Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting

Measure Specification

Despite major efforts to broadly disseminate the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and use of COPD performance measures across different specialty societies, diagnosis and management of COPD, and specifically prescription for long-acting inhaled bronchodilators, remains suboptimal. Although spirometry use has increased, it remains underutilized to confirm airflow obstruction and accurately diagnose COPD.

Studies show proper COPD diagnosis with spirometry is done on just over half of patients in the US and Canada. A study of physician-diagnosed COPD patients hospitalized for exacerbations found that 22% of patients did not have COPD upon spirometry testing. Treatment of presumed COPD without accurate diagnosis and understanding of true etiology of symptoms results in patients not receiving medication that would improve symptoms and quality of life, prevent exacerbations and reduce costly use of emergency and hospital services.

Patients may be exposed to adverse effects of unneeded medication and or delays in true diagnosis and management of another condition increasing overall cost of care. Several recent studies emphasize the association between both under- and over- diagnosis of COPD with increased respiratory symptoms and health care utilization. Studies show a wide range of deficiencies in adherence to guidelines regarding long-acting inhaled bronchodilator use across different settings.

Underuse of bronchodilators were found related to hospital readmissions and to increased total costs of services when compared to patient care adhering to GOLD guidelines. Suboptimal COPD management has implications for severity of illness, disease progression, patient quality of life and health status, exacerbations (and associated costs) and mortality.

Improved adherence to COPD management guidelines, specifically appropriate use of long-acting inhaled bronchodilators, has the potential to improve clinical outcomes and cost of care related to COPD. As a result, we believe this measure will continue to increase appropriate long-acting inhaled bronchodilator use, improving patient management and total costs of COPD.

Although recent guidelines state dual long-acting bronchodilator medication are “preferred” for treatment initiation, patients well-controlled on one long-acting bronchodilator do not necessarily require escalation. For this reason, prescription of one or more long-acting bronchodilators is all that is required to meet the measure.

Spirometry: Recommendation 1: ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (Grade: strong recommendation, moderate-quality evidence)” (Qaseem, et al.

, 2011). “COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis in this clinical context; the presence of post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD in patients with appropriate symptoms and significant exposure to noxious stimuli.

Spirometry is the most reproducible and objective measurement of airflow limitation. It is a noninvasive and readily available test” (GOLD 2022). Inhaled Bronchodilators: In patients with chronic obstructive pulmonary disease who complain of dyspnea or exercise intolerance, we recommend long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy (strong recommendation, moderate quality evidence) (Nicci et al, 2020).

LABA and LAMAs are preferred over short-acting agents except for patients with only occasional dyspnea (Evidence A), and for immediate relief of symptoms in patients already on long-acting bronchodilators for maintenance therapy. When initiating treatment with long-acting bronchodilators, the preferred choice is a combination of a LAMA and a LABA. In patients with persistent dyspnea on a single long-acting bronchodilator treatment should be escalated to two (Evidence A).

The combination can be given as a single inhaler or multiple inhaler treatment (GOLD 2023).

There are 2 Submission Criteria for this measure: 1) Patients diagnosed with COPD who have documented airflow obstruction (FEV1/FVC < 70%) as measured by spirometry in the medical record. AND 2) Patients diagnosed with COPD who have documented airflow obstruction (FEV1/FVC < 70%) and are symptomatic, who were prescribed a long-acting bronchodilator.

This measure contains two submission criteria which together ensure that the proper evaluation and treatment is provided for patients with COPD and that patients without COPD are not provided inappropriate therapy. Submission Criteria 1 evaluates whether spirometry was performed for patients diagnosed with COPD and results confirming airflow obstruction are documented.

Submission Criteria 2 evaluates whether a long-acting inhaled bronchodilator was prescribed for COPD patients who have symptoms. This measure will be calculated with 2 performance rates: 1) Percentage of patients aged 18 years and older with a diagnosis of COPD who have a documented airflow obstruction (FEV1/FVC < 70%) as measured by spirometry. 2) Percentage of patients aged 18 years and older with a diagnosis of COPD who have documented airflow obstruction (FEV1/FVC < 70%) and are symptomatic, who were prescribed a long-acting inhaled bronchodilator.

Submission of the two performance rates is required for this measure. A simple average, which is the sum of the performance rates divided by the number of the performance rates will be used to calculate performance. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient for the performance period.

The most advantageous quality data code will be used if the measure is submitted more than once.