Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Wednesday, December 12, 2007

Don’t Hold Your Breath-Changes Needed in Lung Health Education- Rachel Hill

The National Lung Health Education Program (NLHEP) is a group of professionals including doctors, respiratory therapists, and esteemed members of the American Association of Respiratory Care (AARC) who are dedicated to increasing the awareness of Chronic Obstructive Pulmonary Disease (COPD) across the spectrum of healthcare and the general population. They utilize pamphlets, speaking engagements, and documented research to help further their goal. I am going to argue that the NLHEP has failed in its goal to create a successful program of intervention and early detection of COPD in its early stages among the population at risk, and to increase awareness of COPD within the general public or among healthcare professionals. The NLHEP has also been unsuccessful in raising awareness among primary care physicians about the use of simple spirometry testing as a tool for early detection and diagnostic criteria of COPD. And focus even less on early intervention of those at risk for COPD. This is the primary method to which this institution states it uses to achieve its goals of increasing awareness, early intervention, and early diagnosis of COPD. Their goals of increasing awareness and promoting early screenings, while great ideas, are not being executed in the best possible methods.

The NLHEP campaigns have traditionally not focused on any specific population. Their target population as stated in the mission statement is “all smokers, former smokers, and people who are regularly exposed to environmental tobacco smoking or occupational exposures” as well as, “physicians, all health care professionals, patients and the public” (6). The population target is just too broad and expansive with each group requiring specific needs in order to have any form of success within each target group. Physicians require a more medical message of screening and diagnosis using statistics and peer reviewed studies. The general population message needs to focus more on awareness and risk factors. By trying to figure out the best most understandable message for each group instead of focusing on one single message that is either too elementary or too complex, they would be more successful in having more people being aware of COPD in the dimension that makes the most sense for each group. For Example: A person with no medical training does not need (or want) to know what the specific diagnostic numbers in the spirometry testing formally point to the diagnosis of COPD. Nor does a physician need someone telling them what COPD stands for and what diseases encompass COPD.

Based on Social Marketing Theory which is basically figuring out what people want and understand and tailoring the message to that target population. We can not deliver a message to physicians in the same manner as we would address the public. Physicians require a different language and tone in order to capture their attention (generally more scientific and statistical) than the general public which has little (if any) medical training and varying educational backgrounds. Not only does each group have specific requirements regarding message delivery, they also have different outlooks about lung health (2, 7). Physicians are generally ready and able to promote lung health, while the general population does not see lung health as an overt problem until symptoms arise. This is partly shown by the number of late stage diagnoses of COPD and emergency room visits for shortness of breath by the general public whom if diagnosed earlier would be better managed (8). Among people aged 45-54 years 32% had an unscheduled emergency doctor’s visit for their COPD and 27% among the same population had emergency room visits for COPD. Had these people been diagnosed earlier they would have been better managed and not needed so many emergency services. COPD is not getting diagnosed in this population who is most at risk until they exhibit such severe symptoms it warrants emergent trips to a physician or the ED. This is proof that the word about COPD is not out in public and the message is obviously not clear, people continue to remain in denial of COPD until it is too late.

People generally lack a self-efficacy around their lung health status, especially the smokers. They tend to feel that the damage is already there and they can do nothing to change it. There is a nihilistic attitude among smokers and even among healthcare workers about the status of their lungs. The NLHEP campaign messages should emphasize that behavior change can make a difference in the status of their lung health, not the nihilistic attitude that you did this to yourself now you have to deal with it. Once people start to realize that it is not too late to quit smoking or make a lifestyle change and they will still make a positive impact on their health, I think people will develop a more positive attitude towards taking control of their lung health.

Physicians tend to focus on secondary prevention (or diagnosis and cessation) and in the general population it is primary prevention that is needed specifically around the area of what COPD is and ways to prevent it (such and not smoking). There is no mention of primary interventions of COPD within the NLHEP.

