COPD Performance Improvement Teleconference · Performance Improvement Enrolling in this PI program is the 1st step in improving care for your patients Key component to improvement

COPD Performance Improvement Teleconference

Roy C. Blank, MDRoy C. Blank, MDDennis E. Niewoehner, MDDennis E. Niewoehner, MD

Learning Objectives

Describe inhaled pharmacotherapy options for stable COPD

Explain optimal management strategies for acute exacerbations

Accreditation Statement

Boston University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.Boston University School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Clinicians should only claim credit commensurate with the extent of their participation in the activity.In order to receive CME/CE credit for this teleconference, complete the Program Evaluation and Claim for Credit forms that are on our Website at www.mentorqi.com. Click on the EVENTS tab at the top and look for Teleconference #1.

Target AudiencePrimary care physicians, nurse practitioners, and physician assistants

Grant SupportThis program is supported by an educational grant from Boehringer Ingelheim and Pfizer Inc.

Planning Committee Disclosures

Julie White, MSAdministrative DirectorContinuing Medical EducationBoston University School of MedicineBoston, Massachusetts

Julie White has nothing to disclose.

Lara Zisblatt, MAAssistant DirectorContinuing Medical EducationBoston University School of MedicineBoston, Massachusetts

Lara Zisblatt has nothing to disclose.

Elizabeth GiffordProgram ManagerProgram ManagerContinuing Medical EducationContinuing Medical EducationBoston University School of MedicineBoston University School of MedicineBoston, MassachusettsBoston, Massachusetts

Elizabeth GiffordElizabeth Gifford has nothing to has nothing to disclose.disclose.

Faculty Disclosure Information

Roy C. Blank, MDSouthern Piedmont Primary CareMonroe, North Carolina

Roy C. Blank, MD, has nothing to disclose.

Dr. Blank plans to discuss off-label/investigational uses of tiotropium for COPD exacerbations and inhaled steroids for certain patients with severe COPD symptoms.

Faculty Disclosure

Dennis E. Niewoehner, MDProfessor of MedicineUniversity of MinnesotaMinneapolis, Minnesota

Dennis E. Niewoehner, MD, is on the speakers’ bureau for Boehringer Ingelheim and Sepracor and serves as a consultant for GlaxoSmithKline and AstraZeneca.

Dr. Niewoehner plans to discuss off-label/investigational uses of ipratropium, aminophylline, antibiotics, prednisone, prednisolone, or budesonide for managing exacerbations of COPD.

COPD Performance Improvement: Overview

Lara Zisblatt, MALara Zisblatt, MAAssistant DirectorAssistant Director

Continuing Medical EducationContinuing Medical EducationBoston University School of MedicineBoston University School of Medicine

Boston, MassachusettsBoston, Massachusetts

Participants in the Program

224 people registered

42 finished baseline chart review

29 submitted their action plans

4 completed the program

Performance Improvement

Enrolling in this PI program is the 1st step in improving care for your patients

Key component to improvement is chart review– Simple way to look at baseline measures of your

practice

– Very act of reviewing charts can be illuminating

Chart Review Challenge

Biggest challenge = Time

Ways to overcome this barrier: – Requirement lowered from 10 charts to 5 charts for review

– Ask support staff to review patients seen in the past month with any ICD 9 code for COPD and pull charts or review EMR

– Complete the chart review with another member of your team

– Make a plan to complete this chart review

Schedule 2 one-hour sessions over the next week using administrative time or your lunch hour

COPD Project

Make a commitment to yourself and to your patients to work toward improving care

Complete the chart review as soon as possible as your first step toward improvement

If you are having trouble completing the chart reviews, please let us know. We can help!

