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Point/Counterpoint Editorials |

Point: Should Storefront Clinics Provide Case Finding and Chronic Care for COPD? YesStorefront Clinics for COPD? Yes FREE TO VIEW

Paul Enright, MD; William Nevin, MD, FCCP
Author and Funding Information

From the University of Arizona (retired) (Dr Enright); and Pulmonary Associates of Southern Arizona (Dr Nevin).

Correspondence to: Paul Enright, MD, PO Box 675, Mount Lemmon, AZ 85619; e-mail: lungguy@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(6):1191-1193. doi:10.1378/chest.13-2860
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Published online

Thousands of storefront clinics (SFCs), often located in nationwide pharmacy chains, have already become popular in the United States for health screenings, treatment of acute illness (cold, bronchitis, influenza, sinusitis, etc), and management of common chronic medical conditions such as diabetes, hypertension, gastroesophageal reflux disease, and osteoarthritis.1 Some SFCs are adding asthma and COPD to their menu of services. Access to these retail walk-in clinics is more convenient and less expensive to the patient compared with traditional primary care and specialist offices. Another advantage is that the nurse practitioners and physician assistants who provide care at SFCs are more likely to adhere closely to published clinical practice guidelines (CPGs) for both the acute and the chronic phases of these conditions.

About 30 million patients will be insured under the Affordable Health Care Act. Most will be poor and likely to be smokers. About 10% of such adults have clinically important COPD or asthma. SFCs can help to ease the burden of this influx of new patients into the health-care system.

Many major problems with the diagnosis and outpatient management of COPD currently exist in the United States, despite a proliferation of CPGs for the diagnosis and treatment of COPD over the past 2 decades and the promotion of these guidelines by professional pulmonary organizations (the American College of Chest Physicians and the American Thoracic Society), the industry-sponsored GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines for COPD, and the drug companies who market COPD inhalers. COPD remains underdiagnosed and overdiagnosed as well as undertreated and overtreated. We believe that SFCs have the potential to reduce these problems.

Only one-fourth of US adults who report a physician diagnosis of COPD have ever had a spirometry test to confirm the “O” in COPD. It seems too easy for a smoker with dyspnea or chronic cough who sees an attractive advertisement on television for a COPD inhaler to ask his or her physician for that COPD “cure,” and the physician is likely to simply confirm an increased likelihood for COPD and prescribe the desired inhaler to “see how well it works” without performing a spirometry test or considering other conditions (eg, asthma or rhinosinusitis). We believe that SFCs should provide screening (case finding) for COPD for smokers aged > 40 years and then confirm COPD (or asthma) with spirometry.

We recommend a two-stage process to detect and confirm clinically important airway obstruction.2 Patients with a low peak flow will be referred for good-quality prebronchodilator and postbronchodilator spirometry (performed in a pulmonary function testing laboratory or by a skilled respiratory therapist who visits the SFC once a month with a diagnostic-quality spirometer). Following the diagnosis of clinically important COPD, SFCs are in an ideal position to address and provide important aspects of pulmonary rehabilitation (ie, smoking cessation, immunizations, daily exercise, and inhaler technique). Evaluations will be done for treatment efficacy, medication adherence, and drug side effects as will rapid evaluation and treatment of exacerbations. Patients with a moderate to severe exacerbation (FEV1 < 0.7 L, resting oxygenation as measured by pulse oximetry < 90%) will be referred to a local pulmonary subspecialist (or to a local ED, if indicated).

Currently in the United States, nurse practitioners and physician assistants successfully manage many chronic diseases.3-6 Respiratory therapists should be added to manage asthma and COPD. In other countries, nurses, pharmacists, and nonphysician respiratory care providers (similar to our respiratory therapists) are running outpatient COPD clinics.7-12 They have more time to interact with patients than most busy physicians. Patients like them.

