The impact of the diseases that fall under the umbrella of COPD — chronic bronchitis, emphysema, asthma and cystic fibrosis — is enormous for the home medical equipment industry.
More than 14 million Americans have been diagnosed with chronic obstructive pulmonary disease, and it is estimated that millions more remain undiagnosed. COPD claims the lives of 120,000 Americans every year, and is one of the only chronic diseases with increasing prevalence and growing mortality rates. Health care expenditures for the disease were $37.2 billion in 2004.
Knowledge Is Power
Early identification of COPD, followed by treatments like long-term oxygen therapy to slow its progression, has been the recommended approach since the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report was issued in 2001. Fortunately, the push for early diagnosis has made an impact, says Bob Messenger, RRT, clinical manager of respiratory products for Invacare Corp.
“The education has been to get physicians up to speed on the importance of doing early spirometry in their offices, and those that have adopted it have been very successful,” he says. “In fact, they have reported diagnosing about twice as many patients as they had when they hadn't adopted this model.”
Yet, there are challenges to early identification. “The diagnosis and medical management of COPD has improved significantly over the last few years but there is still room for improvement. Part of the challenge in diagnosis and management is that COPD is a disease that develops over many years,” explains Joseph Lewarski, BS, RRT, vice president of clinical and government affairs for Inogen.
“Often the early symptoms are discounted or overlooked by patients, and without additional testing such as basic pulmonary function testing, the early presence of disease can be overlooked.”
Bonnie Douglas, Chad Therapeutics' director of strategic sales and marketing, agrees. “Even with increased awareness, many sufferers are reluctant to report their symptoms. Smokers often believe they just have a ‘smoker's cough,’ and those with shortness of breath might think it's just a symptom of getting older or being ‘out of shape,’” she adds.
The benefits of early diagnosis, though, are numerous.
According to Douglas, early diagnosis and treatment often result in longer, more active lives for COPD patients since they can learn strategies to live longer.
“In the case of smokers, who account for the majority of COPD patients, persuading them to quit stops further lung damage,” she says. “While it is difficult for someone diagnosed with COPD to come to terms with their disease, education can begin earlier. Patients who learn the importance of good nutrition and exercise have a much better chance of living a normal life for a longer period of time.”
Lewarski adds that there is some reversibility of certain components of COPD that early identification and intervention can affect. Likewise, it is beneficial for the irreversible components.
“For disease components that are not reversible, early diagnosis and treatment can dramatically slow the disease progression, and through effective symptom management, reduce the risk of infections and greatly improve the quality of life for persons with COPD,” he says.
Jacki McClure, BS, RRT, director, Med Respiratory Network, The Med Group, says the goals of early identification of COPD are similar to those of the group's COPD Chronic Care Pathway: to improve the patient's activities of daily living, and to decrease unscheduled physician office visits, emergency department visits and hospital admissions due to decreasing acute exacerbations of the patient.
Keeping Patients Active
Fortunately, recent advancements in technology are allowing those with COPD to experience a more active and independent lifestyle.
“New oxygen technologies focusing on portability help COPD patients become more active and achieve freedom and a lifestyle much closer to life before COPD,” says Lewarski. “This new level of activity and exercise will undoubtedly play a role in improved disease management.”
McClure says the improvements in ambulatory oxygen — such as those provided by Inogen's Inogen One and the home filling systems offered by Chad and Invacare — now provide more options for patients regarding ambulation.
This is good news for today's COPD patients who have a strong desire to be more active.
“If you go to a Better Breathers club or a pulmonary rehab group, clearly the focus is on activity and exercise,” says Messenger. “Yet, studies show four out of five patients feel they don't have enough oxygen and have to ration their portable oxygen to meet their activities.”
Messenger adds that is one reason why there is a current focus on small, portable oxygen delivery systems. “[The emphasis] is on the development of systems that provide the patient with true independence so they have an unlimited supply of ambulatory oxygen and do not have to wait for a delivery by their oxygen supplier,” he says.
The ability to receive the correct amount of oxygen is essential, and now, possible, notes Chad's Douglas. “Strides are being made in oxygen therapy every day with new technology [to help] ensure the patient is getting the prescribed oxygen dose whether they are active or at rest,” she explains, so patients “are much better able to consistently maintain beneficial levels of oxygen saturation, resulting in fewer instances of activity-related fatigue.”
Douglas adds that COPD patients want convenient, lightweight portability solutions that permit them to lead active lifestyles. Like Messenger, she says home filling systems are meeting an industry need because they can give COPD patients a long-lasting portable oxygen solution that allows them to “be active, social and away from home for extended periods.”
According to Joe Priest, president and CEO of AirSep Corp., much of the technology over the past 20 years has focused on providing a product that is more reliable, as well as enhancements such as quiet operation. While these are important but “subtle” changes, he says, the pre-eminent leap has been in portability.
“With the portable concentrator, we are literally providing something that is changing the patient's life — they literally control their entire destiny,” he says.
Because of the benefits of portability, Priest forecasts a renaissance in how COPD patients receive their oxygen. “I think over the next three to five years we will see the portable concentrator do for ambulation what the stationary concentrator did 20 years ago for in-home use,” he explains.
