A New Vision for Health

Guest Editorial for Case Review
November/December, 1998
pages 10, 43-44.

by: Thomas L. Petty, M.D.

The mission of the National Lung Health Education Program (NLHEP) suggests a major new health care investment by managed care organizations that can reduce the impact of COPD, lung cancer, heart attack, and stroke.


    The National Lung Health Education Program (NLHEP) is a new national health care initiative directed at chronic obstructive pulmonary disease (COPD) and related disorders. These disorders include lung cancer, heart attack, and stroke, all of which are more common in patients with airflow abnormalities identified by spirometry. The NLHEP is specifically aimed at reducing the socioeconomic impact of COPD by early identification of asymptomatic patients who have only mild to moderate stages of airflow obstruction, and a reduction in the forced expiratory volume in one second (FEV1). The key to the success of the NLHEP is public awareness, and action by primary care practitioners, health management organizations, and, indeed, the entire health care delivery system.

    The need for the NLHEP is obvious. The incidence of COPD has risen so that it is now the fourth most common cause of death. Hospitalization rates are rising dramatically. Economic costs include $2 billion a year for oxygen alone, as shown in Table 1 below:

                  Table 1: 1994 Medical Costs for COPD

Hospital Care               $6,500,000

Professional Services     4,500,000

Medications                   2,500,000

Oxygen                          2,000,000

Nursing Home Care       1,500,000

                                                               TOTAL                 $17,000,000

Source: NHLBI Morbility and Mortality Chart Book, 1994.

Pulmonary rehabilitation is expensive. Lung volume reduction surgery is a subject of a major, highly expensive controlled clinical trial, and deals only with end stage disease. At best, lung volume reduction surgery, oxygen, and pulmonary rehabilitation, although highly valuable in selected patients, are only palliative therapy.

    The foundations for the NLHEP are found in the Lung Health Study. Briefly, the Lung Health Study enrolled 5,887 patients over the age of 35, but not yet 60. Subjects had to be smokers of more than 10 pack years, and have airflow obstruction, with an FEV1 of less than 70% of predicted and an FEV1/FVC ratio of < 0.7. The reduction in airflow was only mild in these relatively young patients. Twice as many patients were randomized to receive special care, including an aggressive smoking cessation program; one-third were randomized to receive usual care. Smoking cessation was advised in both groups. Both groups also were given an inhaled bronchodilator (ipratropium), an anticholinergic bronchodilator, with an excellent safety profile.1

    The results of the Lung Health Study were impressive. Smokers who quit had a slight improvement in airflow initially, followed by a modest decline, as seen below. Thus, at the end of 5 years, the airflow, as judged by FEV1, was only slightly lower than on entry. By contrast, those patients who continued to smoke had much more rapid declines on the pathway to symptomatic COPD. However, none of these patients reached the symptomatic threshold, which is usually an FEV1 of less than 1.5 liters per second.1 However, only 22% of patients who were randomized to receive special care actually stopped smoking throughout the 5 years of follow-up, compared with 5% who received usual care.

Sustained Quitters vs Continuing Smokers

    The other dramatic finding in the Lung Health Study was the cause of death, which is presented below:

 

The Lung Health Study:  Death Within 5 Years

Cause Special Care Usual Care Total
Lung Cancer 38 19  57
Cardiovascular Disease 25 12  37
Other 35 20  55
Total  98 51 149
Source: Anthonisen NR, et al.


There were 57 cancer deaths compared with only 37 heart attack and stroke deaths; 55 other deaths completed mortality statistics, and included many patients with other smoking-related cancers, such as cancer of the esophagus, larynx, uterus, pancreas, bladder, and colon.1 In a subsequent follow-up, 50 additional lung cancers have been identified. Thus, more than 2% of the patients with only mild to moderate airflow obstruction also had lung cancer. Those who developed lung cancer were the heaviest smokers, approximating 30 pack years.

