Pharmacists as Agents of Innovation in COPD Diagnosis and Management

Tatiana Makhinova, BScPharm, PhD Assistant Professor Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta

Outline

• COPD: why do we care?

• COPD: gaps in care

• The role of the pharmacist in prevention and screening

• The role of the pharmacist in management

• Future steps and opportunities for innovative care

2

Facts about COPD

• COPD is currently the fourth leading cause of death in the world

• COPD is projected to be the 3rd leading cause of death by 2030

• More than 3 million people died of COPD in 2012 accounting for 6% of

all deaths globally

• Globally, the COPD burden is projected to increase in coming decades

because of continued exposure to COPD risk factors and aging of the

population

Lozano, 2012; Mathers, 2006

3

Facts about COPD: Alberta context

Economic surveillance for chronic obstructive pulmonary disease (COPD) in Alberta, IHE 2016 4

Facts about COPD: Alberta context

Economic surveillance for chronic obstructive pulmonary disease (COPD) in Alberta, IHE 2016 5

6 © Canadian Pharmacists Association, December 2016

Pharmacy Services Framework

7

Patient assessment services

• Injections

• Prescribing

• Follow-ups (CACP, SMMA)

Comprehensive chronic care assessment

• Comprehensive annual care plan (CACP)

• Structured medication management assessment (SMMA)

CACP/SMMA eligibility

8

Chronic disease

Hypertension

Diabetes Mellitus

Heart Failure

Ischaemic Heart Disease

Angina Pectoris

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Mental Health Disorders

Risk factor

Tobacco

Obesity

Addictions

CACP • ≥2 Chronic diseases

OR

• Chronic disease + ≥1 Risk factor

SMMA • Chronic disease + 3 medications

OR

• Diabetes + Insulin/medication

OR

• Daily tobacco use

Prevention

9

https://www.sancda.org.za/who-world-no-tobacco-day-2018-awards-call-for-nominations/

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Primary prevention

• 85% of all COPD cases are attributed to

smoking

• The level of awareness of COPD is

inadequate

• Common belief: dyspnoea and

limitations in performing daily

activities/exercise are a part of the

ageing process

11 Jarab, 2012; van der Molen, 2016

Gaps in prevention

• Extent of services and programs, their use and effectiveness is

somewhat limited

• Services are underutilized

• About 10% of patients diagnosed with COPD had claims for

prescription smoking cessation drugs

12 Economic surveillance for chronic obstructive pulmonary disease (COPD) in Alberta, IHE 2016

What is the role of the community pharmacist?

Smoking cessation

Screening

Screening

13

Primary prevention

Pharma-cological treatment

Behaviour support

Effective strategy

Meta-analysis: RR=2.21

(95% CI 1.49-3.29)

14 GOLD, 2016; Mdege, 2014; Saba, 2014

Community pharmacists in Alberta

• An SMMA Tobacco Cessation Initial Assessment may be claimed for a resident

using a tobacco product daily and willing to receive Tobacco Cessation

Services.

• Up to four SMMA Tobacco Cessation Follow-up Assessments may be claimed

during the 365 day period after the SMMA Tobacco Cessation Initial

Assessment.

• Tobacco Cessation Services are defined as the provision by a clinical

pharmacist of evidence-based tobacco cessation support and counselling

including pharmacotherapy support. Use ICD-9 diagnosis code 305.1 for

Tobacco Use. 15

Community pharmacists in Alberta

16

Components for success

17 Greenhalgh et al. BMC Medicine (2016) 14:209

Early diagnosis

18

Importance of early disease management

• Patient health outcomes

• Reduced treatment benefit

• Increased risk hospitalization

• Costs to healthcare system

• Costs for treatment rise 10x when treating severe stage vs. mild

• Increased expenditures for inpatient/outpatient resources

19 Lyngso, 2010; APhA White paper on expanding role of pharmacists in COPD, 2011

Where are the gaps in care?

