prognostication in copd: science or fiction?
TRANSCRIPT
Prognostication in COPD: science or fiction?
Dr Laura-Jane Smith ST5 Respiratory Medicine
Wellcome Trust Clinical Research FellowWhittington Respiratory Meeting June 2015
COPD and death
Prognostication
Future practice
COPD REFRESHER
Inhaled noxious particles
(eg cigarette smoke, solid fuel fire smoke)
Inflammation, white cell
recruitment
Bronchial wall thickening
and fibrosis
Mucous gland hyperplasia
Alveolar destruction (neutrophil proteases)
CHRONIC BRONCHITIS
SMALL AIRWAYS NARROWING AND
OBSTRUCTION
EMPHYSEMA, BULLAE LOSS OF ELASTIC RECOIL
DYNAMIC AIRWAYS COLLAPSE
COPD is a systemic dise
ase
Images from Eureka: Respiratory Medicine 2015. Smith, Quint, Brown
WHAT DO WE DIE OF?
Prevalence of COPD increasing
globally, and projected to be the 3rd leading
cause of mortality and 5th leading
cause of disability by 2020
Many people die with COPD, or
from a complication related to it
COPD may not be cited as the
primary cause of death on their
death certificate - under-reported as a cause of death
HOW DO COPD PATIENTS DIE?
Trajectories of death
Trajectories of death
COPDHeart failure
Dementia Frailty
Cancer
From Spathis and Booth 2008. End of life care in chronic obstructive pulmonary disease: in search of a good death. International Journal of COPD. 2008;3(1):11–39. Adapted from Murray et al.
Respiratory failure
Lung cancer
Myocardial infarction Other
12%61%
14% 13%
Functional impairmentSymptom burden (breathlessness, anorexia, pain, cough, insomnia, confusion,
fatigue, low mood, anxiety, panic) Social isolation
Impaired HRQoLTreatment preferences
Invasive interventions near the end of life Advance care planning
Access to specialist palliative care services
Habraken JM et al. 2009Edmonds P et al.. 2001;15(4):287–95Gore et al 2000
COPD Lung cancer
All of these factors suggest that a palliative care approach would be beneficial for patients with advanced COPD. National and International guidelines recommend such an approach.
WHO definition of Palliative CarePalliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care:• provides relief from pain and other distressing symptoms• affirms life and regards dying as a normal process• intends neither to hasten or postpone death• integrates the psychological and spiritual aspects of patient care• offers a support system to help patients live as actively as possible until death• offers a support system to help the family cope during the patients illness and in their own
bereavement• uses a team approach to address the needs of patients and their families, including
bereavement counselling, if indicated• will enhance quality of life, and may also positively influence the course of illness• is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications
Why don’t COPD patients access palliative care?
Enhance access to a palliative
care approach
Improve prognostication
Move to a needs-based approach
Identify transitions in the course of disease
as triggers
Enhance access to a palliative
care approach
Improve prognostication
Move to a needs-based approach
Identify transitions in the course of disease
as triggers
PROGNOSIS IN COPD
How good is human intuition?
Chow et al 2001, Christakis 2000, Wildman 2007
Can data help?
FEV1% Hypoxaemia Breathlessness Cor pulmonale
Exacerbation frequency Hospitalisation Exercise
tolerance Biomarkers
Low BMI Older age RVSP Low serum albumin
ICU admission Co-morbid CCF Functional status Use of NIV
Nishimura 2002
Soler-Cataluña 2005 Knaus 1991, Almagro 2002
Ai-Ping 2005
Pinto-Plata 2004 Coxson 2013
Connors 1996 Connors 1996, Almagro 2002
Connors 1996 Connors 1996
Connors 1996 Dallari 1994
Anthonisen 1989 NOTT 1980
Plant 1998
Incalzi 1999
Can more data help?
BODE
Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. New England Journal of Medicine. 2004;350(10):1005–12.
BODE
For each one-point increment in the BODE score the hazard ratio for death from any cause was 1.34 (95%CI 1.26-1.42) and the hazard ratio for death from a respiratory cause was 1.62 (95%CI 1.48-1.77).
Kaplan-Meier Survival curves for the 4 quartiles of the BODE index and the 3 stages of severity of COPD based on FEV1% as defined by the ATS.Quartile 1 = 0-2Quartile 2 = 3-4Quartile 3 = 5-6Quartile 4 = 7-10
Stage 1 = FEV1 >50% predictedStage 2 = FEV1 36-50% predictedStage 3 = FEV1 <36% predicted
Puhan MA, Hansel NN, Sobradillo P, Enright P, Lange P, Hickson D, et al. Large-scale international validation of the ADO index in subjects with COPD: an individual subject data analysis of 10 cohorts. BMJ Open. 2012 Jan 1;2(6):e002152.
BODE v2
ADO
Making models count
Wyatt JC, Altman DG. Commentary: Prognostic models: clinically useful or quickly forgotten? BMJ. 1995 Dec 9;311(7019):1539–41.
Clinical credibility• Patient data required for model is easily and reliably accessible• Avoid arbitrary thresholds for continuous variables• Simple to calculate at point-of-care
Evidence of accuracy• At least as accurate as clinician prediction• Error rates tested in large data set not used to generate model
Evidence of generality• Model testing in other populations, in time and space• Each item of data clearly defined to ensure easy use in different settings/languages• Prospective validation in well-defined populations
Evidence of clinical effectiveness• Measure effects on practice and outcomes of using model• Similar to phase III study in drug trials
FEV1% Specific co-morbidities
Multi-morbidity Breathlessness
Functional status
Previous need for
NIV/ventilationHRQL QoL
Socioeconomic group
Healthcare utilisation
Weight loss/cachexia/B
MI <21Sarcopenia
Exercise capacity Social isolation Use of long
term steroids
Contact with comm resp/pall
care team
IMPLICATIONS FOR PRACTICE
COPD model of care
Does this capture what patients and physicians want?What needs to happen to achieve this?
YouGov poll 2014
http://compassionindying.org.uk/
QUESTIONS?
Conclusions
• Many patients with COPD have a high symptom burden and poor quality of life, yet fail to access a palliative care approach
• Patients, carers, physicians, and policy makers would welcome greater prognostic certainty
• Current prognostic markers and scores are limited in their ability to accurately predict prognosis in individual patients
• There are great opportunities to improve the lives of patients with COPD and their carers, which requires research and investment
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