    As a result of the successful Lung Health Study, a workshop was organized by the Lung Division of the National Heart, Lung, and Blood Institute in 1995. Results of this meeting were published last year.2 A new national strategy for the identification and treatment of COPD was envisioned by the workshop. Efforts were aimed at involving all primary care physicians in discouraging the starting of smoking, and in controlling occupational exposures. Although the workshop advised increased efforts at preventing smoking initiation, it was recognized that the powerful forces of the tobacco industry made this unlikely, so smoking cessation for those already addicted to nicotine would also be required. The NLHEP showed that when smoking cessation was achieved, the course of quitters was nearly always beneficial by slowing the deterioration of lung function. These results showed that success in smoking cessation could protect lung function in a group at high risk of development of progressive decline in FEV1 as a prelude to symptomatic COPD.1

    The cost of primary prevention and early detection would be offset by decreased health care costs, the conference concluded. AFormer smokers have lower health care costs than nonquitters, within 4 years of stopping.@2AIf all MCOs (managed care organizations) implement smoking cessation programs, then all will benefit, irrespective of patients switching@2 from one HMO to another.

    Early detection efforts should be implemented to track patients= smoking and occupational histories and to offer spirometry in all primary care physicians= offices. Today, there are approximately 200,000 primary care physicians who see the great majority of smokers each year. These patients are simply not seen by pulmonologists, who only number 10,000.

    In addition, it was recognized by the conference that the presence of airflow limitation was a powerful indicator of comorbidity and mortality from other causes, especially lung cancer, heart attack, and stroke. It was hoped that this new health care initiative could have a major impact on health by involving primary care physicians in the detection of risk of the four most common causes of death in this country. Such early detection and intervention focusing on smoking cessation and the use of drugs to reduce inflammation in the airways could reduce the premature morbility and mortality associated with COPD. Simultaneously, by also identifying patients at risk of lung cancer, heart attack, and stroke, a major new health care initiative is possible. Educational programs for all primary health care practitioners, the public, third-party payors, and health care administrators would be necessary.

Why should the NLHEP be supported by the health care industry?

    Pulmonologists do not see smokers or other patients with asymptomatic airflow obstruction. Yet, 70% of all patients see a physician for some health problem every year. The majority of the patients see primary care practitioners, nurse practitioners, and physicians assistants. When patients are found with COPD that does not respond to the interventions offered by the primary care practitioner, referral to a pulmonologist will be appropriate. Since patients with airflow obstruction who are heavy smokers have at least a 2% chance of having lung cancer, which can be detected by chest x-rays, CT scans, sputum cytology, and newer bronchoscopic techniques, more referrals to find and treat lung cancer will result. It is now time to reopen the issue of lung cancer identification in a high-risk population.3-4

Why should industry support the NLHEP?

    Encouraging the identification of the undiagnosed population of COPD patients, estimated to be at least 15 to 16 million persons, would be important. This could expand the market for bronchoactive and anti-inflammatory drugs, early in the course of disease, which could prevent or forestall premature morbidity and mortality. Participation of the public as well as physicians in a grassroots nationwide education program was encouraged by the NLHEP.

Why should HMOs support the NLHEP?

    The prevention of premature morbidity and mortality and the provision of better care of patients is the right thing to do. In addition, providing less costly care and eliminating the need for oxygen, pulmonary rehabilitation, mechanical ventilation, lung volume reduction surgery, or nursing home care would have obvious economic advantages. Identification of patients also at high risk of lung cancer, heart attack, and stroke would be additional advantages. HMOs will need to offer comprehensive smoking cessation programs for all smokers with airflow obstruction, because of their extremely high risk of premature morbidity and mortality from the four most common causes of death. Here is where a special investment in smoking cessation will have a major payoff.