If you have any questions, please e-mail us at [email protected] or call us at 617.638.4605

Inhaled Pharmacotherapyfor Stable COPD

Roy C. Blank, MDRoy C. Blank, MDSouthern Piedmont Primary CareSouthern Piedmont Primary Care

Monroe, North Carolina Monroe, North Carolina

Case Study: Patient Presentation

Rob C is a 71-year-old man who presents for follow-up of COPD

Past history– COPD: known diagnosis X 15 years

– Carotid artery disease

– Peripheral vascular disease

– Dyslipidemia

– Hypertension

– Hyperthyroidism

Case Study: Patient History

Social history– Smokes 1 pack per day and has done so for 50 years

• Will quit when “hell freezes over”

Medications– ASA 325 mg / day– Propylthiouracil 50 mg po TID– Simvastatin 40 mg po daily– Lisinopril 20 mg po daily– Tiotropium 88 mcg daily inhalation since 5/1/08

• Previous treatment with ipratropium bromide + albuterol sulfate

– Continuous O2 at 2 liters / minute / 24 hours– Albuterol HFA PRN for symptoms

ASA = acetylsalicylic acid; TID = three times daily; po = oral; HFA = hydrofluoroalkane; PRN = as needed.

Case Study: Diagnostic Testing

ECG– RBBB

CXR– Flattened diaphragms

– Emphysematous changes

– Scattered fibrosis

Cardiac echo– Moderately dilated right ventricle

– Pulmonary pressures not estimated

– Ejection fraction 50%

ECG = electrocardiogram; RBBB = right bundle branch block; CXR = chest x-ray.

Case Study: Pulmonary Function Tests

Pulmonary Function Tests 2008– FVC: 1.41 L 34%

– FEV1 1.0: .63 L 21%

– FEV1 1.0 / FVC 45%

– FEF 25%-75% L/sec 0.27 12%

– No significant change with bronchodilators

– O2 sat with oxygen 93%

Pulmonary Function Tests 2009– FVC: 1.74 L 48%

– FEV1 1.0: .65 L 22%

– FEV1 1.0 / FVC 38%

– FEF 25%-75% L/sec 0.27 10%

– No significant change with bronchodilators

– O2 sat with oxygen 94%

FVC = forced volume vital capacity ; FEV = forced expiratory volume; FEF = forced expiratory flow; O2 = oxygen.

Patient Follow-up

Follow-up visit– Symptoms: chronic shortness of breath unchanged over the

past year; no new symptoms• Previously attended pulmonary rehabilitation

– No exacerbations over the past year and no hospitalizations

– Vital signs stable

– BMI 16.5

– Pulse oximetry 94%

– Examination: reduced lung breath sounds with no bronchospasm; no respiratory distress; no findings for congestive heart failure

BMI = body mass index.

Spirometry Interpretation –Obstructive Defect(s)

Obstructive disease– FEV1/FVC <70%– Severity classified as FEV1 % of predicted normal– PEFR — NOT used to diagnose or monitor COPD

8 6 4 2

10

5

Flow

(L/s

ec)

Severe

Mild

Normal

Thoracic Gas Volume (liters)

FEV1 = forced expiratory volume in 1 second; in 1 second; PEFR = peak expiratory flow rate.

SpirometryObstructive Disease, WHO Classification

SeveritySeverity FEVFEV11/FVC/FVC FEVFEV11 ImpactImpact

Stage 1 Stage 1 ““MildMild”” <70%<70% Normal Normal

((≥≥80%)80%)

Majority of patientsMajority of patientsMinimal impact on HRMinimal impact on HR--QOLQOLModest expenditureModest expenditure

Stage 2Stage 2““ModerateModerate”” <70%<70% 50%50%--80% 80%

predictedpredictedMinority of patientsMinority of patientsSignificant impact on Significant impact on HRHR-- QOLQOL

Stage 3Stage 3““SevereSevere”” <70%<70% 30%30%--49% 49%

predictedpredicted

Stage 4Stage 4““Very severeVery severe”” <70%<70% ≤≤29% 29%

predictedpredicted

Large expenditureLarge expenditureMinority of patientsMinority of patientsProfound impact on HRProfound impact on HR--QOLQOLVERY large expenditureVERY large expenditure

WHO = World Health Organization; HR-QOL = health-related quality of life.Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD. Updated 2006. http://www.goldcopd.org.

SpirometryFEV1 and Survival Prognosis

100

Anthonisen N, et al. Am Rev Respir Dis. 1986;133:14-20.

