2008 New Jersey Academy of Family Physicians

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1 Chronic Obstructive Pulmonary Disease: Using Spirometry to Diagnose COPD in the Family Physician Office An evidence-based CME program developed by the New Jersey Academy of Family Physicians 2008 New Jersey Academy of Family Physicians

2 This program has been made possible through an educational grant from Boehringer Ingelheim and Pfizer, Inc. Disclaimer The EB CME credit awarded for this activity was based on practice recommendations that were the most current with the highest level of strength available at the time of release of this activity. Because clinical research is ongoing, the American Academy of Family Physicians recommends a reconfirmation of the recommendations and sources prior to implementation into practice.

3 Learning Objectives Appropriately use a spirometer to diagnose patients with COPD Appropriately integrate spirometry into the management of patients with COPD Accurately interpret the results of spirometry in patients with COPD Apply appropriate procedure codes to receive payment for the use of spirometry in diagnosing COPD

4 Review Questions

5 Question 1 Prior to the year 2000, more women died from COPD than men. 1. True 2. False True 0% 0% False 5

6 Question 2 COPD can be diagnosed based on medical examination and history alone. 1. True 2. False True 0% 0% False 5

7 Question 3 Physicians must conduct all spirometry testing 1. True 2. False 0% 0% True False 5

8 Question 4 Spirometry is only reimbursable if conducted in patients who currently smoke. 1. True 2. False True 0% 0% False 5

9 Question 5 An obstructive pattern in spirometry signifies asthma only. 1. True 0% 0% 2. False True False 5

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11 Epidemiology of COPD The fourth leading cause of death in people over age ,987 deaths attributed to COPD in the year 2004 Calverley PM, Walker P. Lancet. 2003;362(9389): American Lung Association. COPD Fact Sheet, September

12 Epidemiology of COPD By 2020, COPD will be the third leading cause of death in the United States and worldwide In 2000, for the first time ever, more women than men died from COPD Centers for Disease Control and Prevention. Deaths from Chronic Obstructive Pulmonary Disease - United States, Murray CJ, Lopez AD. Lancet. 1997;349(9064):

13 Risk Factors Most COPD cases arise from prolonged exposure to tobacco smoke National Heart, Lung, and Blood Institute

14 Practice Recommendation Smoking cessation is the single most effective and cost-effective intervention in most people to reduce the risk of developing COPD and stop its progression (Global Initiative for Chronic Obstructive Lung Disease, p.42). Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated Web site: Strength of evidence: Level of Evidence: A - Randomized controlled trials (RCTs). Rich body of data. Definition: Evidence is from endpoints of well-designed RCTs that provide a consistent pattern of findings in the population for which the recommendation is made. Category A requires substantial numbers of studies involving substantial numbers of participants.

15 COPD Definition and Symptoms Airflow limitation that is not fully reversible, associated with an abnormal inflammatory response to noxious particles or gases. Chronic cough Sputum production Dyspnea with activity Celli BR, MacNee W, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23:

16 Natural History of COPD A progressive disease, especially if exposure to the inciting agent (usually tobacco smoke) continues Stopping exposure will slow or even halt further progression

17 Practice Recommendation In patients with respiratory symptoms, particularly dyspnea, spirometry should be performed to diagnose airflow obstruction. Spirometry should not be used to screen for airflow obstruction in asymptomatic individuals (Qaseem et al., p.633). Source: Qaseem A, Snow V, Shekelle P, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2007; 147 (9); Web site: Strength of evidence: Strong recommendation, moderate-quality evidence.

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19 Spirometry Spirometry is to dyspnea as an EKG is to chest pain. Petty TL. Sensible spirometry.

20 Spirometry Screening Guidelines NLHEP: Screen all current and former smokers 45 and older, regardless of symptoms ACP, ATS, ETS, CTS: Screen only symptomatic patients Dales RE, et al. Chest. 2005;128(4): Qaseem A, et al. Ann InternMed. 2007;147(9): ; 638; Wilt TJ, et al. Evid Rep Technol Assess (Summ). 2005(121):1-7; Celli BR, et al. Eur Respir J. 2004;23(6):

21 Spirometry Indications Establish baseline lung function Evaluate dyspnea Detect pulmonary disease Monitor effects of therapies Evaluate respiratory impairment and operative risk Provide surveillance for occupational-related lung disease Miller MR, et al. Eur Respir J. 2005;26(2):

22 Key Parameters in Spirometry FVC (forced vital capacity): Normal lungs typically empty 80% or more of volume in 6 seconds or less FEV 1 (forced expiratory volume in the first second of the forceful exhalation): Reduction in this reading may signify loss in maximum inflation of the lungs, airway obstruction, or respiratory muscle weakness FVC/FEV 1 : Core for clinical decision making Miller MR, et al. Eur Respir J. 2005;26(2):

23 Proper Spirometry Technique Explain the test to the patient Prepare the patient through instruction and demonstration Help the patient maintain correct posture sitting straight up Make sure the patient inhales completely Miller MR, et al. Eur Respir J. 2005;26(2):

24 Proper Spirometry Technique Make sure the patient exhales as forcefully and as long as possible - at least six seconds Make sure the patient keeps lips sealed tightly around the mouthpiece Record at least 3 acceptable tests Confirm that acceptability criteria as described above are met Miller MR, et al. Eur Respir J. 2005;26(2):

25 Spirometry Contraindications Hemoptysis of unknown origin Pneumothorax Unstable angina Recent myocardial infarction (MI) Thoracic, abdominal, or cerebral aneurysms Recent eye, abdominal, or thoracic surgery History of syncope associated with forced expiration Barreiro TJ, Perillo I. Am Fam Physician. 2004;69(5):

26 Are the Results Acceptable?

27 Reversibility Testing Minimizes variability 4 inhalations of 100 mcg albuterol every 4-5 seconds, followed by spirometry in minutes, or. 4 inhalations of 40 mcg anticholinergic 30 seconds apart, followed by spirometry after 30 minutes. 3 adequate results required Pellegrino R, Viegi G, Brusasco V, et al. Eur Respir J. 2005;26(5): ; 968; Barreiro TJ, Perillo I. Am Fam Physician. 2004;69(5): ; 1114; Johannessen A, Lehmann S, Omenaas ER, et al. Am J Respir Crit Care Med. 2006;173(12): ; 1325; Johannessen A, Omenaas ER, Bakke PS, Gulsvik A; Thorax.

28 Normal Spirometry Adapted with permission from ndd Medical Technologies, Inc. All Rights Reserved

29 Obstructive Pattern Adapted with permission from ndd Medical Technologies, Inc. All Rights Reserved

30 Restrictive Pattern Adapted with permission from ndd Medical Technologies, Inc. All Rights Reserved

31 Combined Obstructive/ Restrictive Adapted with permission from ndd Medical Technologies, Inc. All Rights Reserved

32 Spirometry in the Family Physician Office Can be conducted by trained office staff Machines are small and portable Initial baseline may be obtained in about 10 minutes Test is reimbursed by most insurance, including Medicare

33

34 The Goals of an Effective COPD Management Plan Prevent disease progression, in most cases through smoking cessation Relieve symptoms Improve exercise intolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality Use spirometry to manage the disease

35 Practice Recommendation Use spirometry to track the progression of COPD in patients and to evaluate complications and new or worsening symptoms. Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Updated Web site: Strength of evidence: Randomized clinical trials

36 NLHEP Recommended Spirometers Company Spirometer/Model # Web Site ndd EasyOne Frontline ndd EasyOne Diagnostic Welch Allyn CP200 models CP2AS-1E1 and CP2S-1E1 only

37 Coding for Spirometry Office-based spirometry ($34.00)* Spirometry pre- and post- bronchodilation ($58.00)* Must use -25 modifier for E&M code for visit * Average reimbursement in 2007 National Lung Health Education Program (NLHEP).

38 Medicare Physician Quality Reporting Initiative Measures percentage of patients 18 and older with COPD diagnosis who had spirometry results documented Centers for Medicare and Medicaid Physician Quality Reporting Initiative (PQRI) Physician Quality Measures.

39 Web Sites for Additional Information on COPD American Thoracic Society: Canadian Thoracic Society: National Institute for Health and Clinical Excellence American Academy of Family Physicians Tar Wars Ask and Act vwww.aafp.org/online/en/home/ clinical/publichealth/tobacco/askandact.html

40 Conclusions COPD is an enormous public health problem that can be addressed only with increased public awareness, improved delivery of care, and effective therapies The family physician is uniquely positioned as the point of first contact for COPD patients Integrating spirometry into your practice can assist in the early diagnosis and treatment of patients with spirometry.

41 Review Questions

42 Question 1 Prior to the year 2000, more women died from COPD than men. 1. True 2. False True 0% 0% False 5

43 Question 2 COPD can be diagnosed based on medical examination and history alone. 1. True 2. False True 0% 0% False 5

44 Question 3 Physicians must conduct all spirometry testing 1. True 2. False 0% 0% True False 5

45 Question 4 Spirometry is only reimbursable if conducted in patients who currently smoke. 1. True 2. False True 0% 0% False 5

46 Question 5 An obstructive pattern in spirometry signifies asthma only. 1. True 0% 0% 2. False True False 5

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