Årskontroll ved KOLS

1. Årskontroll ved KOLS -Er det noe for Norge? Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

2. ”…4-6 % of the adult population suffer from clinically relevant COPD”European Lung Whitebook • Prevalence and severity is increasing • The socioeconomic burden for societies and individuals is high • COPD is a preventable and treatable disease • Despite this: COPD is under- recognised COPD is under- diagnosed COPD is under- treated AmundGulsvik et al ERS.

3. KOLS Mortality by Gender,U.S., 1980-2000 Number Deaths x 1000

4. Ischemic heart disease CVD disease KOLS Pneumonia Lung cancer Road traffic accident Tuberkulos Stomach cancer HIV Suicide 3rd Forventetdødelighetinnen2020 1990 2020 Ischemic heart disease CVD disease Pneumonia Diarrhoeal disease Perinatal disorders KOLS Tuberculosis Measles Road traffic accident Lung cancer 6th Ref. Murray and Lopez Lancet 1997:349-1498

5. Variation in COPD care and outcomes Vast variation in diagnosis rate Vast variation in service provision Major differences in health outcomes although unclear whether prevalence is key factor here Dødelighet Sykehus Diagnose Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

6. Respiratory Medicine (2005) 99, 493–500Attaining a correct diagnosis of COPDin general practice C.E. Bolton et al Results of spirometry in 125 patients previously diagnosed as COPD on the basis of history and examination Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

7. Diagnosis after spirometry:Glenfield Practice of 12,000 patients Patients (%) n=260 (prescribed bronchodilator therapy) 70 60 Post-study 60 Pre-study 50 44 40 34 30 17 20 13 11 10 7 10 4 0 0 0 0 None COPD Mixed Other NRD Asthma Freeman D et al. Am J Respir Crit Care Med 1999

8. Symptoms in patients with COPD 126 patients with COPD Glenfield Surgery Audit

9. Rationale for early detection • COPD 4th largest killer globally • COPD may be present before symptoms and signs occur, exacerbations may be unrecognised • Most people with early COPD do nor recognise and/or report symptoms • All with COPD will benefit from: • Targeted smoking cessation • Vaccination • Lifestyle advice, Diet advice • Optimisation of therapy

10. When are exacerbations likely to be at their worst? Fleming D. Prim Care Resp J2002: 11(3);86-87

11. approaches to early diagnosis • Screening with spirometry? • Target those most as risk-’Case Finding’ • Case finding = focusing detection efforts on subgroups at known increased risk • GOLD recommendation: • consider a diagnosis of COPD "inany patient who has dyspnea, chronic cough or sputum production,and/or a history of exposure to risk factors for the disease"and that the "diagnosis should be confirmed by spirometry"

12. Many people are living with severe breathlessness Responders without CHD diagnosis (%) 30 Number who said they were too breathless toleave their house or became breathless when dressing/undressing 25 20 15 10 5 0 France Germany UK US Price D, Freeman D. Primary Care Respiratory Journal 2002; 11: s12-s14

13. Education and information To have tests done A diagnosis To have a discussion about the condition A medicine/prescription To be told to stop smoking To be referred to a hospital specialist Patient expectations from a visitto the doctor Sought medical help (n=291) Did not seek medical help (n=155) 0% 20% 40% 60% Price D, Freeman D. Primary Care Respiratory Journal 2002; 11

14. Outcomes from a visit to the doctor n=236 Told to stop smoking Had tests done Diagnosis Medicine/prescription Had a discussion about the condition Education and information Referred to a hospital specialist 0% 20% 40% 60% Price D, Freeman D. Primary Care Respiratory Journal 2002; 11: s12-s14

15. What experts think matters to patients with COPD MRC dyspnoea score 0 no breathlessness 1 breathless after Xs 2 breathless when hurrying 3 walks slower than others 4 stops for breath every 100 m 5 too breathless to leave house Patients (%) 35 n=2,442 30 25 20 15 10 5 0 1 2 3 4 5 Living with COPD BLF survey Aug 2000

16. Climbing stairs Gardening Walking outside Making the bed Washing / bathing n=2,413 Socialising outside house Dressing Working 0 20 40 60 80 100 Responders (%) What really matters to patients with COPD What really matters to patients is not theirMRC dyspnoea score…… Living with COPD BLF survey Aug 2000