People need to realize that COPD starts up to 20 years prior to symptoms. Our bodies are amazing in that they will compensate as long as they can, functioning at a lower level (of oxygen) until something happens and it just can not compensate anymore. The importance of a primary care physician being able to do a simple spirometry is that the physician is able to earlier diagnose COPD and act through early interventions (education, medication, etc…) so our bodies do not have to keep compensating. This is part of the mission behind the NLHEP however; there is no plan within the mission for reimbursement for spirometry testing. The cost of doing this test, while relatively small, would just be another added expense to the overhead unless there was a way to reimburse for the test. Currently insurances do not reimburse for spirometry screening, only spirometry as a means of diagnosing symptoms. If it were possible to conduct this simple test more often, we would be able to diagnose earlier and provide earlier intervention (1). There have been a few studies that show that when a diagnosis of COPD is coupled with intervention of smoking cessation there is a much higher rate of success quitting smoking. NLHEP encourages health care professionals to use simple spirometry to conduct prescreenings of patients, primarily those at risk, in the same way we use mammography, for early detection of COPD. This is a great idea, however, they go on to only support certain brands of spirometers fail to propose ways for physician’s offices to be reimbursed for the expense of doing the test. Because of the challenges physicians face with reimbursement for spirometry testing, only 20% of primary care offices (in the US) even have a spirometer to screen patients (4). This means that if a physician would want to screen a patient (or test a patient) they would have to send the patient out to another facility for testing, wait for the test to be scheduled, wait for the results to be read by the physician at the referral facility, wait for a copy of the test to be sent, schedule a follow up visit or follow up testing, the potential for this process to take months is not unusual. Also, the test that would be done would be a full pulmonary function test, a very time consuming and expensive test of which all portions may not be necessary to diagnose and stage COPD compared to the simple spirometry. The initial cost of a spirometer and its set up (computer software, disposable mouthpieces, and other necessary equipment) is expensive estimated at $2000 and up according to several medical device companies including medicalresources.com. Why would a physician spend the money out of pocket with no means of reimbursement? Looking closer into what the physician would want/need in order to comply with the goals of screening all patients (at least those most at risk) for COPD the two things most important to the physician is autonomy in which spirometer they feel most comfortable using. Forcing someone to use equipment they do not like or do not understand is not helpful is furthering the goal of getting this particular population to use the spirometer. The other issue is monetary. While we all would like to see as many patients screened for COPD as possible, if the physician is going to lose money on the project, they can not be expected to give their services away for free. Would you do that? The importance of financing this screening program with the insurance companies, Medicare but more importantly the private insurances and Medicaid is fundamental in the program’s success. We are aiming to identify these people with COPD in early stages, before they qualify for Medicare which is why the private insurances and Medicaid is most important.

NLHEP needs to rally with other groups to start lobbying for more reimbursement coverage for screening of COPD with simple spirometry, especially with Medicare. By working to get more coverage, more and more physicians will be able to afford to test their patients earlier and physicians will be more likely to consider having a spirometer in their office.

The NLHEP has many professional affiliates including the American Thoracic Society, American College of Physicians, American College of Allergy, Asthma, and Immunology, The National Heart, Lung and Blood Institute, and several other prestigious groups (6). Among their affiliates there are several missing key affiliates. Those would be the grassroots affiliates by using community leaders as “elite opinion”. By using these significant people (such as a clergy person, school principal, or social action leader) within their target audience groups (neighborhood, religious, or cultural communities, for example) for their message of prevention and early intervention there is a higher chance of getting the message of COPD translated within that community. This is the institutional diffusion model (7). By using the elite within the community they are able to translate behavior throughout the institution including policy changes, and social norms which in turn affects individual behavior (such as smoking) (7). A person’s attitude towards a specific behavior is based on the person’s perception of social norms associated with that behavior. This means that by getting grassroot affiliates (especially the elite) involved in helping to pass on the word of lung health chances are more likely that people in that target group would be more likely to listen.

