TYLER, TEX-Chronic obstructive pulmonary disease (COPD) is costly, in both economic and human terms. Indeed, the disease is responsible for more than 10 million physician visits and 2 million hospitalizations annually. It is the fourth leading cause of death in the United States.¹

Because of its enormous public health impact, COPD is at the center of the ongoing debate about how to provide quality health care that is cost-effective. In a recent interview with Pulmonary Reviews, Rick Carter, PhD, MBA, discussed this issue as it relates to COPD, focusing on such key areas as smoking cessation, spirometry, screening, and rehabilitation.

"Smoking cessation is probably the number one priority in COPD management," said Dr. Carter, who is a professor of medicine and physiology at the Center for Clinical Research and Specialty Care Medicine at the University of Texas Health Center in Tyler. "It should be targeted for all individuals--in fact, the younger the better."

Widespread smoking cessation would be ideal. "Smoking is the leading risk factor for pulmonary disease, as well as a major risk factor for other chronic diseases such as cardiovascular disease, stroke, and cancer," Dr. Carter explained. "If total smoking cessation were to occur, the impact would be phenomenal in all of these disease areas."

Even an annual decrease in smoking prevalence of just 1% would be worthwhile. Research suggests such a decrease would reduce annual hospitalizations for heart attack by nearly 64,000 and for stroke by more than 34,000. It would save an estimated $3.2 billion in direct medical costs each year.²

A national smoking cessation policy is necessary if a large-scale reduction in the number of smokers is to be achieved, Dr. Carter pointed out. In addition, he urged individual physicians to take every opportunity to encourage smokers to participate in smoking-cessation programs.

Physicians can take several steps to ensure quality spirometric assessment of COPD patients. The first is to make sure that the spirometer they are using conforms to American Thoracic Society (ATS) standards. It is also important to attend workshops or other formal training to maximize spirometry knowledge and familiarity for those individuals performing these tests.

"The third thing I would do is perform quality checks each day that testing is performed," Dr. Carter advised. Quality checks should always include using a verified 3-L syringe to check the volume accuracy of the spirometer. The accuracy check should be performed after completion of any calibration maneuvers to scale the microprocessor output properly. It should include checking the accuracy at both slow and fast injection rates for the 3-L syringe. Although the value of the spirometric screening for COPD is controversial, Dr. Carter remains a strong advocate of screening. Spirometric screening, he said, can identify early disease and, thus, provide evidence for early intervention. Early intervention may then reduce the overall costs of the disease and reduce the deterioration in quality of life associated with this chronic disease process. "Certainly, spirometry is simple and easy, and it should not be a costly screening tool for COPD," he remarked.

However, spirometry does not necessarily have to be the first-line method of COPD screening. Physicians can start by simply asking patients a few pointed questions, such as "Do you smoke?" "Do you have trouble breathing when you walk?" and "Has there been any recent change in your breathing?"

Screening for COPD does not typically require a test for a1-antitrypsin deficiency (a genetic risk factor for chronic airflow obstruction). For one thing, the test is fairly expensive, according to Dr. Carter. "But if a genetic predisposition is suspected, the patient should be screened for an alpha₁-antitrypsin deficiency," he said, "especially if there are breathing problems that look like emphysema, at least on chest x-ray or spirometry testing, and there's no major exposure history--for example, to cigarette smoke."

The current recommendations call for a stepped-care approach to COPD treatment.^3,4 "Stepped care from a clinical perspective involves the use of an algorithm outlining those interventions [deemed] appropriate at each given level," Dr. Carter explained. "If an intervention fails or is not completely satisfactory, then the next level of care can be implemented."

To help cut costs, stepped care starts with the simplest therapy and progresses to the most complex. "Normally, you run through at least one or two levels before you produce any great impact," Dr. Carter noted. "But you have to try them to begin with because you don't know if they're going to work or not."

For COPD patients with variable mild airway obstruction, the ATS recommends starting treatment with a ß-agonist via a metered-dose inhaler with spacer for optimal drug delivery, minimal side effects, and lowest cost. However, physicians should consider substituting ipratropium if the patient has persistent bronchospasm or develops arrhythmia when taking ß-agonists.

Antibiotic prophylaxis has not been found to be effective for preventing acute exacerbations of COPD, which tend to occur several times a year. However, short-course broad-spectrum antibiotic therapy can reduce the duration and severity of these episodes in patients with increased purulent sputum.

Dr. Carter specifically suggests using ampicillin, tetracycline, doxycycline, or trimethoprim-sulfamethoxazole. These agents are relatively inexpensive and also effective against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis--the bacteria that are most often associated with COPD exacerbations.

Pulmonary rehabilitation is invaluable for COPD patients because it can increase quality of life and avoid costly hospitalizations. It calls for a variety of interventions in addition to exercise, including education to improve COPD self-management, nutrition, dyspnea desensitization, and preventive measures such as annual immunization, proper medication use, and avoidance of environmental respiratory irritants. When it is used in concert with a quality medication oxygen therapy and smoking cessation regimen, many positive benefits are realized.

"Lung volume reduction surgery (LVRS) is an expensive proposition, and it is associated with increased morbidity and mortality," said Dr. Carter. Furthermore, it is unknown whether the procedure has significant long-term benefits, although researchers are currently trying to resolve this issue in clinical trials.

Nevertheless, LVRS has received a great deal of publicity because it can produce significant short-term improvement in dyspnea, quality of life, and physiologic lung function measures such as elastic recoil, airway resistance, and exercise capacity. "But we're looking for a long-term fix," stressed Dr. Carter, "because of the risk to the patient and the amount of money invested." (The procedure costs about $26,000 on average). "Unfortunately," he continued, "our best knowledge suggests that some of the long-term benefits of the procedure that were proposed up front may not exist down the line." He therefore emphasized that prevention is still the best weapon against COPD. "This would reduce overall health care costs to the nation," he concluded.

-Timothy Begany

References
1. Carter R, Blevins W, Stocks J, et al. Cost and quality issues related to the management of COPD. Semin Respir Crit Care Med. 1999;20:199-212.
2. Lightwood JT, Glantz SA. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation. 1997;96:1089-1096.
3. Celli BR. ATS standards for the optimal management of chronic obstructive pulmonary disease. Respirology. 1997;2(suppl 1):S1-S4.
4. Roche N, Huchon GJ. Current issues in the management of chronic obstructive pulmonary disease. Respirology. 1997;2:215-229.