Issue 3 • 2021

Ensure you are up to date with the latest evidence in thoracic medicine from Evolve and TSANZ

The Thoracic Society of Australia and New Zealand (TSANZ) partnered with Evolve to develop the ‘Top-5’ recommendations on low-value practices in thoracic medicine. The recommendations, which were launched in May 2021 during Lung Health Awareness Month, span a range of conditions, ranging from common, such as Chronic Obstructive Pulmonary Disease (COPD), to rare, such as sarcoidosis.
View the latest Top-5’ recommendations on low-value practices in thoracic medicine
RACP Fellow and TSANZ representative, Associate Professor Lucy Burr, a respiratory and sleep physician working at Mater Hospital in Brisbane and Director of the Mater Cystic Fibrosis service, endorses the recommendations.
“The focus for the respiratory topics was on common respiratory diseases that are usually seen in routine care, including general practice and emergency medicine. Two of the three recommendations covered the management of COPD, the most common respiratory condition encountered in adult care. The other three covered pulmonary embolism, pulmonary nodules and sarcoid. The intended impact for these recommendations was to aim to reduce the use of unnecessary tests that do not change the management of the patient as well as not exposing patients to unhelpful treatments,” shares Associate Professor Burr.
COPD and low-value care
According to the Australian Institute of Health and Welfare Chronic Obstructive Pulmonary Disease (COPD) Report:
“In Australia, COPD accounted for over half (51%) of the total burden of disease due to respiratory conditions and 3.9% of the total disease burden in 2015 (AIHW 2019a). Between 2003 and 2015, there was a 6.0% decrease in the total disease burden due to COPD.
Overall, COPD was the third leading specific cause of total disease burden. COPD is the leading cause of total burden in women aged 65–74 (22.6 DALYs per 1,000 population), and the second leading cause of total burden in men aged 65–74 (33.2 DALYs per 1,000 population) and 75–84 (54.3 DALYs per 1,000 population). The total disease burden due to COPD was split fairly evenly between non-fatal burden (51%) and fatal burden (49%) in 2015 (AIHW 2019a).
The prevalence of COPD was higher in the lowest socioeconomic area compared with that in the highest socioeconomic area.”
The recommendations emphasise the following regarding COPD care:
Recommendation 2: Do not use long term systemic corticosteroids for management of COPD.
Recommendation 3: Do not initiate maintenance inhalers in minimally symptomatic COPD patients with a low risk of exacerbation.
“The rationale for recommendation 2 is really quite simple. Long-term systemic steroids for any chronic condition, particularly COPD, is associated with significant systemic side effects and really should only be used as a last resort. We are much better at phenotyping our patients nowadays, enabling access to highly effective treatments that don’t involve systemic steroids. A good example would be the use of combination triple inhalers or even considering biologics in those with significant asthma overlap.
“The rationale for recommendation 3 comes from careful assessment of the risk benefit ratio for that particular patient. In a completely asymptomatic patient with minimal risk for exacerbation, i.e. absent a previous or recent exacerbation, adding in maintenance inhalers, such as long-acting muscarinic antagonists, is likely to be burdensome for the patient and not give the patient any additional clinical benefit. A greater focus on smoking cessation and lifestyle modification is far more important in this group,” explains Dr Burr. Physicians are encouraged to reduce risk of harm by applying the recommendations. “These recommendations are relevant as it’s important to not only look at the evidence for why we do things, but also to re-look at some things that may have previously been standard of care and re-assess what the value of that intervention is, both from an evidence perspective and at a practical level. It is essential to always consider whether the intervention/assessment will change management and/or improve care for the patient before embarking on a particular pathway. Always question the value of an intervention, both economically and most importantly, for the patient,” stresses Dr Burr.
© 2021 The Royal Australasian College of Physicians