Subscribe
Share
Share
Embed
"From Lab to Life" is a cutting-edge podcast that bridges the gap between groundbreaking medical research and real-world clinical practice. Hosted by leading experts in the healthcare field, each episode delves into the latest innovations in medicine, offering insights on how scientific discoveries translate into practical solutions for patient care. From emerging therapies to case-based discussions, this podcast equips healthcare professionals with the knowledge they need to bring the future of medicine into their daily practice. Join us as we explore the journey from the lab to life.
Welcome to Leveling Up COPD Care, Closing Critical Gaps in Vaccination, Guideline Adoption, Improving Clinical Inertia, and Integrating Personalized Approaches to Care. My name is Felix Reyes, and I'm a clinical director of the COPD program in Northwest Medical Center, Tucson, Arizona. I'm joined today by my esteemed colleague, Dr. Stephanie Christensen, associate professor of medicine at the University of California. For full financial disclosure information, please see the
iridium.com landing page for this activity. This educational activity supported by an independent educational grant from GSK. We would like to thank them for their support for this initiative. The learning objective of this program is to review the skills to assess and promptly adjust treatment plans when necessary. I'd like to discuss some of the challenges of translating evidence-based recommendations into clinical practice and strategies to overcome these challenges.
Dr. Christensen, can you walk us through this? There are certainly many challenges in translating evidence-based recommendations into clinical practice. Lack of awareness of the GOLD strategy recommendations is certainly a challenge. In one study assessing physicians understanding adherence and barriers to implementation of the GOLD strategy, the leading barriers were lack of familiarity, lack of awareness, lack of time or disagreement with the recommendations are also certainly barriers.
more teaching about what the GOLD report has recommended is certainly going to help us get that implemented more broadly. Another challenge to implementation of recommendations is poor eulogization of spirometry, meaning that we can even make incorrect diagnoses because we don't have a clear diagnosis of COPD.
So symptoms alone are not enough to diagnose COPD. We really do need that spirometry. And half of patients with spirometry confirmed COPD actually do not have respiratory symptoms. So spirometry leads to management changes in about half of COPD patients. And unfortunately, very few patients receive formal pulmonary function tests. So using spirometry more in our practice is gonna be really important to making sure are we actually diagnosing the correct disease and are we.
implementing the correct therapeutic strategies for our patients. A third challenge to implementation of GOLD recommendations is that there is inadequate symptom assessment. Spirometry alone does not capture the full impact of COPD. Further, many COPD patients often underestimate the severity of their disease. And that is really kind of shown in this graph. A lot of times patients will actually stop doing activities that they had once done. And that is how they cope with having
increased symptoms, they may just do less so that they don't exacerbate their symptoms. And so it is really important to kind of get a better broad view of what symptoms patients are having. You can sometimes do that with the different symptom assessment scores. So there's the COPD assessment tests or the CAT score. There's the MMRC dyspnea scale and there's the St. George's respiratory questionnaire. So if those can be implemented in
your clinic, sometimes that can give you a better idea of really how poorly a patient is feeling or how their quality of life is. Another challenge in implementation of guideline recommendations is the lack of smoking cessation counseling. A systematic review of 19 studies estimated the proportion of general practitioners and family physicians with negative beliefs and attitudes toward discussing smoking cessation with patients showed that
While the majority do not have negative beliefs and attitudes towards discussing smoking, that there is a sizable portion that do. So the most common negative beliefs are that discussions are too time consuming, discussions may be ineffective, and there is also a lack of confidence in ability to discuss smoking. Clinical guidelines do recommend addressing patient smoking habits by giving even brief advice. So you don't necessarily have to take a long time to discuss this.
The first model would be the five A's and that includes asking about tobacco use, advice to quit, assess willingness to make a quit attempt, assist in quit attempt, and arrange follow-up appointments to address smoking. An even briefer model would be to ask about current and past smoking and give advice about the consequences of smoking and smoking cessation, and then provide options for later or additional support and advice on stop smoking medications
that you might be able to provide to the patient. A fifth challenge to the implementation of GOLD recommendation is improper selection of pharmacotherapy. So a study evaluating COPD management found that the following percentages of patients were getting inappropriate therapies. So 49 % of group A, so that group that's not having symptoms or exacerbations.
46 % of group B, so that's still the same under the current guidelines. So the group that having symptoms, but no exacerbations. 44 % of group C, so that would be the exacerbation prone group that doesn't have symptoms and 3 % of group D. So that's the exacerbation prone and symptom prone group. So we're seeing that actually many of our groups here are really getting inappropriate therapies. And so we need to do a better job of making sure they're on the...
appropriate therapies, including the appropriate inhalers to really prevent symptoms or improve symptoms and hopefully prevent exacerbations. A sixth challenge to the implementation of the GOLD recommendations are low participation in pulmonary rehabilitation. I think this is a very big one. Pulmonary rehabilitation can be incredibly helpful to our patients. One study analyzing why patients do not participate in pulmonary rehab
showed some of the following reasons. Hospitalization, also work-related reasons, COPD exacerbations, transportation problems, and lack of motivation. Strategies to improve enrollment at the patient level fall into several categories. So increasing patient knowledge, and that can be through bedside education, flyers about pulmonary rehab, community outreach, promotional materials, tours of facilities. But there's also increasing motivation through
motivational interviews, promotional swag, and actually peer support. Overcoming transportation barriers is a huge one for many of our COPD patients. Parking vouchers, providing rides, ride sharing programs, offering transportation, and offering actually tele-rehab options as well, which has really grown since the pandemic. Overcoming financial barriers is also certainly a big one. So providing payments or financial counseling or financial incentives.
can also be a way to improve participation in pulmonary rehab. So there are additional strategies that can be used to improve implementation of the GOLD recommendations, specifically discharge recommendations. So a clinical decision support tool was designed to automatically generate discharge recommendations for COPD patients based on the GOLD report.
