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

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Presentasjon om: "-Er det noe for Norge? Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen."— Utskrift av presentasjonen:

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

2  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 Amund Gulsvik et al ERS.

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

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

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

6 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen Results of spirometry in 125 patients previously diagnosed as COPD on the basis of history and examination

7 Pre-study NoneCOPDMixedOtherNRDAsthma n=260 (prescribed bronchodilator therapy) Post-study Patients (%) Freeman D et al. Am J Respir Crit Care Med 1999

8 126 patients with COPD Glenfield Surgery Audit

9  COPD 4 th 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 Fleming D. Prim Care Resp J2002: 11(3);86-87

11  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 "in any 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 Responders without CHD diagnosis (%) FranceGermanyUSUK Number who said they were too breathless to leave their house or became breathless when dressing/undressing Price D, Freeman D. Primary Care Respiratory Journal 2002; 11: s12-s14

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

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

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

16 What really matters to patients is not their MRC dyspnoea score…… Living with COPD BLF survey Aug Responders (%) Climbing stairs Gardening Walking outside Making the bed Washing / bathing Socialising outside house Dressing Working n=2,413

17 Page 17 - © IPCRG 2007 Svein Høegh Henrichsen AIMEF Bari 2008 © IPCRG 2007 A smoking aware practice Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: Increase in quit rate GP time A ‘no-smoking practice’ Brief intervention Moderate intervention Intense intervention >5 mins <1 mins 2-5 mins 2 fold 3 fold 4 fold 5-7 fold

18  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 “ Smoking is not a bad habit- It is a chronic medical condition”  Michael C. Fiore, MD ◦ Failure to appreciate the chronic nature of nicotine addiction may impair clinicians’ motivation to treat nicotine dependence long-term, including counselling, support, and appropriate pharmacotherapy 1 Svein Høegh Henrichsen Lunger i Praksis 1.Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. US Department of Health and Human Services. Public Health Service, May Available at:

20 1. CDC. Surgeon General Report 2004: American Cancer Society. Guide to Quitting Smoking. Available at: Accessed June American Cancer Society. Guide to Quitting Smoking. Available at: Accessed June 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 Available at: Accessed July Lung function may start to improve with decreased cough, sinus congestion, fatigue, and shortness of breath 3 months Lung cancer risk is 30-50% that of continuing smokers Cessation CHD: excess risk is reduced by 50% among ex-smokers Cardiovascular heart disease (CHD) risk is similar to never smokers Stroke risk returns to the level of people who have never smoked at 5-15 years post-cessation 1 year 5 years 10 years 15 years

21 IV: Very Severe IV: Very Severe III: Severe III: Severe II: Moderate II: Moderate I: Mild I: Mild Therapy at Each Stage of COPD  FEV 1 > 80% predicted  50% < FEV 1 < 80% predicted predicted  30% < FEV 1 < 50% predicted  FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add long term oxygen if chronic respiratory failure. Consider surgical treatments

22 22 Rehabilitation (training), COPD and treatment: Reference: Modified from Casaburi et al, Chest 2005; 127: Average time work (minutes) % 32% 42% * * Rehabperiod Usual care n=44 Tiotropium n=47 Treatment weeks n=91 *p<0,05

23 CCQ?

24  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 status 1,2  Following a COPD exacerbation, the likelihood of further exacerbations increases 3  High frequency of COPD exacerbations is associated with a rapid decline in lung function and increased risk of hospitalization 4,5 1. Osman LM et al. Thorax 1997; 2. Seemungal TA et al. Am J Respir Crit Care Med Seemungal TA et al. Am J Respir Crit Care Med 2000; 4. Donaldson GC et al. Thorax Garcia-Aymerich J et al. Am J Respir Crit Care Med 2001

25 Mortality Following Severe COPD Exacerbation Hospital stay d1 yr2 yr % Connors AF Jr et al. AJRCCM 1996;154: Survival (%)

26  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:

27 Hjem S.h Rehab Hjem…… Tid Kostnad

28 Kostnad som funksjon av komplikasjoner Tid FødselDød Dagens situasjon Ønsket forløp Røyk Kols 1 Kols2 Kols 3 KOLS4

29 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen29

30 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh HenrichsenKronisk sygdom- patient,sunnhedsvæsen og sygdom Sundhetsstyrelsen Danmark /3 av ressursene brukes idag på 10-20% av pasientene

31 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen31

32  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:

33  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.” 33 Pulmonary Rehabilitation*Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines\\\CHEST May 2007 vol. 131 no. 5 suppl 4S-42S

34  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 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen P M U 08 American Thoracic Society, European Respiratory Society.. ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006;173, F

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

36 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen P M U 08

37 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen P M U 08 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/kronisk e luftveisproblem Hvem bør vurderes av lungelege? Forverrelse Rask Allmennlege /spesialist Bruker vurdering/ egenbehandlin g Vurdere behov for innleggelse Komorbiditet Medikamenter Prosedyrer for hvem gjør hva og samarbeid Akutt rehab/oppfølg in spesialist Samarbeid allmenlege – kommune- spesialist Bruker Videre-føring Oppfølging- monotorering Avlastning? Beredskap Hospital at home Terminal pleie Oksygen? Samarbeid spes/ allmenlege- kommune/Bruk er Rask vurdering Utredes med tanke på nytte av ltot /kirurgi evt terminal team Tilrettelegging bolig/transport Trening/rehab Rehabilitering Allmenlege vurderer grad-evt henvisning Spes rehab Eller i primærhelse Yrkesveiledni ng Trening Kost Pasientopplæ ring ergonomi Helhets- vurdering komorbiditet Bruker- medvirk Oppfølging Allmennlege Fysioterapi? Rehabilitering ? Kols register Oppfølging svarende til alvorlighetsgr ad Årskontroll Egenbehplan Inf.vaksine fysioterapi Koordinering Individuell Plan Bruker-medv Komorbiditet 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 Røykere(+eks),yrkesbelastede /symptomatiske FEV1>50 FEV FEV1 <30 Symptomer-hostte, slim og spes.dyspnoe MRC 1-2 MRC 3 MRC 4 MRC 5

38 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen38 Lunger i Praksis

39 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen P M U Proportion of 1965 Rate –59% –64% –35% +163% –7% Coronary Heart Disease Coronary Heart Disease Stroke Other CVD COPD All Other Causes All Other Causes

40 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen PMU08 25% død/uførhet før 65 år Kostnad x4 innen 2020 Kvinner rammes hardere


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