1. COPD in Primary Care
Amy Shaheen, MD, MSc

2. Learning Objectives
Learn structural changes needed provide high quality care COPD in primary care settings
Learn what can/could be targeted in primary care to prevent admissions and readmissions

3. Quick Facts Over 10,000 patients in COPD registry at UNCHC
Over half have had an admission in the last one year
3rd most common reason for admission and readmission at UNC
Our readmission rates have hovered around 30%
Serve a large indigent and rural population
Interventions that prevent admissions also prevent readmissions

4. What is Possible in Primary Care?
Prevention
Tobacco Cessation
Appropriate pharmacotherapy
Diagnosis
Spirometry
Education
Inhaler education
Anticipatory Guidance
Outreach
Identifying admissions real time and scheduling follow up
How do you identify who needs what?

5. Structural Changes-Registry
Built a registry in the EMR
High sensitivity to identify patients
Remove patients only after normal spirometry and central review
Using this can identify admissions, poorly controlled patients, patients out of care, visit dates, medications and class, action plan, oxygen status, pulmonary rehab participation, antibiotic or steroid use in the last year.
Visit Based Reminders for Spirometry, Rescue inhalers, Annual Inhaler education, Symptom Assessment, and Stepped Care for therapy

6. Practice changes Spirometry Device
Nurse/MA training (via Clinical implementation coaches)
Physician training (via LMS)
Knowledge Gap
VBR help providers learn best practices
Teaching alone does not help
Stepped care VBR must be supported with care management (medication access)
Pulmonary availability must support good primary care

7. Practice Changes Train the teachers (MAs, Nurses) Demo inhalers
Documentation
Symptom assessment consensus
Teach stepped care algorithm
Provide easy access to formularies

10. Audit and Feedback
Institutional Goal Setting

11. Some promising early data…

15. Anticipatory Guidance
Use system form or standard text for Action Plans
Reach agreement on antibiotic and steroid use

16. Care management Use registries to Identify admissions real time
Readmission prevention/hospital follow up clinic-Staffed by pharmacist and hospitalist
Seen within 7 days
MUST address socioeconomic and educational barriers to pharmacotherapy
Suggest using a check list to be comprehensive during visit

17. Summary and suggestions:
Step wise implementation in one practice and then spread (5 in out pilot)
Start with high sensitivity (i.e. diagnoses, problem list, inhalers, smoker with inhalers, etc)
Use Office based spirometry with supportive training to exclude patients
Implement symptom assessment with VBR (don’t need to be computerized to start)
Use symptoms to guide therapy using VBR
Build momentum, data, and then use to get institutional buy-in
Set practice and organizational goals
Create Toolkits for use in your organization-See handouts
Measure, measure, measure