KEYS TO SUCCESS

    The keys to success will be both the public=s and the health care industry=s perception of need. Practical spirometers are needed for all primary care physicians= offices and clinics. Fortunately, as a direct result of the NLHEP, industry has come forward with a new generation of simple, handheld devices, which measure the two important parameters in spirometry: FEV1 (the flow test) and FVC (the volume test). ATest Your Lungs, Know Your Numbers@, has become the battle cry of the NLHEP. Whether or not early identification and intervention can succeed, and what cost savings will result, will be the subject of future prospective trials. Two fundamental questions asked by the NLHEP are as follows:

1.    If the early diagnosis of COPD is possible, is it necessary? Obviously, it is necessary since COPD is the only killer in the top 10 causes of death whose incidence continues to rise. The growing problem of COPD in our aging population is creating a tremendous economic burden to health care resources. Identification of patients at risk of other major disease states offers additional value.

2.    If the early diagnosis of COPD is necessary, is it possible? Yes! Simply by measuring spirometry in all smokers over the age of 40, and in all patients with symptoms of cough, shortness of breath, sputum, or wheeze, in some 15 to 16 million Americans who do not know that they have airflow obstruction and could be identified. Recent data from the third National Health and Nutrition Examination Survey indicate that only 25% of people with spirometric abnormalities in a random population actually had a diagnosis of chronic lung disease.5 Thus, the challenge for the future is obvious. Successful implementation of the NLHEP creates a new vision for health promotion and disease prevention in the future.

The Case Manager=s Role in the NLHEP

    The foundations of the NLHEP and the recommendations of its Executive Committee, strongly suggest that all case managers should facilitate having simple spirometry done in all smokers over the age of 40, and in anyone with symptoms of cough, dyspnea, wheeze, or excess mucus. By doing so, patients who are susceptible to the damaging effects of tobacco may be identified in the presymptomatic and early stages of disease. These patients may be much more motivated to stop smoking than previously believed, since they will recognize their increased risk, not only of COPD, but of related disorders. Many symptomatic patients and their physicians do not realize that moderate or even severe airflow abnormalities may be present. Coupled with new approaches in dealing with nicotine withdrawal, success in preventing premature morbidity and mortality from a variety of causes is a realistic possibility. The case manager can play a key role in this new health care movement.

The Uniqueness of the NLHEP:

    Unlike the National Hypertension, Cholesterol, and Asthma Education Programs, which received millions of dollars of support from the National Heart, Lung, and Blood Institute, the NLHEP is a private initiative with private funding. However, the NLHEP enjoys the sponsorship of many societies, including the American Association for Respiratory Care (AARC), American College of Chest Physicians (ACCP), the American College of Physicians (ACP), the American Osteopathic Association (AOA), the American Thoracic Society (ATS), the Society of General Internal Medicine (SGIM), American Association for Cardiovascular and Pulmonary Rehabilitation (AACVPR), and the American College of Allergy, Asthma, and Clinical Immunology (ACAACI). The NLHEP is also endorsed by the National Cancer Society (NCS), the National Heart, Lung, and Blood Institute (NHLBI), and the National Institute of Occupational Safety and Health (NIOSH). With such a broad base of support, the NLHEP should be able to achieve its ambitious objectives.

References:

1.    Anthonisen NR, Connett JE, Kiley JP, et al. The Lung Health Study Research Group. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. JAMA 1994;272:1,497-1,505.

2.    Petty TL, Weinmann GG. Building a national strategy for the prevention and management of and research in chronic obstructive pulmonary disease. JAMA 1997;277:246-253.

3.    Petty TL. Lung cancer screening. Compre Ther 1995;21:432-437.

4.    Strauss GM, Gleason RE, Sugerbaker DJ. Screening for lung cancer. Another look; a different view. Chest 1997;111:754-768.

5.    Petty TL, Gagnon RL, Lydick E. Prevalence and severity of airflow obstruction by age, gender, and ethnicity, and smoking status: analysis of spirometry data from a statistical sample of the U.S. population. Chest 1998;114:266S.

Thomas L. Petty, M.D., is chairman of the National Lung Health Education Program and professor of medicine, University of Colorado Health Sciences Center, Denver, Colorado.

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