Surv

ival

(%)

Years

Normal>50% predicted40%-49% predicted30%-39% predicted<30% predicted

FEV1

0 1 2 3

90

80

70

60

Goals of COPD Management

Prevent disease progression

Relieve symptoms

Improve lung function

Improve exercise tolerance

Improve health status

Prevent and treat complications

Prevent and treat exacerbations

Reduce mortality

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2006. http://www.goldcopd.org

Treatment of COPD by Stage

Active reduction of risk factor(s); influenza vaccinationActive reduction of risk factor(s); influenza vaccinationAddAdd shortshort--acting bronchodilator (when needed)acting bronchodilator (when needed)

• FEV1/FVC <0.70• FEV1 ≥80% predicted

Add long-term oxygen if chronic respiratory failureConsider surgical treatments

Add inhaled glucocorticosteroids if repeated exacerbations

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation

• FEV1/FVC <0.70• 50% ≤FEV1

<80% predicted

• FEV1/FVC <0.70• 30% ≤FEV1 <50%

predicted

• FEV1/FVC <0.70• FEV1 <30% predicted

plus chronic respiratory failure

I: MildI: Mild II: ModerateII: Moderate III: SevereIII: Severe IV: Very SevereIV: Very Severe

NHLBI/WHO Global Initiative for Chronic Obstructive Lung DiseaseNHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease.. November 2006.November 2006.

Salmeterol for Stable COPD

SalmeterolSalmeterol

IpratropiumIpratropium

PlaceboPlacebo

22 44 66 88 1010 121200

0.10.1

0.50.5

0.40.4

0.30.3

0.20.2

∆∆FE

VFE

V 11(L

)(L

)

Time (hours)Time (hours)

FEVFEV1 1 = forced expiratory volume in 1 second.= forced expiratory volume in 1 second.

Mahler DA, et al.Mahler DA, et al. Chest. Chest. 1999;115:9571999;115:957--965.965.

Prevention of Exacerbations:Inhaled Long-acting Beta Agonists*

*Off*Off--label indication.label indication.

Relative Risk (95% CI) of ExacerbationRelative Risk (95% CI) of Exacerbation

Favors LABAFavors LABA Favors PlaceboFavors Placebo

0.20.2 110.50.5 22 55

Mahler 2002Mahler 2002BrusascoBrusasco

Calverley 1Calverley 1CelliCelli

ChapmanChapmanRennardRennard

Van NoordVan NoordMahler 1999Mahler 1999

BoydBoydSubtotal


Subtotal

0.82 (0.76 0.82 (0.76 –– 0.90)0.90)0.84 (0.74 0.84 (0.74 –– 0.97)0.97)

0.81 (0.73 0.81 (0.73 –– 0.90)0.90)Calverley 2Calverley 2

AalbersAalbersRossiRossi

WadboWadboDahlDahl

SzafranskiSzafranskiSubtotal

FormoterolFormoterol

Subtotal

TotalTotal

LABA = longLABA = long--acting beta agonists.acting beta agonists.

Wilt T, et al.Wilt T, et al. AHRQ Report 05AHRQ Report 05--E017E017--2, 2005.2, 2005.

Tiotropium AM Dosing: Improvement in FEV1 Over 24 Hours

0.70.7

0.80.8

0.90.9

1.01.0

1.11.1

1.21.2

1.31.3

––33 00 33 66 99 1212 1515 1818 2121 2424

Tiotropium (Tiotropium (nn=37)=37)Placebo (Placebo (nn=33)=33)

FEV

FEV 11

(L)

(L)

Time (hours)Time (hours)9 9 AMAM 3 3 PMPM 9 9 PMPM 3 3 AMAM 9 9 AMAM

FEVFEV1 1 = forced expiratory volume in 1 second.= forced expiratory volume in 1 second.Calverley PM, et al. Thorax. 2003;58:855-860.

VA Tiotropium Trial:Primary Outcomes*

>>1 Exacerbation (%)1 Exacerbation (%) >>1 COPD Hospitalization (%)1 COPD Hospitalization (%)

PlaceboPlacebo TiotropiumTiotropium

P = P = .037.037

32.232.227.927.9

PlaceboPlacebo TiotropiumTiotropium

P = P = .056.056

9.59.5

7.07.0

Niewoehner DE. Ann Intern Med. 2005;143:317-326.

*Off*Off--label indication.label indication.VA = Veterans Administration.VA = Veterans Administration.

