NEWS & EVENTS
Second NHLBI Federal COPD Workshop
NIH
Bethesda, MD
Description

COPD, the third leading cause of death in the U.S., affects 6.5% of the adult U.S. population aged 25 years and older. This translates into almost 14,000,000 million people (60% of whom are women) affected by the disease, according to data obtained through the CDC Behavioral Risk Factor Surveillance System (BRFSS) for 2011. This prevalence is accompanied by an annual estimated number of more than 10,000,000 physician office visits for COPD as the first-listed diagnosis for 2010 with an equal gender representation. Almost 1,000,000 women and more than 500,000 men are estimated to make an emergency department visit for COPD as the first-listed diagnosis each year, and about 400,000 women and 300,000 men are hospitalized for COPD as the first-listed diagnosis. The toll that COPD takes on the population has prompted intense research efforts both in the US and abroad, leading to significant diagnostic and therapeutic improvements for the disease. While progress has been made, additional efforts to develop and implement coordinated preventive, diagnostic, and therapeutic approaches are needed.

Underscoring the importance of COPD to the health of the nation, the Senate Appropriations Committee in FY2012 encouraged the NHLBI “to work with community stakeholders and other Federal agencies, including CDC, to develop a national action plan to respond to the growing burden of this disease”. The NHLBI, the NIH component with primary responsibility for lung diseases, supports research and education activities on COPD and interacts with many of the various Federal agencies and Institutes of the NIH that deal with this disease. In response to this congressional encouragement, the NHLBI hosted a meeting in 2013 with representatives from various Federal government agencies and Institutes. The purpose of that initial meeting was to share information about ongoing activities related to COPD and discuss opportunities for further cooperation and enhanced effectiveness of the Federal response to COPD (see link to the report of that meeting below). To build momentum on the progress made at that meeting, Federal parties were re-convened by NHLBI for an update teleconference on Thursday November 20, 2014. This report provides a summary of that second meeting.

Recap

Workshop Description

The teleconference began with a report on follow-up activities related to the Federal meeting held in 2013. Federal partners described their contributions to the November 2014 National COPD Awareness Month and other COPD-related activities that had been pursued since the previous meeting. A general discussion followed on how to improve performance and coordination of programs in COPD within the context of HP2020 COPD objectives: RD-9, Reduce activity limitations among adults with COPD; RD-10, Reduce deaths from COPD among adults; RD-11, Reduce hospitalizations for COPD; and RD-12, Reduce emergency department (ED) visits for COPD.  There was consensus among the participants that targeting specific objectives could help focus efforts among the Federal partners. Regarding RD-11 and -12, discussants agreed that a re-examination of the policies that regulate respiratory rehabilitation reimbursements and certification of rehabilitation centers could constitute a worthwhile goal and, in light of rehabilitation’s beneficial effects in hospitalized exacerbating COPD patients, could possibly reduce both ED visits and re-hospitalization rates for these patients. Final discussions considered what approaches could be used to engage non-Federal COPD stakeholders in the pursuit of HP2020 goals and to increase cooperation and enhance effectiveness of the national response to COPD.  To this end, and in preparation for the next meeting, each participant was invited to submit to NHLBI, a list of non-Federal attendees that should be engaged in future activities.

Highlights of the continued and new COPD activities of some of the Agencies/Institutes participating in the teleconference.

Centers for Disease Control and Prevention (CDC)

CDC coordinates state surveillance systems (BRFSS) to monitor COPD prevalence.

CDC collects data through a range of data collection systems that obtain information on COPD prevalence and risk factors, COPD-associated use of ambulatory (physicians' offices, hospital outpatient clinics and emergency departments) and inpatient health care, and associated mortality.

CDC analyzes data, interprets findings, and disseminates information from existing data collection systems to increase public awareness about COPD. Of special note: COPD surveillance report published in the journal Chest (July 2013);  State fact sheets on COPD using Behavioral Risk Factor Surveillance System data made available at cdc.gov/copd (July 2013); Geospatial team used COPD as a case study for modeling prevalence in sub-state areas (counties, congressional districts, census tracts) published in the American Journal of Epidemiology (April 15, 2014); Report on COPD costs with projections to 2020 published in Chest (Online First, July 2014). An accompanying CDC Feature with infographic is available at cdc.gov.

