Exploring the Generalist-Subspecialist Interface

1. Exploring the Generalist-Subspecialist Interface Higher quality caring for patients with asthma and COPD Mark Linzer MD

2. Disclosures and Objectives • No financial support for the talk • Learning Objectives: to better understand • National scene for generalists and specialists • ASP Workforce Committee • Literature on outcomes for patients with respiratory disorders • Proposed practice patterns for managing patients with asthma and COPD

3. Overlecturing and Underteaching • J Willis Hurst, recent Archives (Arch Intern Med. 2004;164:1605-9; thanks to Tom McCarthy) • Most lectures are a waste of time • Teach interactively; engage the listeners’ brains. • Teach based upon patient problems

4. 3 cases • 70 year old man with HBP, BPH and mild-moderate, well controlled COPD initially managed by pulmonary consultant, now by me. Referred back ’95, stable sx on ICS, FEV1 78% predicted, FEV1/FVC 68%. Meds include albuterol, theo, fluticasone. Last hospital stay >10 yrs ago. • Does he need periodic pulmonary consultation? • How am I (and he) doing?

5. Case 2 • 60 yr old woman with HBP, sinusitis, asthma, sleep apnea (desats to low 80s, now on O2), gout, alcohol use, seen by me, allergist and pulmonary specialist. Takes the right meds (Advair, flonase, albuterol). BMD nl. On exam, wt. 200, clear lungs, resolving SI after recent Rx by allergy with steroids and Abx. FEV1 77%; FEV1/FVC 63%. • Does she need the allergist? Does she need the sleep specialist? • Does she need me?

6. Case 3 • 30 yr old male: dyslipidemia, hypothyroid, GERD, HBP and RAD presents 6/04 with severe asthma attack (went to ER, sent home on oral steroids). Followed for several yrs on Advair, albuterol, Flonase, PPI. One hospital stay 10/03 for asthma exacerbation after chemical exposure. He does not have an allergist. • Does he (did he) need one?

7. The national scene • ACGIM (Assn Chiefs in GIM) and SGIM joined ASP (Assn Subspecialty Professors) in 2003. • Agreement: 2 generalist Council reps; name change; annual meeting with chairs (APM); article each year in AJM; new committee on generalist-specialist interactions (Workforce Comm.) • For first time, generalists and specialists sit together and discuss policy.

8. ASP Workforce Committee • 3-4 generalists, 4 specialists • Charge: discuss models for management of chronic illness • Co-Chairs: ML and Bob Myerburg, Chief, Cardiology, Miami. Both sit on Executive Committee. • Agreement: no turf battles. What is best for the patient will guide our recommendations.

9. Questions for the Workforce Committee* • When to refer (from GIM to SSIM)? • When to refer back (from SSIM to GIM)? • What are communication issues? • What are educational issues for GIM? • What are workforce implications? • Where are new data required? • *Linzer M. SGIM Forum. 2004;27(5):2,8

10. Illnesses to address first • Diabetes • CAD • HTN • Atrial fibrillation • Chronic renal disease • RA and O.A. • RAD and COPD • Inflammatory bowel disease and Irritable Bowel

11. Questions • What do you think of bringing generalists and specialists together for these purposes? • What additional questions might you ask of the committee? • Any strategic suggestions?

12. Practice pattern grids • When to refer • When and how to co-manage • When to refer back • Education and communication issues

13. RAD: NAEPP guidelines (www.nhlbi.nih.gov) • All patients: SA beta agonists (minimize) • Mild intermittent – no daily meds • Mild persistent – low dose ICS • Moderate persistent – low-med. dose ICS plus LA beta agonist (can use leukotriene modifer or theo) • Severe persistent – high dose ICS and LA beta agonist – may need oral steroids

14. RAD: Peak Flow meters? • Evidence neither supports nor refutes that their use improves outcomes; if so, only in severe disease.

15. RAD: the literature • In 2000 mgd care pts (Wu A, Arch Intern Med. 2001;161:2554-2560, from HSR&D Ctr, JHU), allergists did better than generalists re: asthmatic patients’: • Cancelled activities • Hospitalizations and ED visits • Quality of care ratings • Physical function

16. More RAD literature • In 400 HMO pts (Vollmer WM. Arch Intern Med 1997;157:1201-8), allergists gave better care (e.g. 92% of pts with mod-severe disease took inhaled anti-inflammatory agents vs 43% of generalists pts). • At Stony Brook (Frieri M. J Asthma. 2002;39:4-5-12), allergists gave more frequent F/U, used PEFs, prescribed more controller medications (ICS, LA beta agonists), Rx’ed more comorbidities impacting on asthma (allergic rhinitis).

17. More RAD Lit • In 260 parents of children with asthma (Diette GB. Pediatrics. 2001;108:432-7), asthma specialists compared with generalists used more controller meds (OR 6.5), ordered PFTs (OR 6.5), and told parents about asthma triggers and how to avoid them (OR 5.9).