We recommend that clinical demonstration projects (or large, simple clinical trials) in multiple SFC locations be performed to determine noninferiority (or superiority) for important clinical outcomes.13,14 It is possible that short-term economic and patient satisfaction benefits will be at the expense of higher long-term morbidity or mortality. For example, a well-designed study of structured care following hospitalization for a COPD exacerbation (patients at very high risk for another exacerbation) at six US veterans hospitals was discontinued because of a 30% higher all-cause mortality rate.15

The SFCs are here to stay, so our job as pulmonologists is to ensure that they “do the right thing” for patients with asthma or COPD. We worry that the retail pharmacy chains that own most walk-in clinics will have a financial incentive to overprescribe and push adherence to drugs with a high-profit margin, so monthly reviews of the electronic medical records (including prescriptions and refills) by a group of financially independent pulmonary subspecialists must be done to detect problems with quality.

We must help SFCs to integrate their value-added services into traditional health-care delivery systems (usual care) in a way that improves overall quality of care and long-term outcomes.14 We need to use the guaranteed accessibility of the SFC to improve communication with patients. The SFC must develop relationships with the patients’ established usual care teams. Two-way communication between providers must include direct phone contact for urgent conditions as well as immediate access to electronic medical records to share vital signs, test results, diagnoses, treatments, immunizations, and patient education. A properly functioning communication structure should reduce the concern of many usual care teams that the SFC will steal the patient and function as the new usual care team until some serious condition arises requiring the usual care team to become the bailout service.

We as pulmonologists must retain responsibility for both the short-term and the long-term needs of patients with severe COPD or asthma. The SFC will be seeing patients with short-term needs and will need consultation and support from the usual care teams, especially with laboratory and radiology services. Standards (protocols based on CPGs) for care for acute and chronic conditions will be critical and the role of the pulmonologist essential. The SFC will need training in the recognition of conditions that do not fit the usual care guidelines, such as the development of acute respiratory symptoms due to carcinoma, heart failure, or some other condition in patients with long-standing stable COPD or asthma. The SFC providers must be taught to recognize and avoid shortcuts to short-term profits that lead to long-term overall cost increases and reduced quality of care.

Abbreviations

CPG

clinical practice guideline

SFC

storefront clinic

Pharmacy & health. Walgreen Co website. http://www.walgreens.com/pharmacy/healthcareclinic. Accessed September 20, 2013.
 
Jithoo A, Enright P, Burney P, et al; BOLD Collaborative Research Group. Case-finding options for COPD: results from the Burden of Obstructive Lung Disease study. Eur Respir J. 2013;41(3):548-555. [CrossRef]
 
Lowery J, Hopp F, Subramanian U, et al. Evaluation of a nurse practitioner disease management model for chronic heart failure: a multi-site implementation study. Congest Heart Fail. 2012;18(1):64-71. [CrossRef]
 
Sanders J, Guse C, Onuoha BC. Pilot study of a new model for managing hypertension in an uninsured population. J Prim Care Community Health. 2013;4(1):44-49. [CrossRef]
 
Yu J, Shah BM, Ip EJ, Chan J. A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. J Manag Care Pharm. 2013;19(2):102-114.
 
Allen JK, Dennison Himmelfarb CR, Szanton SL, Frick KD. Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities [published online ahead of print April 30, 2013]. J Cardiovasc Nurs. doi:10.1097/JCN.0b013e3182945243.
 
Bischoff EWMA, Akkermans R, Bourbeau J, van Weel C, Vercoulen JH, Schermer TRJ. Comprehensive self management and routine monitoring in chronic obstructive pulmonary disease patients in general practice: randomised controlled trial. BMJ. 2012;345:e7642. [CrossRef]
 
Ram FSF, Wedzicha JA, Wright J, Grenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review of evidence. BMJ. 2004;329:315. [CrossRef]
 
Upton J, Madoc-Sutton H, Sheikh A, Frank TL, Walker S, Fletcher M. National survey on the roles and training of primary care respiratory nurses in the UK in 2006: are we making progress? Prim Care Respir J. 2007;16(5):284-290. [CrossRef]
 
Wood-Baker R, Reid D, Robinson A, Walters EH. Clinical trial of community nurse mentoring to improve self-management in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2012;2012(7):407-413. [CrossRef]
 
Fletcher MJ, Dahl BH. Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care? Prim Care Respir J. 2013;22(2):230-233. [CrossRef]
 
