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 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. A substantial number of p suffer from copd . Most of us meet them every day . In my presentation I will focus on the burden of disease and on diagnosis.

KOLS Mortality by Gender, U.S., 1980-2000 Number Deaths x 1000 It is disturbing to see that women death because of KOLS has increased three times as fast as men in the last decades, reflecting changes in smoking habits.

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

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

Results of spirometry in 125 patients previously Respiratory Medicine (2005) 99, 493–500 Attaining a correct diagnosis of COPD in 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 n=260 (prescribed bronchodilator therapy) 70 Post-study 60 60 Pre-study 50 44 40 34 30 20 17 13 10 11 10 7 4 None COPD Mixed Other NRD Asthma Freeman D et al. Am J Respir Crit Care Med 1999

Symptoms in patients with COPD Glenfield Surgery Audit

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

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 "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"

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

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

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 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 1 2 3 4 5 Living with COPD BLF survey Aug 2000

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

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

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

SMOKING It is a chronic medical condition” Michael C. Fiore, MD “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 pharmacotherapy1 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 2008. Available at: www.surgeongeneral.gov/tobacco/default.htm. Svein Høegh Henrichsen Lunger i Praksis

Why Quit? Potential Lifetime Health Benefits of Quitting Smoking 1/CDC/SGR/ p. 2 & 3 of printout 2/ACS/p 4/¶1-6. 3/USDHHS 1990/p vi/¶1,2 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 Key Point The health benefits of quitting smoking start immediately and are sustained such that 15 years after quitting smoking, the coronary heart disease risk of a former smoker is equal to that of a nonsmoker. Background When gauging the health benefits from smoking cessation one is encouraged to assess both the short-term and long-term improvements. Within 2 weeks to 3 months lung function may begin to improve and there may be notable decreases in coughing, sinus congestion, fatigue and shortness of breath. Around the year mark, coronary heart disease risk, the leading cause of death in the United States, improves with smoking cessation to a point where excess risk is reduced by 50% and continues to decline thereafter. Within the 5-15 year range, the risk of stroke for smoking cessators returns to the level of a person who has never smoked. Other potential long-term benefits include: the risk of lung cancer, the most common cause of cancer death in the United States, declines steadily after smoking cessation; and by 10 years after cessation, the risk of lung cancer is 30-50% that of continuing smokers. And beyond this, smoking cessation may also reduce the risk of cancers of the larynx, oral cavity, esophagus, pancreas, urinary bladder and of developing ulcers of the stomach or duodenum. Other long-term benefits include the rate of decline in lung function among former smokers returns to that of never smokers, reducing the risk of COPD. And, the risk of coronary heart disease, after 15 years of abstinence, becomes similar to that of a person who has never smoked. Clearly, a patient has health benefits to gain if they successfully cessate. References 1. CDC. Surgeon General’s 2004 Report. The Health Consequences of Smoking on the Human Body. Online slides. http://www.cdc.gov/tobacco/sgr/sgr_2004/sgranimation/flash/index.html Accessed on April 15, 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. 1/CDC/SGR/p. 2 & 3 of printout ¶2; 2/ACS/ p 3/¶9,10 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. 2/ACS/p 4/ ¶1-6. 3/USDHHS 1990/p vi/¶1,2

Active reduction of risk factor(s); influenza vaccination Therapy at Each Stage of COPD I: Mild II: Moderate III: Severe IV: Very Severe FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure 30% < FEV1 < 50% predicted 50% < FEV1 < 80% predicted FEV1 > 80% predicted Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) This provides a summary of the recommended treatment at each stage of COPD. Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long term oxygen if chronic respiratory failure. Consider surgical treatments

Rehabilitation (training), COPD and treatment: 24 * Rehabperiod * 22 Tiotropium n=47 20 32% 42% 18 Average time work (minutes) 16 Usual care n=44 14 16% 12 In both groups the the average time-work increases. When you even give a broncho In summary, combining PR with a long acting bronchodilatation, in this case tiotropium resulted in superior outcomes than utilizing PR alone With the addition of a bronchdilatation, the efficacy of PR was maintained for at least 3 months" 10 n=91 *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

