Dr Sanjay Sethi on How Social Determinants of Health Affect Outcomes in Patients With COPD

By focusing on lifestyle modifications, providers are able to better treat patients with chronic obstructive pulmonary disease (COPD) and other comorbidities, said Sanjay Sethi, MD,professor and chief, Pulmonary, Critical Care and Sleep Medicine; assistant vice president for Health Sciences, Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, Buffalo, NY. In this interview, he discusses the complications of managing patients with multiple comorbidities that are not preventable. He notes that payers and providers need to place a stronger focus on patients after they suffer acute events along with addressing underdiagnosis to better treat patients with COPD and cardiovascular disease.

AJMC: Are there particular age groups that we should focus on when attempting to identify and treat comorbid cardiovascular disease in the COPD population?

Sethi: I think COPD generally starts in the 40s and 50s. That is the usual age. We don't have screening for cardiovascular diseases that are beneficial at this point. I don’t think it's not really a particular age group. I think it spans all age groups. Again, I think the most important intervention in that context still remains smoking cessation. Diagnosing it earlier and intervening earlier would be useful in those populations.

AJMC: Are there any population health initiatives that could help address the under treatment of comorbid cardiovascular disease and people with COPD?

Sethi: I am not sure of the specific population health initiatives that are really focused on this particular issue. In terms of lifestyle modifications, you will definitely help cardiovascular disease and you will also help COPD. I think that's important. There is a lot of interest now in social determinants of health and how that contributes to both chronic diseases like cardiovascular disease and COPD. I think those are the kinds of things we need to focus on. More lifestyle modifications. Obesity makes cardiovascular disease worse, but it also makes COPD worse. It also makes the diagnosis of COPD quite difficult because when they get obese they get short of breath and they don't know what's causing what. I think working on lifestyle modifications would deliver much more bang for the buck than any kind of treatments that we use for these conditions.

AJMC: How does multi-morbidity with COPD impact quality measures for organizations?

Sethi: I think the classic example is again the exacerbation concept. When you have exacerbations, hospitals get penalized. This is part of the readmission reduction program from Medicare. What they said was you need to reduce 30-day readmissions, which are below a certain level after a COPD. They added COPD to the diagnoses. The problem is more than half of those readmissions are not COPD related. They are related to other conditions. The more comorbidity you have in COPD patients, the more likely they are going to get readmitted after a COPD exacerbation. It may not be specifically preventable. That is one example. In general, if you are looking at improvement in quality, if you start looking at those kinds of measures, it becomes more challenging to really move the needle. In fact, some people have criticized this whole hospital reduction readmission because you really can move the needle only so much. These are chronic conditions. The path of physiology in these patients is permanent. Our current medications don't change that. So, you can only improve lung function so much. Those are limitations. Another multi-morbidity which really gets in the way is people with bad arthritis like osteoarthritis with COPD. That becomes a real challenge because you want them to stay active and you want to offer them rehab when you know that will improve the dyspnea, but again, it becomes a challenge because of the comorbid severe arthritis that they can't really ambulate much or exercise in any way. So, those are the kinds of challenges we come up with. That is going to definitely affect how these people's outcomes and quality measures are.

AJMC: In your opinion, what are the biggest unmet needs for those with concomitant COPD and cardiovascular disease? How can payers or providers best work to bridge this gap?

Sethi: There is still a fair amount of underdiagnosis. I think increasing awareness of the fact that they are coexistent, that they make each other worse, and therefore, in those patients who have the risk factors and symptoms, doing the appropriate testing is quite important. I think education is really, really important. The second one, I think, is really focusing on patients after a hospitalization, especially with COPD, and to some extent, maybe even with cardiovascular disease. It is really hard focusing on patients with COPD after a hospitalization because we know that they are going to be at increased risk.Those people you look at very carefully. Is there a concomitant cardiovascular disease that's not been paid attention to? Do we need to optimize that management? In my mind under diagnosis and a focus on patients after acute events to make sure that both COPD and concomitant cardiovascular disease are being addressed adequately.

AJMC: What are you working on in COPD that you're excited to share with others?

Sethi: Right now, from the research point of view, we are doing actual work in system biology of COPD. That is our bench work in the sense. For years, we've looked at mediators that are involved in COPD inflammatory molecules one at a time. But actually, that is not the way they work in a body they work as networks. We are now working with my core collaborator, a computer scientist, because he creates networks and we look at networks of molecules. With the omics abilities now we can get so much information on multiple molecules and then we can create these networks. We are trying to understand how they change in stable disease during exacerbations and how the progression of COPD. That is part of the exciting work we are doing. The second thing is focusing on the social determinants of health. Because COPD has progressively become a disease of the people who can least afford it. It's most common in rural areas in poor communities. We are working on the social determinants of health in the context of readmission reduction, but also in the context of chronic management. How do you optimize it? That is a couple of areas that we're working on right now.