Ingadottir TS, Jonsdottir H. Partnership-based nursing practice for people with chronic obstructive pulmonary disease and their families: influences on health-related quality of life and hospital admissions. J Clin Nurs. 2010;19(19-20):2795-2805. [CrossRef]
 
Lenferink A, Frith P, van der Valk P, et al. A self-management approach using self-initiated action plans for symptoms with ongoing nurse support in patients with chronic obstructive pulmonary disease (COPD) and comorbidities: the COPE-III study protocol. Contemp Clin Trials. 2013;36(1):81-89. [CrossRef]
 
Nici L, ZuWallack R; American Thoracic Society Subcommittee on Integrated Care of the COPD Patient. An official American Thoracic Society workshop report: the integrated care of the COPD patient. Proc Am Thorac Soc. 2012;9(1):9-18. [CrossRef]
 
Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012;156(10):673-683. [CrossRef]
 

Figures

Tables

References

Pharmacy & health. Walgreen Co website. http://www.walgreens.com/pharmacy/healthcareclinic. Accessed September 20, 2013.
 
Jithoo A, Enright P, Burney P, et al; BOLD Collaborative Research Group. Case-finding options for COPD: results from the Burden of Obstructive Lung Disease study. Eur Respir J. 2013;41(3):548-555. [CrossRef]
 
Lowery J, Hopp F, Subramanian U, et al. Evaluation of a nurse practitioner disease management model for chronic heart failure: a multi-site implementation study. Congest Heart Fail. 2012;18(1):64-71. [CrossRef]
 
Sanders J, Guse C, Onuoha BC. Pilot study of a new model for managing hypertension in an uninsured population. J Prim Care Community Health. 2013;4(1):44-49. [CrossRef]
 
Yu J, Shah BM, Ip EJ, Chan J. A Markov model of the cost-effectiveness of pharmacist care for diabetes in prevention of cardiovascular diseases: evidence from Kaiser Permanente Northern California. J Manag Care Pharm. 2013;19(2):102-114.
 
Allen JK, Dennison Himmelfarb CR, Szanton SL, Frick KD. Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities [published online ahead of print April 30, 2013]. J Cardiovasc Nurs. doi:10.1097/JCN.0b013e3182945243.
 
Bischoff EWMA, Akkermans R, Bourbeau J, van Weel C, Vercoulen JH, Schermer TRJ. Comprehensive self management and routine monitoring in chronic obstructive pulmonary disease patients in general practice: randomised controlled trial. BMJ. 2012;345:e7642. [CrossRef]
 
Ram FSF, Wedzicha JA, Wright J, Grenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review of evidence. BMJ. 2004;329:315. [CrossRef]
 
Upton J, Madoc-Sutton H, Sheikh A, Frank TL, Walker S, Fletcher M. National survey on the roles and training of primary care respiratory nurses in the UK in 2006: are we making progress? Prim Care Respir J. 2007;16(5):284-290. [CrossRef]
 
Wood-Baker R, Reid D, Robinson A, Walters EH. Clinical trial of community nurse mentoring to improve self-management in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2012;2012(7):407-413. [CrossRef]
 
Fletcher MJ, Dahl BH. Expanding nurse practice in COPD: is it key to providing high quality, effective and safe patient care? Prim Care Respir J. 2013;22(2):230-233. [CrossRef]
 
Ingadottir TS, Jonsdottir H. Partnership-based nursing practice for people with chronic obstructive pulmonary disease and their families: influences on health-related quality of life and hospital admissions. J Clin Nurs. 2010;19(19-20):2795-2805. [CrossRef]
 
Lenferink A, Frith P, van der Valk P, et al. A self-management approach using self-initiated action plans for symptoms with ongoing nurse support in patients with chronic obstructive pulmonary disease (COPD) and comorbidities: the COPE-III study protocol. Contemp Clin Trials. 2013;36(1):81-89. [CrossRef]
 
Nici L, ZuWallack R; American Thoracic Society Subcommittee on Integrated Care of the COPD Patient. An official American Thoracic Society workshop report: the integrated care of the COPD patient. Proc Am Thorac Soc. 2012;9(1):9-18. [CrossRef]
 
Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012;156(10):673-683. [CrossRef]
 
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