4040 1212

3030 99

2020 66

1010 33

00 00

UPLIFT Trial: Long-term Tiotropium Improves QoL, Reduces Exacerbation

In 5,993 patients with COPD, therapy with tiotropium versus placebo was associated with improvements in lung function, quality of life, and exacerbations during a 4-year period

Therapy did not significantly reduce the rate of decline in FEV1

Tashkin DP, et al. N Engl J Med. 2008;359:1543-1554.

Reduction in Hospitalizations:Inhaled Long-acting Anticholinergic

Reference Favors Tiotropium Favors Comparator

Adapted from Barr RG, et al. Cochrane Database Syst Rev. 2006;(2):CD002876(A).

0.2 10.1 5.0 10.0

Casaburi et al, 2002

Niewoehner et al, 2004

Vincken et al, 2002

Brusasco et al, 2003

Brusasco et al, 2003

Summary effect—placebo 0.65 (0.50, 0.85)0.65 (0.50, 0.85)

Summary effect—salmeterol 0.59 (0.29, 1.23)0.59 (0.29, 1.23)

Summary effect—ipratropium 0.59 (0.32, 1.09)0.59 (0.32, 1.09)

Relative Risk

Prevention of Exacerbations:Inhaled Corticosteroids

ICS = inhaled corticosteroids.ICS = inhaled corticosteroids.Wilt TJ, et al. AHRQ Report 05-E017-2, 2005.

Relative Risk (95% CI) of ExacerbationRelative Risk (95% CI) of Exacerbation0.20.2 110.50.5 22 55

Burge Burge Calverley 03 Calverley 03

Mahler 02 Mahler 02 van der Valk van der Valk

Paggiaro Paggiaro SubtotalSubtotal

Bourbeau Bourbeau Calverley 04 Calverley 04

Szafranski Szafranski Vestbo Vestbo

SubtotalSubtotal

FluticasoneFluticasone

BudesonideBudesonide

Weir Weir SubtotalSubtotal

TotalTotal

BeclomethasoneBeclomethasone0.64 (0.41 0.64 (0.41 -- 1.00)1.00)

0.78 (0.66 0.78 (0.66 -- 0.91)0.91)

0.81 (0.68 0.81 (0.68 -- 0.95)0.95)

0.78 (0.70 0.78 (0.70 -- 0.88)0.88)

Favors ICSFavors ICS Favors PlaceboFavors Placebo

Consider Inhaled Steroidsin These COPD Patients*

Patients who have:– Severe symptoms with FEV1 <1 L

– Need for frequent antibiotics, prednisone, or hospitalization to treat exacerbations

*Off*Off--label indication.label indication.

Niewoehner DE, Wilt TJ. Am J Respir Crit Care. 2007;175:103-104.

Combined ICS and LABA to Prevent Exacerbations - TORCH

Exac

erba

tions

/Ex

acer

batio

ns/

Patie

ntPa

tient

-- Yea

rYe

ar

**P P <<.05 compared with placebo.05 compared with placebo††P P <.05 compared with salmeterol or fluticasone<.05 compared with salmeterol or fluticasone

00

0.20.2

0.40.4

0.60.6

0.80.8

11

1.21.2

1.41.4

PlaceboPlacebo SalmeterolSalmeterol FluticasoneFluticasone SalmeterolSalmeterol++


**** ** ††

TORCH = TOwards a Revolution in COPD Health.Calverley Calverley PM, et al. PM, et al. N N Engl Engl J Med. J Med. 2007;356:7752007;356:775--789.789.

Combination Inhalers for Preventing Hospitalizations

PP <.05<.05

Aaron SD, et al. Ann Intern Med. 2007;146:545-555.

00

1010

2020

3030

4040

5050

6060

4949

3838

2626

TiotropiumTiotropium TiotropiumTiotropium++


TiotropiumTiotropium++

SalmeterolSalmeterol++


NSNS

No.

CO

PD

No.

CO

PD H

ospi

taliz

atio

nsH

ospi

taliz

atio

ns

NS = not significant.

Pharmacotherapy Performance Improvement Goals

Increase bronchodilator performance in COPD patients with FEV1 <60% predicted

Obstacle: Medication initiation• Intervention: Clinic flow sheet for medications and interventions

Obstacle: Patient noncompliance due to no immediate effect of medication

• Intervention: Educate to set patient expectations – Have patient education materials on hand

– Discuss medication effects and outcomes

– COPD education at all follow-up visits

Summary

Initiate a long-term bronchodilator(s) for moderate or more severe COPDProvide appropriate patient education at the onset of therapy– Discuss medication mechanisms and expectations

Obtain baseline pulmonary function dataMonitor clinical and therapeutic response– Exacerbations– Hospitalizations– Deterioration of symptoms or PFTs– Adjust therapy if clinical response is unfavorable

PFTs = pulmonary function tests.

