Beta-Agonists, Anticholinergics, Inhaled Corticosteroids: Which, When, and Why? Overview

Overview

• 1 Case Presentation 1
• 2 PE and Lab studies
• 3 Dyspnea in COPD
• 4 Moderate COPD Meds
• 5 LA Bronchodilators
• 6 LABAs/Anticholinergics
• 7 Hyperinflation in COPD
• 8 Question
• 9 Poll
• 10 Summary
• 11 Case Presentation 2
• 12 Poll
• 13 Severe COPD
• 14 "Triple Therapy"
• 15 Question
• 16 Question
• 17 Case 2 Conclusion
• 18 Case Presentation 3
• 19 Maintenance Medications
• 20 Question
• 21 Oxygen Therapy
• 22 Case 3 Conclusion

References Resources

Please scroll down through the general topic overview and the CME activity-specific overview and then click on "I accept". Once you have registered/logged in and accepted this overview, you will see only the specific CME activity overview the next time you select any COPD CME-certified activity

STATEMENT OF NEED: COPD is a significant cause of morbidity and mortality worldwide [1]. According to various burden of disease analyses [2], COPD is the fourth-leading cause of death in the U.S. and worldwide and is projected to become the third-leading cause of death by 2020. In the United States, an estimated 16 million adults have been diagnosed with COPD [2]. Mortality from COPD has increased 22 percent in the past decade, due in part to an aging population.

COPD is associated with high utilization of health care resources, including frequent clinician office visits, frequent hospitalizations due to acute exacerbations, and need for chronic therapy. Primary care physicians are well positioned to make an earlier diagnosis of COPD and potentially improve outcomes in this disease with earlier intervention. However, a 2009 needs assessment of primary care physicians conducted by PennCME/BestPractice revealed the following gaps in disease management:

• Physicians often fail to identify patients with early signs of COPD.
• Physicians and their staff lack adequate training and confidence in the use of and interpretation of the results of spirometry in diagnosis and staging.
• Counseling about lifestyle changes for patients with COPD or at risk of COPD is inadequate, especially counseling and treatment to promote smoking cessation.
• Communications systems that can improve ongoing care are inadequately used.
• Physicians underprescribe safe, effective therapies and overuse ineffective therapies, contributing to exacerbation.
• Physicians lack awareness about evidence-based disease management guidelines.

TARGET AUDIENCE: Primary care physicians, physician assistants, nurse practitioners, and other health care providers and clinical practice teams involved in the care of patients with COPD.

EDUCATIONAL GOALS & OBJECTIVES: After participating in this educational initiative, learners are expected to:

• Improve timely diagnosis of COPD
• Change practice patterns to reflect current guidelines and best practices
• Minimize risk and improve management of comorbidities in patients with COPD
• Demonstrate improved knowledge and application of guidelines/best practices for treatment of patients with COPD
• Apply new knowledge to improve the organization of delivery of medical care in their practice setting; better integrate with community resources provided to patients; and provide culturally competent care to improve patient’s risk recognition and motivation to participate in health self-management

FORMATS & METHOD OF LEARNER PARTICIPATION IN THE PennCME/BestPractice COPD CURRICULUM LEARNING PROCESS:

