimize)
Mild intermittent – no daily meds
Mild persistent – low dose ICS
Moderate persistent – low-med. dose ICS
plus LA beta agonist (can use leukotriene
modifer or theo)
• Severe persistent – high dose ICS and LA
beta agonist – may need oral steroids
RAD: Peak Flow meters?
• Evidence neither supports nor refutes that
their use improves outcomes; if so, only in
severe disease.
RAD: the literature
• In 2000 mgd care pts (Wu A, Arch Intern Med.
2001;161:2554-2560, from HSR&D Ctr, JHU), allergists did
better than generalists re: asthmatic
patients’:
–
–
–
–
Cancelled activities
Hospitalizations and ED visits
Quality of care ratings
Physical function
More RAD literature
• In 400 HMO pts (Vollmer WM. Arch Intern Med
1997;157:1201-8), allergists gave better care (e.g. 92%
of pts with mod-severe disease took inhaled antiinflammatory agents vs 43% of generalists pts).
• At Stony Brook (Frieri M. J Asthma. 2002;39:4-5-12),
allergists gave more frequent F/U, used PEFs,
prescribed more controller medications (ICS, LA
beta agonists), Rx’ed more comorbidities
impacting on asthma (allergic rhinitis).
More RAD Lit
• In 260 parents of children with asthma (Diette
GB. Pediatrics. 2001;108:432-7), asthma specialists
compared with generalists used more
controller meds (OR 6.5), ordered PFTs
(OR 6.5), and told parents about asthma
triggers and how to avoid them (OR 5.9).
Asthma: a generalist survey (Ann
Allergy Asthma Immunol. 1999;83:203-6)
• 37 FP and IM MDs at Mayo Clinics: when
they refer:
–
–
–
–
–
46% if pt requests
38% for immunoRx
27% for a single life threatening attack
14% for allergy testing
11% for poorly controlled asthma
RAD: Conclusions
• Asthma patients appear to get care more
consistent with guidelines and have better
outcomes when managed by specialists
• Ouch
The Unity Experience
(Communicator. 2003;4:1-2)
• Appropriate use of ICS: 1999 – 71%
• 2002 – 78% (9th highest in the country).
• How did we do it: MD reminders re: ICS and
patient empowerment?
– Member guidelines
– Quarterly newsletter re: meds, triggers, PEFs, cig.
cess’n, flu vax.
– NIH pamphlet – how to take meds, identify triggers,
how to avoid.
RAD referral grid
•
Setting
•
Mild
•
•
•
•
Mod-severe
(prolonged steroids,
frequent sx, nearfatal asthma)
Primary Care
Ongoing mgmt
Refer if unstable, uncertain
dx, adherence problems
Co-manage with subspec
Pulm/Allergist
Available to consult
Principle care of pts
with severe RAD;
co-manage with PC
for complex RAD
(SI/GERD); refer
back if stable, mildmoderate sx.
Question:
• When do you refer? What if anything do we
need to do to improve mgmt of patients
with RAD by facilitating better referrals,
back referrals, communication and
education?
COPD – guidelines*
• GOLD Guidelines (Global Initiative for
Chronic Obstructive Lung Disease, expert
and evidence based):
– Mild (FEV1 >80%): SA BDs (beta ag, ipatrop)
– Mod. (FEV1 50-80%): LA BDs +/- ICS
– Severe (FEV1 <50%): LA BDs + ICS
• All: flu vax, pneumovax, smoking cess’n
– *Sutherland ER. Management of COPD. NEJM. 2004;350:2689-97
GOLD Guidelines: Classifications
Therapy at Each Stage of COPD
Old
0: At Risk
I: Mild
New
0: At Risk
I: Mild
Characteristics
• Chronic symptoms
• Exposure to risk
factors
• Normal spirometry
II: Moderate
IIA
IIB
II: Moderate
III: Severe
• FEV1/FVC < 70%
• FEV1 ≥ 80%
• With or without
symptoms
• FEV1/FVC < 70%
• FEV1/FVC < 70%
• 50% < FEV1 < 80% • 30% < FEV1 < 50%
• With or without
• With or without
symptoms
symptoms
III: Severe
IV: Very Severe
• FEV1/FVC < 70%
• FEV1 < 30% or
presence of chronic
respiratory failure or
right heart failure
Avoidance of risk factor(s); influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or
more long-acting bronchodilators
Add rehabilitation
Add inhaled corticosteroids
if repeated exacerbations
Add long-term
oxygen if
chronic
respiratory
failure
Consider
surgical
treatments
Adapted from Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management,
and Prevention of Chronic Obstructive Pulmonary Disease: Executive Summary—Updated 2003. Bethesda, Md: NIH,
NHLBI; 2003.
COPD – the literature*
• In 450 Belgian MDs:
– GPs underused spirometry to Dx
– Both GPs and pulmonologists overused ICS (50% of
GPs gave to all COPD pts vs 25% of pulmonologists)
– GPs and pulmonologists overused systemic steroids in
stable disease
– Neither GPs nor pulmonologists gave enough pts
pharmacoRx for smoking cessation.
• *Decramer M. Monaldi Arch Chest Dis. 2003;59:62-80.
COPD – Hx vs PEF?
• Data from the Veterans Health Study (Ren XS. J
Ambulatory Care Mgmt, In Press), in
352 pts with COPD:
– Severity measure by history alone: frequency and
intensity of dyspnea, wheezing, cough.
– Explained 19% of variance in physical function and
19% of variance in future hc visits; PEF explained only
10% and 2% of variances, respectively.
COPD – What’s new
• Tiotropium (Spiriva) (Med Letter 2004;46:41-42): LA
anticholinergic BD (peak 3 hrs, lasts 24)
– More sustained response than salmeterol
– Cost: 1 mo. Rx: $115 vs $68 for ipatropium and
$88 for salmeterol.
• Advair in COPD: better impact than either
(salmeterol, fluticasone) alone. Watch for
next GOLD guidelines (Weissler J, personal
communication)
COPD referral grid
• Setting
PC MD
SSIM
• Mild-moderate
Ongoing mgmt
Refer if unstable,
uncertain Dx (ILD)
Available for
consultation
• Severe COPD
• (pCO2 >60, cor
• pulmonale, O2 dep.,
General med care;
co-mgmt of stable,
severe cases
Principle care of
COPD; if stable,
co-manage with
• frequent exacerbations)
PC MD
COPD - Conclusions
• More balanced literature: both generalists
and specialists overRx with ICS
• PFTs might not add much to Hx
• Vaccines and smoking cessation count
• Watch for some new developments (Advair,
Tiotropium)
Question:
• Do generalists know that the mainstay of Rx
for COPD is not ICS (though this may be
changing)?
• What do you think is the best way to
facilitate the highest quality care for pts
with COPD?
Issues
• Bringing generalists up to speed and into
the guideline development process
• Models of co-management – dynamic
equilibrium between GIM and SSIM
• Communication issues (esp. GIM to SSIM)
• Patient activation?
The cases
• My 70 yo with COPD, BPH and HBP.
Needs pulmonary?
• My 60 yo with SI, sleep apnea, EtOH and
RAD. Needs me, pulmonary (sleep) and/or
allergy?
• My 30 yo with a severe bout of asthma.
Time for an allergist?
Next up
• Jason Knuffman with tips for managing pts
with RAD