“Today, 80 percent or more of home oxygen patients are on oxygen concentrators. My prediction is in the next three to five years you will see 80 percent of the ambulatory patients on portable concentrators.”
Dave Henry, RRT, respiratory education coordinator for Sunrise Medical, says conserving devices are also helping patients stay active and ambulatory. “Conserving devices really take care of making sure the patient's oxygen level stays stable and that the patient is conserving oxygen with [fewer] tanks involved,” he explains.
The Right System
Although new drugs have been developed for COPD, says Invacare's Messenger, oxygen therapy is the focus of prolonging life for these patients. “Oxygen therapy is the only therapy that has been shown to date to prolong life in COPD,” he says.
“It is great that the market has moved in the direction that it has. It has forced everybody to be competitive, and [now there are products] that are truly designed with the patient's best interest in mind — something small and lightweight and unlimited in terms of supply.”
He emphasizes, however, that the patient's best interest must be considered in the choice of system as well as function and design. He notes that HME providers need to talk to their customers to determine how active they are and to understand their lifestyles. For example, do they travel? Or do they have arthritis, which could impact their ability to operate small buttons and knobs?
“You can't just show up with one system and try to pigeonhole your patient into using a particular product when that product may not be right for them. That's foolish,” says Messenger.
“This is a disease that progresses, so the products need to be designed in such a way that it is easy for patients to be able to see what they're doing and easy for them to be able to make adjustments.” For example, he says, knobs have to be large and easily grasped, “and because we are talking oxygen, [products] need to be light in weight.”
Henry of Sunrise adds that there will be certain limitations with products that are designed to be small. While portability can be good for the patient, “again, the biggest issue is being aware of the patient's limitations,” he advises. “HME providers should not try to fit everybody into that one mold.”
For most patients, the experts agree, it is about taking away excuses and encouraging use. “If patients get on oxygen and have the ability to sustain their current level of activity and the current health of their lungs for a longer period of time, I think … we could end up finding that not only earlier diagnosis but earlier use by patients might increase because they don't find it quite as limiting,” says Priest.
Today's new products certainly offer COPD patients options and reliable sources of oxygen that enable them to live active and healthy lives.
“It is too early to tell — and the data is hard to quantify in home care — but anecdotally, I think we are improving patient care and the quality of life for persons with COPD,” says Inogen's Lewarski. “Ask a COPD patient who gets to fly for the first time in years to a new vacation destination while wearing oxygen on the plane and throughout the trip. I think an achievement like that speaks to the impact we are having on patient care and quality of life.”
Experts Interviewed
Bonnie Douglas, director of strategic sales and marketing, Chad Therapeutics, Chatsworth, Calif.; Dave Henry, RRT, respiratory education coordinator, Respiratory Products Division, Sunrise Medical, Longmont, Colo.; Joseph Lewarski, BS, RRT, vice president of clinical and government affairs, Inogen, Goleta, Calif.; Jacki McClure, BS, RRT, director, Med Respiratory Network, The Med Group, Lubbock, Texas; Bob Messenger, RRT, clinical manager of respiratory products, Invacare Corp., Elyria, Ohio; Joe Priest, president and CEO, AirSep Corp., Buffalo, N.Y.
Is COPD Disease Management Right for You?
Disease management, which exists in many forms, certainly can have a positive influence on patients with chronic obstructive pulmonary disease. But, is it something home medical equipment providers should invest in, particularly since it is not always a reimbursable service?
“I think a little industry secret is that HME providers have long been providing various forms of disease management. This happens every time a respiratory therapist discusses a patient's disease and treatment, each time we communicate with a physician to change or correct an order, etc.,” says Joseph Lewarski of Inogen. “Developing more organized disease programs that someone is willing to pay separately for is another issue, but I think many HME providers are excellent and appropriate points of care for disease management and should pursue this line of service.”
According to Bonnie Douglas of Chad Therapeutics, HME providers should create disease management programs. “Often, payers will recognize additional reimbursement for such programs when outcomes provide decreased hospitalizations and emergency room visits,” she says. “Adding excellent COPD programs can set them apart from their competition, increase referrals and increase revenue in preferred product lines, while providing better care for the COPD patient.”
On the respiratory side, one of the dilemmas in home care is that respiratory therapists are not reimbursed for their services directly, notes Dave Henry of Sunrise Medical. “These therapists are paid by the revenues of the company,” he explains. “In other industries like physical therapy, physical therapists can bill directly for their services.”
Invacare Corp.'s Bob Messenger sees a distinct marketing benefit to COPD disease management programs.
“Having a program such as this allows you to hold yourself up as being a true clinical company — an extension, if you will, of the physician,” he says. “This also gives you the opportunity to intervene with your patients so that they are more compliant with their oxygen therapy. They will be more active and, in the end, those increased levels of activity and compliance with oxygen therapy should result in those patients being on oxygen therapy a longer period of time.”
Messenger goes on to say that a “little work at the back end is going to result in gain for the business as well as offer clinical benefits to the patients.
“I am a big advocate of the whole idea of disease management programs and patient education in general. As we evolve as a health system, we'll become less reactive and more proactive with our approach to care,” he says. “As we do, disease management will become better defined and play a bigger role in the health care industry.”