• Clinical reviews in COPD present critical areas of knowledge in the disease organized in a coherent pathway, along with practical approaches to achieving best practices. This section provides a foundation and reference base for other featured interventions.
• Hot Topics are short, newsworthy articles in a focused area of the diagnosis or management of COPD. These articles are designed to engage the participant in the topic area and lead them to content that provides the opportunity for more in-depth learning.
• Interactive Minicases offer a valuable learning experience based on real-life scenarios of interactions between primary care physicians, the health practice team, and patients with COPD. This method of engagement allows participants to build their knowledge and competence as they engage and progress through case simulation of  both the clinical management of patients with COPD and some system-specific issues  in their practices. 
• Point-of-Care Search CME (PoC) includes structured, self-directed online learning on topics relevant to their clinical practice. Learning for this activity occurs through a reflective process in which physicians document the clinical question, cite the sources consulted, and identify the application of the learning to their practice.   
• Simulations place physicians in the active role of problem solvers, letting them learn critical skills in a practical setting. The Patient Simulator provides individually tailored learning, allowing physicians to Increase Competence by applying new knowledge to diagnostic and therapeutic challenges in a non-threatening clinical environment.
• Performance-Improvement CME consists of four phases. During the assessment phase, learners’ practice data is collected and assessed based on pre-determined evidence-based quality indicators. In the improvement phase, the learner is allowed meaningful time to make changes and improve practice based on a self-directed and structured improvement plan. A large number of targeted learning opportunities, interventions and strategies are provided during this phase. The evaluation phase allows for assessment of the impact of improvements made in the practice, using the same data collection and submission tools from the original assessment. Finally, reflection on the results of the practice-based performance improvement will establish an opportunity for the setting of future improvement goals.

FACULTY, AUTHORS, & CONTRIBUTORS:

Zalman S. Agus, MD, Editor-in-Chief Associate Dean for CME Emeritus Professor of Medicine Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania David M. Mannino, MD, Faculty Professor and Director, Pulmonary Epidemiology Research Laboratory Department of Preventive Medicine and Environmental Health University of Kentucky College of Public Health Lexington, Kentucky Jill A. Ohar, MD, FCCP, Faculty Professor of Internal Medicine and Director of Clinical Operations Section on Pulmonary, Critical Care, Allergy and Immunologic Disease Wake Forest University School of Medicine Winston-Salem, North Carolina Lewis Miller, MS, CCMEP, Chairman and Chief Executive Officer Chairman, BestPractice CPD, LLC Principal, WentzMiller & Associates Darien, Connecticut Mila Kostic, CME Director and Chief Learning Officer Director of CME Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania Katherine Wandersee, Medical Writer Medical Consultant and Writer Montclair, New Jersey Wendy Turell, DrPH, Editorial Director BestPractice CPD, LLC White Plains, New York Joseph E. Scherger, MD, MPH, Editorial Board Professor of Clinical Family and Preventive Medicine Director, San Diego Center for Patient Safety Medical Director, Quality Improvement Education Director, Quality Improvement in Correctional Medicine University of California, San Diego School of Medicine (USCD) San Diego, California

Matthew H. Rusk, MD, Editorial Board Associate Professor of Clinical Medicine Program Director, Primary Care Program Staff Internist, Division of General Medicine Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Dennis F. Saver, MD,  Editorial Board President and Staff Physician, Primary Care of the Treasure Coast Clinical Assistant Professor of Family Medicine Florida State University Vero Beach, Florida Peter J. Ziemkowski, MD,  Editorial Board Assistant Professor, Department of Family Medicine College of Human Medicine Michigan State University Clerkship Director and Physician/Faculty Michigan State University–Kalamazoo Center for Medical Studies Kalamazoo, Michigan Patricia M. Bomalaski, MSN, CRNP, Editorial Board Department of Medicine Penn Center for Primary Care Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Michael A. Rackover, PA-C, MS, Editorial Board Associate Program Director & Associate Professor Physician Assistant Program Philadelphia University Philadelphia, Pennsylvania Jesse A. Coale, PA-C, Editorial Board Assistant Professor Philadelphia University Philadelphia, Pennsylvania Denise Fantuzzi, Director of Operations BestPractice CPD, LLC White Plains, New York

DISCLOSURES OF PERSONAL FINANCIAL RELATIONSHIPS: It is policy at the Perelman School of Medicine at the University of Pennsylvania for individuals who are in a position to control the content of an educational activity to disclose to the learners all relevant financial relationships with any commercial interest that provides products or services that may be relevant to the content of this continuing medical education activity. For this purpose, we consider relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

The intent of this policy is not to prevent expert faculty with relevant relationship(s) with commercial interest(s) from involvement in CME, but rather to ensure that Penn CME-certified activities promote quality and safety, are effective in improving medical practice, are based on valid content, and are independent of control from commercial interests and free of commercial bias. Peer review of all content was conducted for all faculty presentations whose disclosure information provided to the Penn Office of CME was found to contain relationships that created a conflict of interest relative to the topic of their presentation. In addition, all faculty were instructed to provide balanced, scientifically rigorous, and evidence-based presentations.