After implementation of a clinical decision support tool, the following discharge recommendations improved. Patients were discharged with more lung acting medications. There was more recommendation for a follow-up with a pulmonologist, recommendations for smoking cessation and recommendations for vaccination. And I think these are really important points that as patients are leaving the hospital, that we need to make sure they're on the right medications. We need to make sure they're getting the appropriate follow-up and getting the important preventative care.
There's also educational activities that can increase patient self-management. Self-management programs with the focus on the educational component were defined in 2003 as any formalized patient education program aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behavior change, and provide emotional support for patients to control their disease and live functional lives.
And there's educational programs that may include exercise advice, again, super important for rehabilitation for our patients, educational programs that are really multidisciplinary pulmonary rehabilitation programs themselves, cognitive behavioral elements, ways that patients can change behaviors to have better quality of life, ongoing clinician and nurse support and optimization of care plans. Let's go through a patient together.
This gentleman, 62 years old, he has a history of smoking and occupational exposure to a very dusty environment. He presents with worsening shortness of breath, chronic cough, and frequent respiratory infections. He was recently hospitalized for a severe COPD exacerbation. His current medications include short acting bronchodilators as needed. So to you, what jumps out to you the most at first when you just kind of hear about this person's situation?
always when I see hospitalized for severe COPD exacerbation, those things are huge red flags to me, because that's huge issues with morbidity and mortality and not just, I'm not feeling well, but like high rates of mortality later on and then, or high rates of increased mortality and high rates of things like stroke and cardiovascular issues. So those are my...
big red flags. And of course then that he's only on short acting bronchodilators. I think it's reasonable if this is a gentleman, he has never had eosinophilia, never really had an asthmatic type disease to start on just a LAMA/LABA I have taken the tack of starting them on triple therapy, knowing that I could always pull back the ICS later. Unless you give me a reason not to, I tend to put people on triple as well. I know that frail people are people who have never seen a high eosinophil in who
you know, especially if you're prone to pneumonias, I might not put you on an inhaled steroid, but otherwise I often, know, controlling those exacerbations is really important. The safety profile of inhaled medication is extraordinarily favorable kind of across the board. So when it comes to this gentleman going from no long acting to dual long acting and inhaled corticosteroid, if you compare the potential benefit, which is we're now
treating his COPD above more than just like symptomatic approaches, whereas trying to control on a day-to-day basis and what their risks may be. I mean, I would probably argue that the juice is certainly worth the squeeze to be quite frank. Yeah. And I think especially seeing, you know, we definitely see across all studies with like inhaled steroids that there's a slightly higher pneumonia risk, but I would say I tend to be like,
pretty aggressive because COPD exacerbations are so bad. So if I can get you under better control, that's what I'm trying to do. Same thing with making sure I'm like referring you to pulmonary rehab, making sure we're looking at adherence, making sure we're doing all the vaccination stuff. So not just the, let's throw a drug at you, but let's make sure you're using it correctly. Let's make sure you're doing all these other things around your treatment. Let's make sure your comorbidities are very well managed since that's often, that can be why they go back into the hospital too.
To your point, I mean, it may be fair to say that the biggest red flag is that this gentleman, you know, hadn't had the opportunity or the access for the time, or just might not have, right. Right. you've gotten that kind of like, multifactorial treatment approach, you know, because if you speak to this guy and he has this overwhelming dyspnea at home, kind of as you described, with people.
adapting their world closing in on them, like what they can and can't do becoming less and less and less, you know, and he really wants to get out, walking his dog, working in the garden, walking around the mall. I mean, that would be a guy where, yeah, you obviously need to do the guideline based inhaled therapy, but he needs to be informed of what pulmonary rehabilitation is because that's going to be the most effective means to really expand upon his day to day functional status.
And then, you know, if there is an access issue, vaccinations. So important. It's, I think what's overlooked a lot, and this guy's actually a gentleman's very illustrative case. What's overlooked a lot is that the treatment for COPD goes far beyond inhaled medication. And, you know, it's important to do the inhaled medication correctly.
But I think it's also important to understand that when you're seeing somebody with COPD, there's kind of this.
there's many different facets of this disease that's very common, true, but very multifactorial, very multifaceted that can and should be addressed and preferably all at once, if you can. Yeah, if you can, but I think you're so right, Bobby. I think it's like, and thinking about those access issues and how that has affected our patients, right? It affects whether they're diagnosed, you know, if they're from a community where they just don't get access, like it can even affect, do they?
to they get COPD, maybe they're having higher exposure to air pollution. So I think it's highly, it's just very important. Thank you for all your insight. In summary, there are some challenges in translating evidence-based recommendations into clinical practice. However, we do have some strategies to overcome these challenges. Challenges to implementation include lack of awareness, poor utilization of spirometry, inadequate symptom assessment,
lack of smoking cessation counseling, improper selection of pharmacotherapy, and low participation in pulmonary rehab. Each of these challenges has strategies to assist with overcoming them. We've reached the end of this episode. I would like to thank Dr. Stephanie Christensen for the engaging discussion. We will also like to thank GSK for their support of this program. Be sure to claim your CME credit by filling out the evaluation and post-test. Be sure to follow
or email on socials to see our COPD Med-Ed threads and more free CME programs.