17. 5-7 fold >5mins Intense intervention 4 fold 2-5 mins Moderate intervention 3 fold <1mins Brief intervention 2 fold A ‘no-smoking practice’ A smoking aware practice GP time Increase in quit rate Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: 175-9

18. Smoking and COPD • Smoking is dominant cause of COPD • Smoking cessation is the most (cost-) effective therapy • Smoking COPD patients need intensive treatment • No special smoking cessation interventions for COPD patients

19. Cardiovascular heart disease (CHD) risk is similar to never smokers Lung cancer risk is 30-50% that of continuing smokers Stroke risk returns to the level of people who have never smoked at 5-15 years post-cessation CHD: excess risk is reduced by 50% among ex-smokers Lung function may start to improve with decreased cough, sinus congestion, fatigue, and shortness of breath 10 years 15 years Cessation 1 year 5 years 3 months Why Quit? Potential Lifetime Health Benefits of Quitting Smoking 1. CDC. Surgeon General Report 2004: http://www.cdc.gov/tobacco/sgr/sgr_2004/sgranimation/flash/index.html. American Cancer Society. Guide to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 2. American Cancer Society. Guide to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 3.US Department of Health & Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 1990. Available at: http://profiles.nlm.nih.gov/NN/B/B/C/T/. Accessed July 2006.

20. Active reduction of risk factor(s); influenza vaccination Addshort-acting bronchodilator (when needed) I: Mild II: Moderate III: Severe IV: Very Severe Addregular treatment with one or more long-acting bronchodilators (when needed); Addrehabilitation Addinhaled glucocorticosteroids if repeated exacerbations Addlong term oxygenif chronic respiratory failure. Considersurgical treatments

21. Rehabilitation (training), COPD and treatment: 24 * * Rehabperiod 22 Tiotropium n=47 42% 20 32% 18 Average time work (minutes) 16 Usual care n=44 14 16% 12 n=91 10 *p<0,05 8 1 3 5 7 9 11 13 15 17 19 21 23 25 Treatment weeks Reference: Modified from Casaburi et al, Chest 2005; 127:809-17. 22

22. CCQ? www.ccq.nl

23. Importance of exacerbations • COPD exacerbations are an important cause of the considerable morbidity and mortality associated with COPD • Prevention of exacerbations is a primary goal in treating COPD • COPD exacerbations are closely associated with symptomatic and physiological deterioration and impaired health status1,2 • Following a COPD exacerbation, the likelihood of further exacerbations increases3 • High frequency of COPD exacerbations is associated with a rapid decline in lung function and increased risk of hospitalization4,5 1. Osman LM et al. Thorax 1997; 2. Seemungal TA et al. Am J Respir Crit Care Med 1998 3. Seemungal TA et al. Am J Respir Crit Care Med 2000; 4. Donaldson GC et al. Thorax 2002 5. Garcia-Aymerich J et al. Am J Respir Crit Care Med 2001

24. Exacerbations • To many COPD patients are diagnosed at their first admission to hospital for respiratory problems • Most of these have an advanced serious disease with high mortality: Death during hospitalization 9% Death rate after 3 months 19% 1 year mortality after admission36% 25% of death occurs in people under 65 yrs Nanna Eriksen et al: Ugeskrift for Læger 2003; 165: 3499-502

25. ”Ressursfordelingsperspektiv” kolspasienten Kostnad Hjem S.h Rehab Hjem…… Tid

26. BHH Forløp kronisk sykdom Kostnad som funksjon av komplikasjoner Dagens situasjon Ønsket forløp Røyk Kols 1 Kols2 Kols 3 KOLS4 Tid Fødsel Død

27. . Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

28. Chronic Care modell 2/3 av ressursene brukes idag på 10-20% av pasientene Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

29. Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

30. Self management • Results Hospital admissions for exacerbation of COPD were reduced by 39.8% in the intervention group compared with the usual care group (P = .01), and admissions for other health problems were reduced by 57.1% (P = .01). Emergency department visits were reduced by 41.0% (P = .02) and unscheduled physician visits by 58.9% (P = .003). Greater improvements in the impact subscale and total quality-of-life scores were observed in the intervention group at 4 months, although some of the benefits were maintained only for the impact score at 12 months. • Conclusions A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status. This approach of care can be implemented within normal practice. Reduction of Hospital Utilization in Patients With COPD- Jean Bourbeau, MD; et al. for the Chronic Obstructive Pulmonary Disease axis of the Respiratory Network Fonds de la Recherche en Santé du Québec Arch Intern Med. 2003;163:585-591.