The staff in the Office of CME at the Perelman School of Medicine at the University of Pennsylvania, Mila Kostic, and Zalman Agus, MD, have reported no relevant financial relationships with any commercial interests related to the content of these educational activities.

The following BestPractice CPD, LLC, staff member and medical writer have reported no relevant financial relationships with any commercial interests related to the content of these educational activities:  

• Wendy Turell, DrPH, Editorial Director
• Katherine Wandersee, Medical Writer

The following BestPractice CPD, LLC, staff members have reported the listed relevant financial relationships with commercial interests related to the content of thee educational activities:

• Denise Fantuzzi, Director of Operations, owns stock in Amgen and Vaxgen.
• Lewis A. Miller, MD, Chairman, is a consultant for Takeda Pharmaceuticals North America, Inc.

The following editorial board members have disclosed that they have no relevant financial relationships with any commercial interests related to the content of these educational activities:  

• Patricia M. Bomalaski, MSN, CRNP
• Matthew Rusk, MD
• Joseph E. Scherger, MD, MPH
• Peter Ziemkowski, MD
• Jesse A. Coale, PA-C

The following faculty and editorial board members have reported the listed relevant financial relationships with commercial interests related to the content of these educational activities. 

Faculty Name	Name of Commercial Interest	Relationship
David M. Mannino, MD	GlaxoSmithKline	Research and Consultant
	Novartis	Consultant
	Forest	Consultant
	AstraZeneca	Consultant and Speaker
	Pfizer	Research
	Boehringer Ingelheim	Research
Jill Ohar, MD	Advanced Life Support	Consultant, Speaker, and Advisory Board
	ATS Pharmaceuticals	Speaker
	AstraZeneca	Consultant, Speaker, and Advisory Board
	France Foundation	Speaker’s Bureau
	GlaxoSmithKline	Speaker’s Bureau
	Neo-Health Care	Speaker’s Bureau
	Pfizer	Consultant
	Prime Inc.	Consultant
	Sepracor	Advisory Board Member
Dennis Saver, MD	Boehringer Ingelheim and Genzyme	Consultant
	First Consult	Board Member
Michael A. Rackover, PA-C, M.S	GlaxoSmithKline	Spouse is an employee

Instructions for Obtaining CME Credit

To obtain Credit Certificate for CME-certified activities follow these steps:

• Review the topic- and activity-specific overview
• Complete the brief case-based pre-activity assessment
• Review the entire educational activity
• Answer all case-based questions in the post-activity assessment
• Complete the evaluation
• Proceed to view or print your certificate stored in your Personal Learning Center

Accreditation
These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the University of Pennsylvania School of Medicine and BestPractice CPD. The Perelman School of Medicine at the University of Pennsylvania is accredited by the ACCME to provide continuing medical education for physicians.

Designation of Credit
These activities have been approved for AMA PRA Category 1 Credit(s)™.

Disclosure of Commercial Support
Supported, in part, by educational grants from Abbott Laboratories,  Daiichi Sankyo, Inc., Genentech, Inc., GlaxoSmithKline, Lilly USA LLC, and Takeda Pharmaceuticals North America, Inc.

INVESTIGATIONAL AND/OR OFF-LABEL USE OF COMMERCIAL PRODUCTS AND DEVICES: The University of Pennsylvania School of Medicine requires all faculty to disclose any planned discussion of an investigational and/or off-label use of a pharmaceutical product or device within their presentation. Participants should note that the use of products outside FDA-approved labeling should be considered experimental and are advised to consult current prescribing information for approved indications.
The faculty reported that there will be no specific mentions of off-label and/or investigational use of products within their presentations.

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