• Underdiagnosis

• Nearly half of COPD sufferers lack a clinical diagnosis

• Patients with spirometrically confirmed but not yet physician diagnosed

COPD utilize the health care system as frequently than those with

physician diagnosed disease

• Delayed case identification and intervention

• Often patients have progressed to mod-severe stages, at which time

treatment benefit is greatly reduced

20 Evans, 2014; Labonte, 2014

What is the role of the community pharmacist?

Smoking cessation

Screening

Screening

21

Early detection and case finding

• Timely diagnosis: earlier intervention improved QoL & reduced

healthcare burden

• Pharmacists are often the first point of contact between the patient

and the healthcare system

• Patient's needs (symptoms/meds): opportunity for screening

• Completion of a validated disease risk assessment questionnaire • Spirometry testing • Referral to a physician for confirmatory diagnosis and treatment

22

Example of Screening Questionnaire (COPD-PS)

23 Martinez, 2008

Early detection and case finding

• Trained community pharmacists are

able to perform accurate and

reproducible spirometry screenings

• Targeted screening could identify one

patient with moderate COPD for every

two individuals screened

• Portable device: Simplifies spirometry

technique (FEV6)

24 Wright, 2015; Castillo, 2015

Remaining knowledge gaps

• Lack of follow up data • Accuracy of pharmacist-led case finding interventions?

• Were the cases ultimately diagnosed with COPD?

• Were the patients initiated on treatment?

• Did the case findings have an impact on patient important outcomes?

• Which screening methods are most effective?

• How generalizable are findings?

• What training should be provided for pharmacists?

• How can we overcome barriers eg. lack of reimbursement models?

Further research is required to demonstrate the effect of pharmacist-led screening

interventions on patient important outcomes

25

Management

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Appropriate management

• Diagnosis of at-risk individuals using spirometry so

that timely intervention can be provided

• Appropriate therapy management

• Strategies to prevent and manage acute

exacerbations

• Promotion of smoking cessation

• Use of routine follow-ups for a regular evaluation

of inhaler technique and adherence

• Influenza and pneumococcal vaccination

• Pulmonary rehabilitation

It is estimated

that only 30-55%

of patients are

provided with this

recommended

care

Mularski, 2006; Seys, 2017

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Gaps in management: pharmacotherapy

• 30% of COPD patients in Alberta were found not to have any pharmacological therapy; of those, almost 22% were considered high severity

• PCP: 34% provided treatment with accordance to guidelines

• 28% of patients were dispensed an ICS inhaler as the first medication,

where only 52.4% of those patients met the CTS criteria for ICS use and only 0.8% had been on LABA or LAMA prior to initiation of ICS

28 Jones, 2014; Bourbeau, 2008

What is the role of the community pharmacist?

Medication management

Inhalation technique

Adherence

Vaccinations

Patient education

29

Inhalation technique: evidence

• Common errors

• Failure to hold breath after inhalation

• Inappropriate inspiration flow

• Failure to shake the canister before use

• Measured through use of checklists

• Increase in percentage of correct steps

performed from 67.6% to 93.4%

• Decrease in major errors from 15.6% to 1.2%

• Average number of errors made per patient

dropped from 2.5 to 0.5

• Written info vs. physical demonstration 30

Tommelein, 2014

Medication management: self-management

• COPD Action Plan

• COPD rescue pack

• Advising on how to recognize an

acute exacerbation

• Monitoring use of both maintenance

and rescue medication

• Improved quality of life, increased

medication adherence, and

reductions in doctor visits and

hospitalization rates 31 Clark, 2009; Bourbeau, 2006

Health resource utilization: evidence

Implementation of structured education programs and its effect on the following

parameters:

• ED visits: • 50% reduction

• Hospitalization: • Hospitalization decreased by 60%

• GP visits: • Per participant level of resource use decreased from 1.40 to 0.90

• Cost to healthcare system • Total National Health Service (NHS) costs reduced by £87.66 per participant

• Cost of intervention was £63.62 per participant

32 Tommelein, 2014

Conclusions

• Pharmacists are well-placed in the community to address

gaps in care

• Pharmacists are capable of preventing, screening,

improving inhalation technique, medication adherence,

and healthcare resource utilization

• Spacialized training: CRE, CTE

• The role of the pharmacist: significant impact

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Thank You! Questions?

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