CDC also participated in other awareness activities: COPD Awareness Month Announcement in Morbidity and Mortality Weekly Report (November 21, 2014); Twitter Chat for World COPD Day 2014 (@CDCChronic and @CDCTobaccoFree); Google+ Hangout for COPD Awareness Month (November 12, 2014); One of the stories in Tips from Former Smokers campaign featured COPD.

Centers for Medicare & Medicaid Services (CMS)

CMS continues interagency collaboration for coverage determination as well as measure development and implementation activities for COPD patients.

The anticipated completion date for the ongoing NHLBI and CMS Long-term Oxygen Treatment Trial (LOTT) is September 2015, with publication of the main results planned for the Spring of 2016. This study evaluates the effectiveness of using supplemental oxygen therapy in COPD patients who have moderately low to normal blood oxygen levels at rest, but have low or very low blood oxygen levels during exercise.

Quality measure development has focused on the person with COPD, emphasizing the burden of co-morbid conditions that lead to functional impairment, increased hospitalizations, readmissions and mortality. The COPD measures group finalized in the Physician Fee Schedule Rule consists of measures of spirometry use, having an advanced care plan, immunization status, tobacco screening and medication reconciliation. Hospital quality measures include 30-day following COPD hospitalization all-cause, risk-standardized mortality rates and readmission rates.

Medicare Accountable Care Organizations use hospital admission rates for COPD or asthma in older adults as one of their quality measures.

Electronic measures under development include functional status assessment and goal setting for patients with COPD.

Health Resources and Services Administration (HRSA) Federal Office of Rural Health Policy

HRSA placed information about COPD and other respiratory diseases in the most recent version of the Black Lung Clinics Program Funding Opportunity Announcement (http://www.hrsa.gov/ruralhealth/philanthropy/carecoordination/index.html).

There are many challenges in rural areas related to pulmonary rehabilitation. For many of our communities, access to certified pulmonary rehabilitation programs is extremely limited. Issues such as the need to travel long distances, lack of specialty providers (pulmonologists, etc.) and financial limitations all play a large part in the small numbers of miners who pursue pulmonary rehab.

National Institute for Occupational Safety and Health (NIOSH)

NIOSH has posted a draft document, Current Intelligence Bulletin: Promoting Health and Preventing Disease and Injury Through Workplace Tobacco Policies (http://www.cdc.gov/niosh/docket/review/docket274/default.html). The document addresses tobacco use among workers; exposure to secondhand smoke in workplaces; occupational health and safety concerns relating to tobacco use and secondhand exposure; electronic nicotine delivery systems; and workplace interventions to reduce tobacco product usage and secondhand exposure. It also includes NIOSH recommendations and a list of additional resources for those seeking assistance with tobacco cessation or additional information about workplace interventions.

NIOSH is undertaking several research efforts to assess risk factors and burden of work-related COPD in association with large national studies such as the National Health and Nutrition Examination Survey (for which NHLBI funded examination of participants with spirometry) and the Multi-Ethnic Study of Atherosclerosis, which evaluated participants with spirometry and chest computed tomography, allowing assessment for radiographic emphysema.

NIOSH supports stakeholders in providing high-quality spirometry through its Spirometry Course Certification Program (http://www.cdc.gov/niosh/topics/spirometry/training.html) and by providing tools to facilitate monitoring and interpreting longitudinal spirometry data (http://www.cdc.gov/niosh/topics/spirometry/spirola-software.html).

National Heart, Lung, and Blood Institute (NHLBI)

NHLBI has a significant basic science and clinical research portfolio related to COPD, which ranges from studies of pathogenetic mechanisms to research on COPD genetics and phenotypes (SPIROMICS, COPDGene, GRADS).

NHLBI has also developed a translational portfolio that promotes the exploration of new therapies for the disease through the Centers for Advanced Diagnostics and Experimental Therapeutics (CADET), and Science Moving towArds Research Translation and Therapy (SMARTT) programs. NHLBI is also conducting small- and large-scale clinical trials testing various therapies in COPD. The results for two large trials in acute exacerations of COPD (azithromycin and statins) have been recently published, and a large-scale trial of oxygen, LOTT, is in completion.