Management of COPD ExacerbationsDennis E. Niewoehner, MDDennis E. Niewoehner, MD

Veterans Affairs Medical CenterVeterans Affairs Medical CenterUniversity of Minnesota University of Minnesota

MinneapolisMinneapolis

COPD Exacerbations: Definition

“A sustained worsening of the patient’s condition from steady state and beyond normal day-to-day variation that is acute in onset and necessitates a change in regular medication”

Rodriquez-Roisin R. Chest. 2000;117(suppl 2):398-401S.

COPD Exacerbations:Adverse Impacts

Human misery

Economic factors

Progression of underlying disease

Adverse effects of treatment

COPD Hospital Discharges in the United States, 1997-2006

US

Dol

lars

http://hcupnet.ahrg.gov/

Mean Charge per COPD Admission in the United States, 1997-2006

US

Dol

lars

http://hcupnet.ahrg.gov/

COPD Exacerbations: Treatment by Severity

MILD MODERATE SEVERE

Increase BDs

Antibiotics Antibiotics,Steroids

Hospitalization,Oxygen

ICU,Assisted

ventilationw/wo unscheduled medical visit

BDs = bronchodilators; ICU = intensive care unit.

COPD Exacerbations:Treatment Modalities

Bronchodilators

Oxygen

Antibiotics

Systemic corticosteroids

Noninvasive positive pressure breathing

Short-acting Bronchodilators for COPD Exacerbations

Favors Favors beta agonistbeta agonist

plus ipratropiumFavors Favors

ipratropiumFavorsFavors

beta agonistFavorsFavors

beta agonistipratropium plus ipratropiumbeta agonist beta agonist

TotalTotal 0.00 (0.00 (--0.19 0.19 -- 0.19)0.19)

Backman 1985Backman 1985

TotalTotal 0.02 (0.02 (--0.08 0.08 -- 0.12)0.12)

Lloberes 1988Lloberes 1988

Lloberes 1988Lloberes 1988

Rebuck 1987Rebuck 1987

Karpel 1990Karpel 1990

Shretha 1991Shretha 1991

Rebuck 1987Rebuck 1987

-1 -0.5 0 0.5 1 -1 -0.5 0 0.5 1

Weighted mean difference (L)Weighted mean difference (L) Weighted mean difference (L)Weighted mean difference (L)

McCrory DC. Cochrane Database System Rev. 2003, Issue 1. Art. No.: CD003900. DOI: 10.1002/14651858.CD003900

Effects of Aminophylline in Hospitalized COPD Patients

Days from AdmissionDays from Admission

FEV

FEV 1

1 (L

)(L

)

1.01.0

0.80.8

0.60.6

0.40.400 11 33 55

Placebo

Aminophylline

PP = 0.49= 0.49

1.01.0

0.80.8

0.60.6

0.40.4

0.20.2

Prop

ortio

n U

nfit

for D

isch

arge

Prop

ortio

n U

nfit

for D

isch

arge

PP = 0.19= 0.19

Aminophylline

Placebo

00

Day Fit for DischargeDay Fit for Discharge

00 44 88 1212 1616 2020 2424

Duffy N. Thorax. 2005;60:713-717.

FEV1 = forced expiratory volume in 1 second.in 1 second.


Bronchodilators

Oxygen

Antibiotics




Bronchodilators

Oxygen

Antibiotics



COPD Exacerbations:Antibiotic Therapy

Favors Favors antibiotic

Favors Favors placeboantibiotic placebo

Alonso 1992Alonso 1992

Anthonisen 1987Anthonisen 1987

Elmes 1965Elmes 1965

Jorgensen 1992Jorgensen 1992

Pines 1968Pines 1968

Pines 1972Pines 1972

TotalTotal 0.67 (0.56 - 0.80)

0.10.1 11 22 55 10100.50.50.20.2

RR (RR (95% CI95% CI) of Treatment Failure) of Treatment Failure

Ram FSF, et al. Cochrane Database System Rev. 2006, Issue 2. Art. No.: CD004403.

