VHA Emphasizes Self-Management in New COPD Care Tool

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A new VHA self-management module is designed to help COPD patients help themselves. Slated for introduction later this year, the tool will allow patients to work more closely with their physicians to maximize lung function and improve the quality of their lives.

By Sandra Basu

CINCINNATI — For the million veterans treated for chronic obstructive pulmonary disease (COPD) in the VHA system, the primary goals are maintaining maximum lung function and improving quality of life.

Later this year, clinicians formally will have a new partner in that effort: the COPD patients themselves. VHA is creating a tool that primary care clinicians can use to assist patients in improving the self-management of their condition. The module is expected to be available later in 2014.

“This is a treatable disease that will have the best outcomes when patients and clinicians work together,” said Marta Render, MD, VHA program director for Critical Care, Pulmonary and Sleep.

At the Cincinnati VAMC earlier this year, a veteran uses a spirometry device to be screened for chronic obstructive pulmonary disease. Photo from Cincinnati VAMC.

At the Cincinnati VAMC earlier this year, a veteran uses a spirometry device to be screened for chronic obstructive pulmonary disease. Photo from Cincinnati VAMC.

A major challenge is helping patients avoid acute exacerbations that often lead to hospital admissions. In fact, COPD is the fourth most common diagnosis among hospitalized veterans.

Render said that trying to manage the disease is “a significant problem especially because patients with COPD have so many other chronic conditions that affect their ability to live.”

“What we want is for people to live well,” Render explained. “There are many elements that improve how patients with COPD perceive their dyspnea and how functional they can be. There are ways for them to reduce the likelihood that they get admitted to the hospital,” she said.

The VA/DoD Clinical Practice Guideline For Management of Outpatient Chronic Obstructive Pulmonary Disease, which was last updated in 2007, notes that providers should consider the diagnosis of COPD in all smokers and ex-smokers over the age of 45. It points out that cigarette smoking accounts for about 85% of the risk of developing COPD and that smoking cessation is the single most effective way to reduce the risk of developing COPD and slow the rate of decline in lung function, compared to that of nonsmokers.

Pulmonary rehabilitation should be offered to all patients with COPD who, despite optimal medical therapy, have reduced exercise tolerance and/or dyspnea limiting exercise, according to the document, which also recommends that educational components and self-management training should be part of rehabilitation programs.

New guidelines also came out this year from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), which sets the standards for COPD treatment worldwide. While recommending the widespread use of nonpharmacologic interventions to improve outcomes, such as smoking cessation, education, rehabilitation and pulmonary rehabilitation, the GOLD guidelines also point out that appropriate pharmacological therapy can reduce COPD symptoms and reduce the frequency and severity of exacerbations.

For example, the GOLD guidelines point out that the anticholinergic tiotropium not only improves the effectiveness of pulmonary rehabilitation but also reduces exacerbations and related hospitalizations, improves symptoms and health status.

Including both exercise and education, pulmonary rehab at the VA helps patients manage their medications and compensate for their disabilities.

“For example, in pulmonary rehab you teach people that if they want to go fishing that they take their shower the day before and lay their clothes out. They get up and their clothes are already laid out so they are able to conserve their energy until they get to the fishing place,” Render said. “You teach them how to pace their activities so they can do the things they love.”

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Click the above table to expand to full-size in a new tab

Some patients have to travel long distances for rehab and, even among patients who find it more convenient to participate, behaviors learned in the program are not always sustained.

Those are some of the reasons facilitating self-management can be beneficial, according to Render, who explained that “there is data that many of the goals of pulmonary rehab can be accomplished remotely and that self-management is part of this and is intended to sustain the behaviors and the benefits.”

The new self-management module will focus on three areas: improving exercise tolerance and patient health status; managing symptoms; and managing/reducing exacerbations. Within these areas, the module will address strategies such as medication, exercise and smoking cessation, among others.

“We are collecting what pulmonologists have done across the country in order to create a coherent packet for the PACT [patient aligned care team] to make it easy to communicate what are the best strategies and what is important,” she said.

Patients Can Literally Take Steps to Improve COPD Symptoms

BOSTON ‑ Chronic obstructive pulmonary disease (COPD) patients can literally take steps to improve their health, according to a new study.

For the observational cohort study over a median of 16 months, Marilyn Moy, MD, of the VA Boston Healthcare System, and her colleagues examined the relationship between physical activity and the risk of moderate and severe acute exacerbations (AEs) and COPD-related hospitalizations.

Employing an ankle-worn accelerometer that measures daily step count, researchers documented the physical activity of 169 veterans with COPD. They also assessed the exercise capacity of the veterans with the 6-minute walk test (6MWT) and patient-reported physical activity with the St. George’s Respiratory Questionnaire Activity Score (SGRQ-AS).

Overall, the study investigators found that lower daily step count, lower 6MWT distance, and worse SGRQ-AS could predict future AEs and COPD-related hospitalizations, independent of pulmonary function and previous AE history.

Moy explained that the study results are encouraging in that they “give all patients with COPD something within their control to change in terms of a positive behavior modification in increasing their physical activity and that it would affect their risk for exacerbations and their outcome.”

Specifically, the study reported there were 263 AEs and 116 COPD-related hospitalizations over 209 person-years of observation. According to the study authors, “for each 1,000 fewer steps per day walked at baseline, there was an increased rate of AEs (rate ratio 1.07; 95%CI = 1.003–1.15) and COPD-related hospitalizations (rate ratio 1.24; 95%CI = 1.08–1.42).”

The report noted that “there was a significant linear trend of decreasing daily step count by quartiles and increasing rate ratios for AEs (P = 0.008) and COPD-related hospitalizations (P = 0.003). Each 30-meter decrease in 6MWT distance was associated with an increased rate ratio of 1.07 (95%CI = 1.01–1.14) for AEs and 1.18 (95%CI = 1.07–1.30) for COPD-related hospitalizations. Worsening of SGRQ-AS by 4 points was associated with an increased rate ratio of 1.05 (95%CI = 1.01–1.09) for AEs and 1.10 (95%CI = 1.02–1.17) for COPD-related hospitalizations.”

Study results support “the importance of assessing physical activity in patients with COPD and provide the rationale to promote physical activity as part of exacerbation-prevention strategies,” the authors wrote.

Moy told U.S. Medicine that the results indicate something as simple as taking steps — any type of walking — can have a positive health impact for COPD patients.

“The step counts that I measured were any kind of step counts. It could be walking around in your kitchen. It could be going to the bathroom. It doesn’t have to mean that you went out for a 30-minute walk for exercise. These are all counts during the day.

“I think that is an important message to our patients, that it doesn’t mean you have to put on your jogging suit and get to the gym or that you have to go exercise. These patients can’t breathe, and hearing the word ‘exercise’ can be intimidating. Our data show that getting up and moving around more, even if it is moving from room to room, every step counts.”

Recommending that physicians talk to their patients about the importance of getting up and moving around, Moy explained, “It doesn’t require the risk of taking a new medication, the risk of having an operation. As easy as that sounds I acknowledge that changing someone’s behavior is no easy task either.”

Moy emphasized that this was an observational study and that and while it is highly supportive of their findings, it is not conclusive until an interventional study is done. Currently, she said she and her colleagues were conducting a randomized control study on the issue.

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