18. Asthma: a generalist survey (Ann Allergy Asthma Immunol. 1999;83:203-6) • 37 FP and IM MDs at Mayo Clinics: when they refer: • 46% if pt requests • 38% for immunoRx • 27% for a single life threatening attack • 14% for allergy testing • 11% for poorly controlled asthma

19. RAD: Conclusions • Asthma patients appear to get care more consistent with guidelines and have better outcomes when managed by specialists • Ouch

20. The Unity Experience (Communicator. 2003;4:1-2) • Appropriate use of ICS: 1999 – 71% • 2002 – 78% (9th highest in the country). • How did we do it: MD reminders re: ICS and patient empowerment? • Member guidelines • Quarterly newsletter re: meds, triggers, PEFs, cig. cess’n, flu vax. • NIH pamphlet – how to take meds, identify triggers, how to avoid.

21. RAD referral grid • Setting Primary Care Pulm/Allergist • Mild Ongoing mgmt Available to consult Refer if unstable, uncertain dx, adherence problems • Mod-severe Co-manage with subspec Principle care of pts • (prolonged steroids, with severe RAD; • frequent sx, near- co-manage with PC • fatal asthma) for complex RAD (SI/GERD); refer back if stable, mild- moderate sx.

22. Question: • When do you refer? What if anything do we need to do to improve mgmt of patients with RAD by facilitating better referrals, back referrals, communication and education?

23. COPD – guidelines* • GOLD Guidelines (Global Initiative for Chronic Obstructive Lung Disease, expert and evidence based): • Mild (FEV1 >80%): SA BDs (beta ag, ipatrop) • Mod. (FEV1 50-80%): LA BDs +/- ICS • Severe (FEV1 <50%): LA BDs + ICS • All: flu vax, pneumovax, smoking cess’n • *Sutherland ER. Management of COPD. NEJM. 2004;350:2689-97

24. GOLD Guidelines: Classifications Therapy at Each Stage of COPD Old 0: At Risk I: Mild II: Moderate III: Severe IIA IIB New 0: At Risk I: Mild II: Moderate III: Severe IV: Very Severe Characteristics • Chronic symptoms • Exposure to risk factors • Normal spirometry • FEV1/FVC < 70% • FEV1 ≥ 80% • With or without symptoms • FEV1/FVC < 70% • 50% < FEV1 < 80% • With or without symptoms • FEV1/FVC < 70% • 30% < FEV1 < 50% • With or without symptoms • FEV1/FVC < 70% • FEV1 < 30% or presence of chronic respiratory failure or right heart failure Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilatorsAdd rehabilitation Add inhaled corticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments Adapted from Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: Executive Summary—Updated 2003. Bethesda, Md: NIH, NHLBI; 2003.

25. COPD – the literature* • In 450 Belgian MDs: • GPs underused spirometry to Dx • Both GPs and pulmonologists overused ICS (50% of GPs gave to all COPD pts vs 25% of pulmonologists) • GPs and pulmonologists overused systemic steroids in stable disease • Neither GPs nor pulmonologists gave enough pts pharmacoRx for smoking cessation. • *Decramer M. Monaldi Arch Chest Dis. 2003;59:62-80.

26. COPD – Hx vs PEF? • Data from the Veterans Health Study (Ren XS. J Ambulatory Care Mgmt, In Press), in 352 pts with COPD: • Severity measure by history alone: frequency and intensity of dyspnea, wheezing, cough. • Explained 19% of variance in physical function and 19% of variance in future hc visits; PEF explained only 10% and 2% of variances, respectively.

27. COPD – What’s new • Tiotropium (Spiriva) (Med Letter 2004;46:41-42): LA anticholinergic BD (peak 3 hrs, lasts 24) • More sustained response than salmeterol • Cost: 1 mo. Rx: $115 vs $68 for ipatropium and $88 for salmeterol. • Advair in COPD: better impact than either (salmeterol, fluticasone) alone. Watch for next GOLD guidelines (Weissler J, personal communication)

28. COPD referral grid • Setting PC MD SSIM • Mild-moderate Ongoing mgmt Available for Refer if unstable, consultation uncertain Dx (ILD) • Severe COPD General med care; Principle care of • (pCO2 >60, cor co-mgmt of stable, COPD; if stable, • pulmonale, O2 dep., severe cases co-manage with • frequent exacerbations) PC MD

29. COPD - Conclusions • More balanced literature: both generalists and specialists overRx with ICS • PFTs might not add much to Hx • Vaccines and smoking cessation count • Watch for some new developments (Advair, Tiotropium)

30. Question: • Do generalists know that the mainstay of Rx for COPD is not ICS (though this may be changing)? • What do you think is the best way to facilitate the highest quality care for pts with COPD?

31. Issues • Bringing generalists up to speed and into the guideline development process • Models of co-management – dynamic equilibrium between GIM and SSIM • Communication issues (esp. GIM to SSIM) • Patient activation?

32. The cases • My 70 yo with COPD, BPH and HBP. Needs pulmonary? • My 60 yo with SI, sleep apnea, EtOH and RAD. Needs me, pulmonary (sleep) and/or allergy? • My 30 yo with a severe bout of asthma. Time for an allergist?

33. Next up • Jason Knuffman with tips for managing pts with RAD