How a Multidisciplinary Approach Enhances COPD Management

Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous disease that has been a leading cause of hospital admissions and death in the United States and around the globe. Due to its several associated phenotypes, patients with the condition require individualized care and management. New research illustrates how a multidisciplinary approach to COPD management can help better identify patients who may benefit from advanced treatments.

“Multidisciplinary approaches to care have become more of a mainstay across medicine,” says Umur Hatipoğlu, MD, the inaugural director of the Center for Comprehensive Care in COPD in Cleveland Clinic’s Department of Pulmonary Medicine and senior author on the paper. “In pulmonary medicine, a multidisciplinary approach has become the preferred method for managing interstitial lung disease. We felt that this approach could also provide significant value in recognizing and managing COPD. Given that many patients with COPD are eligible for therapies but do not receive them, our goal was to reduce this gap in care by involving specialists from various fields to enhance patient care.”

Dr. Hatipoğlu says that a multidisciplinary COPD care team at Cleveland Clinic typically includes general and interventional pulmonologists, thoracic surgeons, radiologists, respiratory therapists and advanced practice nurses. The team meets monthly to discuss data from selected patients with advanced COPD to come up with a consensus diagnosis and management strategy.

Methods

The retrospective cohort study included 510 patient cases of COPD between November 2015 and December 2022. Of those cases, 85 patients were found to be appropriate candidates for lung volume reduction surgery (LVRS), and 36 of those patients underwent the procedure.

“We compared the outcomes of 39 patients between 2004 and 2015 who underwent LVRS prior to multidisciplinary evaluation with the 36 patients who underwent the procedure after multidisciplinary evaluation discussions,” explains Dr. Hatipoğlu.

The group found that patients in the post–multidisciplinary evaluation cohort experienced improvement in mean ± SD FEV₁ of 0.23 ± 0.38 L and mean ± SD reduction in RV by 0.78– 0.98 L at six months after surgery. These were similar to the improvements found in patients before multidisciplinary evaluation (P = .52 and P = .085, respectively).

“Multidisciplinary collaboration has been a major priority at Cleveland Clinic for a while, so the lack of difference could represent the existing institutional culture of communication between different disciplines,” says Dr. Hatipoğlu. “Essentially, implementing the evaluation meetings may have just formalized and facilitated an exchange of clinical assessments that already existed.”

The group also looked at 202 patients who were referred for bronchoscopic lung volume reduction (28 patients underwent the Zephyr valve implantation procedure). They found a statistically significant improvement in pulmonary function test parameters, including FEV₁, FVC, RV and total lung capacity before and six months after the procedure. The mean ± SD 6MWD for this group improved from 245 ± 89 m to 277 ± 80 m, but this improvement did not achieve statistical significance (P = .079).

“The vast majority of the patients in the study were deemed not to be candidates for a lung-volume-reduction surgery because of anatomical, physiological or phenotypical reasons,” explains Dr. Hatipoğlu. “However, while we saw improvements in the patients who were candidates for surgery, the post-surgical improvements were not that different from what we were seeing before the multidisciplinary evaluations. Where we did see the impact of the multidisciplinary evaluations was in the management of patients with advanced COPD. Since few patients qualify for lung volume reduction, improved management may have a greater impact by helping more patients.

Provider perspectives

In addition to the surgical treatments, the group found that there were several other management recommendations made to patients. These included pharmacotherapy recommendations and adjustments, referrals to pulmonary rehabilitation, smoking cessation programs and weight loss programs, lung transplantation, and clinical trials. These managements were considered optimal in accordance with GOLD guidelines, with no specific recommendations for 274 patients (53.7%).

“Because there is so much evaluation and reevaluation involved with managing advanced COPD, we felt that it was important to understand what kind of impact the multidisciplinary evaluations have had on the provider side of things,” says Dr. Hatipoğlu. “We surveyed members of our COPD Center about their experience with the multidisciplinary evaluations and whether they felt it was helpful.”

The group received 34 individual responses, mostly from pulmonary staff physicians (44.1%) and physicians in training (23.5%). Nearly half (44.1%) of the respondents relatively new to the multidisciplinary evaluation meetings (0–2 years of experience), and 26% of respondents were part of the multidisciplinary evaluation since it began in 2016.

More than 70% of respondents felt that their knowledge about advanced COPD had improved and their confidence in taking care of patients with COPD was very high (extremely or very confident) since the advent of the multidisciplinary evaluation. The majority (92.2%) felt that multidisciplinary evaluation discussions improved the time to procedure in eligible patients with advanced COPD. Furthermore, 25 respondents (73.5%) reported improved patient satisfaction.

“On the survey, the respondents who were on staff before the multidisciplinary evaluation discussions noted that their primary means of contact with other members was direct communication via telephone calls, e-mail, or staff messages through the electronic medical,” says Dr. Hatipoğlu. “This further supports the notion that even before the formal evaluation discussions, there was still quite a bit of informal communication across specialties.”

COPD care at Cleveland Clinic

Dr. Hatipoğlu believes that the COPD program at Cleveland Clinic has several factors that make it unique. He highlights the program’s strong ties with lung transplantation and interventional pulmonology. Several physicians and surgeons involved in COPD evaluation are also part of these programs.

“Our study shows how multidisciplinary COPD evaluations can benefit both the patient and the provider,” explains Dr. Hatipoğlu. “Since only a small number of patients with advanced COPD are eligible for advanced interventions, the importance of effective management becomes that much greater. These multidisciplinary evaluation meetings have helped give providers a better understanding of the disease and care, reduced treatment times and improved satisfaction.”