NHLBI in collaboration with several partners within and outside the Federal agencies continues to implement a nationwide COPD awareness campaign aiming to increase the visibility of the disease among persons at risk and healthcare providers (see: http://www.nhlbi.nih.gov/health/educational/copd/index.htm).

Summary and Developments

COPD is a multifaceted disease. Although most COPD is related to present or past cigarette smoking, 10-15% of COPD occurs in individuals who have never smoked. It is characterized by gender and racial/ethnic differences in mortality, including recent increases among American Indian/Alaska Native and non-Hispanic White women. The disease is also characterized by the frequent presence of a variety of co-morbid conditions that require multiple, synchronous and compatible approaches to treatment. This complexity comes at a staggering price as COPD costs over 32 billion annually (in direct health care costs and another $20 billion in morbidity and mortality (2010 data). The disease frequently causes hospital and intensive care unit (ICU) admissions, and it decreases the likelihood of employment while increasing the likelihood of collecting social security disability insurance. The Federal partners highlighted how a re-examination of the policies that regulate respiratory rehabilitation reimbursements and certification of rehabilitation centers could have beneficial effects in prevention of re-hospitalizations and ED visits for COPD patients. The delineation of the best approaches to tackle COPD at the national level will need input from diverse non-Federal stakeholders, allowing this group the opportunity to bring their contribution at the next in person meeting to be held in the Fall of 2015.

Workshop Participants

Administration for Community Living  (ACL)
Robert Hornyak MS

Agency for Healthcare Research and Quality (AHRQ)
David Meyers MD

Centers for Disease Control and Prevention (CDC)
Anne G. Wheaton, PhD
Janet B. Croft, PhD
Wayne H. Giles, MD, MS

Centers for Medicare & Medicaid Services  (CMS)
Alan Levitt MD

Environmental Protection Agency (EPA)
Kathy Sykes PhD

Food and Drug Administration(FDA)
Lydia I Gilbert-McClain, MD, FCCP

Health Resources and Services Administration (HRSA)
Katherine Lloyd, MPH
Nadia Ibrahim, MA, LGSW
Nisha Patel, MD

Indian Health Service (IHS)
Alec Thundercloud, MD
Susan V. Karol, MD, FACS

National Cancer Institute (NCI)
Eva Szabo, MD

National Institute on Aging (NIA)
Sue Zieman, MD

National Institute on Drug Abuse (NIDA)
Jeffrey D. Schulden, MD
Elizabeth Lambert, PhD

National Institute of Environmental Health Sciences (NIEHS)
John Balbus, MD, MPH

National Institutes of Health (NIH)
Office of the Director (OD)

Rashada C. Alexander, PhD

National Heart, Lung, and Blood Institute (NHLBI, organizing)
James P. Kiley,  PhD
Thomas  L. Croxton, PhD, MD.
Monique Ndenecho
Antonello Punturieri, MD, PhD
Lisa A. Postow, PhD
Lisa M. Viviano, BSN, RN

National Institute for Occupational Safety and Health  (NIOSH)
Ainsley Weston, PhD
David  Weissman, MD

National Institute of Nursing Research (NINR)
Karen Huss, PhD, RN
Mary Roary, PhD, RN

National Oceanic and Atmospheric Administration, (NOAA)
Jamese D. Sims, PhD

Office of the Assistant Secretary for Health (OASH)
Juliet Peña, MD, MPH

Office of the Assistant Secretary of Defense (OASD, Health Affairs)
Robin Marzullo, RN, MS

Office of the Surgeon General
Robert DeMartino, MD, USPHS

U.S. Department of Veterans Affairs (VA)
Marta L. Render, MD

References:
COPD surveillance--United States, 1999-2011
http://www.ncbi.nlm.nih.gov/pubmed/23619732

COPD costs
http://www.ncbi.nlm.nih.gov/pubmed/25058738

Healthy People 2020 respiratory diseases link:
http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=36

The summary report of the previous Federal meeting is available at:
http://www.nhlbi.nih.gov/research/reports/2013-copd-workshop.htm