CCQ? www.ccq.nl

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 Exacerbations are common and often have serious consequences in patients with COPD.1,2 Once a patient begins to experience exacerbations, the likelihood of further exacerbations increases; recovery from each exacerbation may be prolonged or even incomplete. A higher frequency of exacerbations is associated with a more rapid decline in health status3 and lung function, and increased risk of hospitalisation. In COPD (unlike asthma), this can lead to high mortality rates.4,5 References 1. Osman LM, Godden DG, Friend JA et al. Quality of life and hospital readmission in patients with chronic obstructive pulmonary disease. Thorax 1997;52:67–71. 2. Seemungal TA, Donaldson GC, Paul EA et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157:1418–22. 3. Seemungal TA, Donaldson GC, Bhowmik A et al. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000;161:1608–13. 4. Donaldson GC, Seemungal TAR, Bhowmik A et al. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax 2002;57:847–52. 5. Garcia-Aymerich J, Monso E, Marrades RM et al. Risk factors for hospitalisation for a chronic obstructive pulmonary disease exacerbation – EFRAM study. Am J Respir Crit Care Med 2001;164:1002–7. 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

Mortality Following Severe COPD Exacerbation 60 50 40 30 20 10 % Survival (%) Hospital stay 60 180 d 1 yr 2 yr Connors AF Jr et al. AJRCCM 1996;154:959-67

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 Gjeninnleggelse etter 3 mån 14%, Etter et år 46% Nanna Eriksen et al: Ugeskrift for Læger 2003; 165: 3499-502

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

BHH Forløp kronisk sykdom Kostnad som funksjon av komplikasjoner Dagens situasjon Ønsket forløp Skal man oppnå ønsket kurve må man forskyve ressurser til før man er syk og sørge for god forebygging. Røyk Kols 1 Kols2 Kols 3 KOLS4 Tid Fødsel Død

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

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

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

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. Methods A multicenter, randomized clinical trial was carried out in 7 hospitals. All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year. Patients were assigned to a self-management program or to usual care. The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up. Over 12 months, data were collected regarding the primary outcome and number of hospitalizations; secondary outcomes included emergency visits and pa 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 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? 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

. Thank You!! . 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

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

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? 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 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 Rehabilitering Allmenlege vurderer grad-evt henvisning Spes rehab Eller i primærhelse Yrkesveiledning Trening Kost Pasientopplæring ergonomi Helhets-vurdering komorbiditet Bruker-medvirk Oppfølging Allmennlege Fysioterapi? Rehabilitering? Kols register Oppfølging svarende til alvorlighetsgrad Årskontroll Egenbehplan Inf.vaksine fysioterapi Koordinering Individuell Plan Bruker-medv 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 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

Kumulativ dødelighet The World Bank:”Curbing the epidemic: Governments and economics of tobacco control ”1999 The World Bank (Curbing the Epidemic: Governments and the economics of tobacco control’,1999) states that if there are no dramatic changes in cessation rates, no new interventions, and if children start smoking at expected rates, then the current figure of 1.1 billion smokers worldwide is predicted to rise to 1.64 billion by 2025. Since the 1950s, more than 70,000 scientific articles have shown that prolonged smoking causes premature death and disability worldwide. Overall, one in two smokers will die prematurely, with one quarter dying in middle age, losing 20-25 years of life. The nature of the tobacco epidemic varies from country to country. In developed countries, cardiovascular disease is the most common smoking-related cause of death. In populations where cigarette smoking has been common for several decades, about 90% of lung cancer, 15-20% of other cancers, 75% of chronic bronchitis and emphysema, and 25% of deaths from cardiovascular diseases at ages 35-69 years are attributable to tobacco. In developing countries, smoking causes about 10% of cancer deaths. In China, smoking accounts for more deaths from chronic respiratory diseases that it does from cardiovascular disease. In addition, smoking causes about 12% of all tuberculosis deaths. (The World Health Report 1999. World Health Organization, 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 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 Whereas all major causes of death have decreased in the period , copd deaths have increased 163% 1.0 0.5 –59% –64% –35% +163% –7% 1965 - 1998 1965 - 1998 1965- 1998 1965 - 1998 1965 - 1998 Norsk Forening for Allmennmedisins referansegruppe for astma og kols Svein Høegh Henrichsen

Kvinner rammes hardere In terms of the Burden of disease this leeds to an increasing ranking of copd as cause of morbidity and cost to patients and society. WHO has estimated cost for societies to quadrouple in this period. 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