Using combinations of Social diffusion models which focus on changing public norms and Institutional diffusion models which focus change from a higher perspective we can incorporate many different uses of grassroot community leaders (Social Network Theory, Social Marketing Theory, Diffusion of Innovations). We can change policy to effect change of individual behavior as well as using social networks to invoke behavior change (7).

Social Networks are a way grassroots organizations can play a vital role in the passage of health promotional messaging. It starts out with just one person being diagnosed with COPD and they tell their family/friends to get themselves checked out before it’s too late. Those people pass it on to their friends/family and pretty soon the group gets larger and larger. People generally belong to more than one community (neighborhoods, jobs, religious, social circles). As more individual communities become more aware of COPD and testing their lungs, the faster the information gets spread. By utilizing a small amount of strategically placed resources we could have a larger influence over a larger population than by just utilizing physicians alone. The use of chain reaction techniques and grassroots organizations could also raise awareness among populations who do not always trust the medical systems. This would work very well among the younger populations (under age 50) who do not necessarily think that they are at risk for COPD. And as we stated earlier, these are the people we need to focus on. This method, although slow moving, has the potential when planned correctly to be more effective and long lasting than the traditional “because the doctor said so” methods. This method is the same as any fashion trend. One person starts a habit such as dying their hair and before we know it everyone is dying their hair. Although a juvenile comparison, the comparison fits. People want to do what is popular. So the goal would be to make testing your lungs popular.

While the NLHEP has many great ideas, their process of implementation is drastically flawed. By applying a more varied method in the way they approach the different target groups they would probably get a more effective message across. They should support a physician’s choice in equipment, not mandate only certain brands. They should also collaborate with the more influential grassroot organizations to develop better strategies to notify and involve the general population in the process of education and intervention. Until the NLHEP opens its eyes to the flaws in its prevention and intervention messages and strategies, they will continue to be unsuccessful in their attempts to decrease the number of people dying from COPD.

References
1. Diagnosis of Airflow Limitation Combined with Smoking Cessation Advice Increases Stop Smoking Rate, Gorecka, D et al. Chest 2003; 123:1916-1923
2. Global Initiative for Chronic Obstructive Lung Disease, Executive Summary 2005, www.goldcopd.org
3. Mechanisms and Management of COPD, Chest/113/4/April, 1998 Supplement
4. Office Spirometry: Key to Ventilatory Assessment. The Clinical Advisor; July/August, 2002
5. Confronting COPD in America; Schulman, Ronca, Bucuvalas, Inc. Access at www.lungusa.org
6. The Early Recognition and Management of Chronic Obstructive Pulmonary Disease, Doherty, Dennis et al, National Lung Health Education Program, http://www.nlhep.org/
7. Edberg, Essentials of Health Behavior, Sudbury, MA Jones and Bartlett 2007
8. GlaxoSmithKline. COPD in America. The Burden of COPD. 2007 http://www.copdinamerica.com/burden.html

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2 Comments:

  • At December 13, 2007 at 7:32 AM , Anonymous Meg Gavaghan said...

    Rachel -- I agree with your argument regarding increasing funding for spirometry testing, but is there evidence that it is a useful screening tool or is it more useful as a diagnostic tool? I was just thinking about that based on our class discussion last week about the effectiveness of screening. Great topic!

     
  • At December 17, 2007 at 11:13 AM , Anonymous Anonymous said...

    Thank you! Actually Spirometry is not just diagnostic, if we were to screen people predominately at risk we can diagnose people in the stage of mild COPD which is where behavior change is most likely to happen and treatment can start prior to symptom based COPD which is usually not diagnosed until the later stages of Severe or Very severe. Once a patient is severe, there are many health complications that can be avoided had they been treated at an earlier stage such as Congestive Heart Failure (Left Heart Failure) which is secondary to low blood oxygen. Had we screened this patient and had started treatment earlier it would be possible to delay or prevent altogether the development of CHF.

     

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