Antibiotics for COPD Exacerbations

100n = 354 n = 114

n = 174n = 88

Moxifloxacin Clarithromycin

% C

linic

al S

ucce

ss

Cefuroxime-Axetil

80

Amoxicillin

60

40

20

0

Wilson R, et al; MOSAIC Study Group. Chest. 2004;125:953-964.


Bronchodilators

Oxygen

Antibiotics



Systemic Steroids and COPD Exacerbations: SCCOPE Trial

6060

% T

reat

men

t Fai

lure

% T

reat

men

t Fai

lure

Days on StudyDays on Study

PlaceboPlacebo22--week steroidweek steroid88--week steroidweek steroid

6060 120120 18018000

4040

2020

00

Niewoehner DE, et al. N Engl J Med. 1999;340:1941-1947.

Systemic Steroids for OutpatientTherapy for COPD Exacerbations

100

Prednisone(n = 74)

% P

atie

nts

Rel

apse

-free

80

60Placebo(n = 73)P = 0.04

40

5 200 15 25 3010

Days on StudyAaron SD, et al. N Engl J Med. 2003;348:2618-2625.

Systemic Steroids and COPD Exacerbations: Meta-Analysis of Treatment Failures

Odds Ratio (95% CI)Odds Ratio (95% CI)

Aaron 2003Aaron 2003

Davies 1999Davies 1999

Maltais 2002Maltais 2002

Niewoehner 1999 Niewoehner 1999

Thompson 1996Thompson 1996

Wood-Baker RR. Cochrane Database System Rev. 2005, Issue 1. Art. No.: CD001288. DOI:10.1002/14651858.CD001288.pub2.

Summary estimateSummary estimate 0.46 (0.310.46 (0.31--0.68)0.68)

Favors Favors treatmenttreatment

Favors Favors placeboplacebo

11 1010 100100 100010000.10.10.010.010.0010.001

Steroid Therapy for COPD Exacerbations: Inhaled vs Systemic

Placebo

Nebulized budesonide(2 mg q 6h)

Oral prednisolone(30 mg q 12h)n = 62

n = 71

n = 66

1.2

Post

-BD

FEV

1(L

)

1.1

1.0

0.9

0.8

BD = bronchodilator.Maltais F, et al. Am J Respir Crit Care Med. 2002;165:698-703.

Hours on Study

12 480 36 60 7224

Systemic Steroids for Exacerbations:Dose Response

Daily PrednisoneEquivalents35

Ster

oid

Effe

ct ∆

FEV 1

%

60 mg1

30 mg3

640 mg4

190 mg2

Study Day

1. Maltais F, et al. Am J Respir Crit Care Med. 2002;165:698-703. 2. Albert RK, et al. Ann Intern Med.1980;92:753-758. 3. Davies L, et al. Lancet. 1999;354:456-460. 4. Niewoehner DE, et al. N Engl J Med. 1999;340:1941-1947.

0

5

10

15

20

25

30

1 20 3


Bronchodilators

Oxygen

Antibiotics



Noninvasive Positive Pressure Breathing (NPPV)

Gershman AJ. Cleve Clin J Med. 2008;75:458-461.

Effects of NPPV on Mortality During COPD Exacerbations

0.010.01 0.10.1 11 1010 100100

Favors NPPVFavors NPPV Favors ControlFavors Control

RR (95% CI)RR (95% CI)

Bott 1993Bott 1993

Servillo 1994Servillo 1994

Brochard 1995Brochard 1995

Kramer 1995Kramer 1995

Angus 1996Angus 1996

Celikel 1998Celikel 1998

Plant 2000Plant 2000

Dikensoy 2002Dikensoy 2002

CRC 2005CRC 2005

Dhamija 2005Dhamija 2005

Keenan 2005Keenan 2005

0.45 0.45 ((0.300.30--0.66)0.66)Pooled summaryPooled summary

Quon BS, et al. Quon BS, et al. Chest.Chest. 2008;133:7562008;133:756--766.766.

Discussion/Questions

Documents

COPD Performance Improvement Teleconference · Performance Improvement Enrolling in this PI program is the 1st step in improving care for your patients Key component to improvement