Effective Management of COPD in Primary Care: Challenges and Opportunities

Almost 16 million Americans have chronic obstructive pulmonary disease (COPD).¹ For many of these individuals, simple activities, such as walking or climbing stairs, leaves them breathless, making their lives a daily struggle.² Primary care providers are the main point of contact for COPD patients, providing about 80% of their care.³ Most of the patients they treat present with symptomatic disease—the most common symptoms being shortness of breath, productive cough, fatigue, and limited exercise tolerance.⁴ Primary care providers’ main focus is to provide treatment to reduce patients’ symptoms and improve their quality of life.^5,6

In treating COPD, it is important for primary care providers to grasp the complexity of the disease.⁷ No 2 COPD cases are alike; both the symptoms and the disease course vary by patient.⁷ Therefore, clinicians should tailor treatment to address individual patients’ symptoms, rather than managing all COPD patients the same. Clinicians also must recognize other key barriers to effective management of COPD. The following are some of the most common challenges in primary care: correctly identifying/diagnosing COPD; improving patient adherence to treatment; and reducing the risk of acute exacerbations. By meeting these challenges head-on, primary care doctors have an opportunity to reduce the potential for unnecessary or sub-optimal care while improving patient outcomes.⁸

Identifying and Diagnosing COPD

A major challenge facing primary care providers is diagnostic confusion between COPD and asthma.⁹ Both are complex, chronic conditions that cause obstructed airflow,⁹ and both share many of the same symptoms, such as shortness of breath and chronic cough.¹⁰ Spirometry testing is widely used in primary care to help clinicians diagnose either condition.⁴ However, a diagnosis based solely on spirometry may be erroneous, as partial reversibility of airflow obstruction with bronchodilator therapy is often seen in COPD and does not reliably distinguish between COPD and asthma.¹¹ For a more accurate diagnosis, spirometry results should be combined with physical exam findings and a careful medical history that considers the patient’s age, onset and progression of symptoms and social and occupational risk factors. For example, some of the primary features of COPD include onset after age 40, persistent symptoms, and heavy exposure to risk factors, such as tobacco smoke or biomass fuels.^4,11

Improving Patient Adherence and Treatment Outcomes

Inhaled bronchodilators are central to COPD treatment.¹² It is becoming evident that certain patients may struggle to reach optimal peak inspiratory flow (PIF) with some inhalers.¹³ As a result, both the mode of delivery and the type of inhaler device are important considerations in COPD treatment.¹³ Device selection should be informed by the patient’s needs, preferences, and abilities.^7,13 For instance, patients who find it hard to reach optimal PIF may benefit from an inhaler that requires less inspiratory effort to activate.¹⁴ Primary care practices should use multiple educational and training methods (eg, verbal, visual, demonstration) to instruct patients on proper inhaler technique. Instruction and review should be repeated at every office visit to ensure effective inhalation and drug delivery to optimize therapeutic outcomes.^8,13

Reducing COPD Exacerbation Risk

Primary care providers’ main focus is to reduce their COPD patients’ symptom burden and associated comorbidities.⁴ Exacerbations — a sudden worsening, or flare-up, of symptoms⁷ — place a huge burden on some patients, as complications from these acute events can cause progressive airflow obstruction and lead to lengthy hospitalizations or even death.¹⁵ However, it is important to note that “frequent exacerbators” (ie, patients with 2 or more exacerbations requiring additional therapy and/or one hospitalization in the previous 12 months) are a small subset of COPD patients in primary care.⁹ In fact, the most severe and hard-to-treat COPD patients — ie, those who tend to experience frequent exacerbations and hospitalizations – mostly receive specialist care from pulmonologists.¹⁶

Nevertheless, primary care providers should assess their patients’ exacerbation status at every visit by monitoring the frequency with which patients require medical intervention for increased COPD symptoms. If a patient meets the criteria for frequent exacerbation, care providers should carefully assess both the patient’s adherence practices and the effectiveness of current therapy, and prescribe additional treatment or refer to specialist care as indicated.⁸

Best Practices in COPD Management

Ultimately, the treatment of COPD is a shared responsibility between the patient and the primary care provider — from the point of diagnosis and throughout the treatment journey. The following primary care best practices may facilitate a successful doctor-patient partnership and enhance COPD treatment outcomes:⁴

• Support patients in their efforts to self-manage COPD by encouraging smoking cessation and healthy lifestyle behaviors
• Provide routine patient monitoring, including spirometry, to identify and address any change in symptoms, manage the risk of acute exacerbations, and assess ongoing treatment goals
• Promote medication adherence by demonstrating and training on correct inhaler technique

References:

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2. American Lung Association. Lung Health and Diseases: Chronic Obstructive Pulmonary Disease (COPD). http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/copd/. Accessed on August 15, 2018.
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8. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. https://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed on August 17, 2018.
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