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Årskontroll ved KOLS. -Er det noe for Norge?. ”…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

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rskontroll ved kols

Årskontroll ved KOLS

-Er det noe for Norge?

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

4 6 of the adult population suffer from clinically relevant copd european lung whitebook
”…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.

forventet d delighet innen 2020

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

variation in copd care and outcomes
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

slide6
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

diagnosis after spirometry glenfield practice of 12 000 patients
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

symptoms in patients with copd
Symptoms in patients with COPD

126 patients with COPD

Glenfield Surgery Audit

rationale for early detection
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
when are exacerbations likely to be at their worst
When are exacerbations likely to be at their worst?

Fleming D. Prim Care Resp J2002: 11(3);86-87

approaches to early diagnosis
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"
many people are living with severe breathlessness
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

patient expectations from a visit to the doctor

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

outcomes from a visit to the doctor
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

what experts think matters to patients with copd
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

what really matters to patients with copd

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

slide17

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

smoking and copd
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
why quit potential lifetime health benefits of quitting smoking

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.

slide20

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

rehabilitation training copd and treatment
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

slide22
CCQ?

www.ccq.nl

importance of exacerbations
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

exacerbations
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

ressursfordelingsperspektiv kolspasienten
”Ressursfordelingsperspektiv” kolspasienten

Kostnad

Hjem S.h Rehab Hjem……

Tid

bhh forl p kronisk sykdom
BHH Forløp kronisk sykdom

Kostnad som funksjon

av komplikasjoner

Dagens situasjon

Ønsket forløp

Røyk Kols 1 Kols2 Kols 3 KOLS4

Tid

Fødsel

Død

slide27
.

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

chronic care modell
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

self management
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.

rehab
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

primary care rehab
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

slide33
.

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

slide35

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

slide36
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

percent change in age adjusted death rates u s 1965 1998
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

slide38

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