31. Rehab • Pulmonary rehabilitation improves HRQOL in patients with COPD. Grade of recommendation, 1A • Regarding changes in health-care utilization resulting from pulmonary rehabilitation, the previous panel concluded that there was B level strength of evidence supporting the recommendation that “pulmonary rehabilitation has reduced the number of hospitalizations and the number of days of hospitalization for patients with COPD.” Pulmonary Rehabilitation*Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines\\\CHEST May 2007 vol. 131 no. 5 suppl 4S-42S

32. Primary care rehab? • Pulmonary rehabilitation should be made available to all patients who need it. This will require the education of health care professionals at all levels of training as to the rationale, scope, and benefits of pulmonary rehabilitation, with a goal of incorporating it into the mainstream of medical practice. In addition, concerted efforts are needed to encourage health care delivery systems to provide this therapy and make it affordable. Recent studies that demonstrate that long-term benefits (including health care resource reductions) are attainable with relatively low-cost interventions should help with these efforts American Thoracic Society, European Respiratory Society.. ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006;173,1390-1413 F Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

33. . COPD starts before the patient gets any symptoms... Do not forget primary prevention. Thank You!! . Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

34. Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

35. Forløpsdiagram ved kols. De fleste pasienter kan og skal følges i primærhelsetjenesten som har ansvar for oppfølging og koordinering. 80% av pasientene har fev1>50, MRC<3 Forebygging primær prevensjon Case-finding Myndighetene bør fokusere på fysisk aktivitet, ernæring og røykeslutt/forebygging Gjennom kampanjer, lovverk,informasjon Leger og annet helsepersonel læres opp i røykesluttmetoder. Arbeidsmiljø: Industri/yrker med eksponering for støv, gasser og partikler må pålegges et særlig ansvar for verneutstyr -case-finding Tidlig oppsporing-case finding Allmenlegens ansvar Diagnostikk Case finding ved spørreskjema til alle røykere over 40 år? Spirometri av alle med hyppige/kroniske luftveisproblem Hvem bør vurderes av lungelege? Oppfølging Allmennlege Fysioterapi? Rehabilitering? Kols register Oppfølging svarende til alvorlighetsgrad Årskontroll Egenbehplan Inf.vaksine fysioterapi Koordinering Individuell Plan Bruker-medv Komorbiditet Rehabilitering Allmenlege vurderer grad-evt henvisning Spes rehab Eller i primærhelse Yrkesveiledning Trening Kost Pasientopplæring ergonomi Helhets-vurdering komorbiditet Bruker-medvirk Forverrelse Rask Allmennlege /spesialist Bruker vurdering/ egenbehandling Vurdere behov for innleggelse Komorbiditet Medikamenter Prosedyrer for hvem gjør hva og samarbeid Akutt rehab/oppfølgin spesialist Samarbeid allmenlege –kommune-spesialist Bruker Videre-føring Oppfølging-monotorering Avlastning? Beredskap Hospital at home Terminal pleie Oksygen? Samarbeid spes/ allmenlege-kommune/Bruker Rask vurdering Utredes med tanke på nytte av ltot /kirurgi evt terminal team Tilrettelegging bolig/transport Trening/rehab . Røykere(+eks),yrkesbelastede /symptomatiske FEV1>50 FEV1 30-50 FEV1 <30 Symptomer-hostte, slim og spes.dyspnoe MRC 1-2 MRC 3 MRC 4 MRC 5 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

36. Kumulativ dødelighetThe World Bank:”Curbing the epidemic: Governments and economics of tobacco control ”1999 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen Lunger i Praksis

37. Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 1.0 0.5 –59% –64% –35% +163% –7% 0 1965 - 1998 1965 - 1998 1965- 1998 1965 - 1998 1965 - 1998 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

38. 25% død/uførhet før 65 år Kostnad x4 innen 2020 Kvinner rammes hardere Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen