National COPD Conference Summary

Abstract

The first National COPD Conference, sponsored by the US COPD Coalition was held in Arlington, Virginia on November 14–15, 2003. The theme for the conference was developed around the Department of Health and Human Services (DHHS) Healthy People 2010 goals for COPD and included plenary speeches, roundtable discussions, abstracts, and workshops on spirometry, patient/physician education materials, and home monitoring/telemetry. The goal was to bring together a multidisciplinary group to identify important issues relating to COPD in the United States, specifically the barriers to a wider recognition of the disease, and to develop an orchestrated action plan. Over 500 scientists, clinicians, respiratory therapists, nurses, patients, government officials, and representatives from pharmaceutical companies participated. This summary provides the recommendations from the conference that will be used to develop an action plan for the US COPD Coalition. It includes actions proposed by plenary speakers, roundtable faculty and conference participants.

• Chronic obstructive pulmonary disease
• COPD
• Chronic disease management

Introduction

COPD is a major public health problem worldwide and its impact is expected to increase in the next several decades [[1]]. In the US, more than 10 million people suffer from COPD and another 14 million show signs of the disease, although they have not yet been diagnosed [[2]]. The COPD death rate for women more than doubled in the past 20 yrs (from 20.1 to 56.7/100,000); in 2000 more women than men died from COPD. The financial burden of COPD is significant, costing an estimated $14.7 billion annually for direct medical costs, and an estimated $15.7 billion annually for indirect costs (loss of productivity and premature mortality) [[3]]. As the population ages, COPD cost of care will increase and as adults work later into life, the impact of COPD on productivity is likely to grow.

To combat COPD as a global health problem, in 1998 the Global Initiative for Chronic Obstructive Lung Disease (GOLD) program was implemented [[4]]. Through the leadership of US scientists active in the GOLD program, a US COPD Coalition was initiated in 2001 to provide a concerted effort among US medical organizations, government agencies and patient groups representing a variety of medical disciplines. The goals of the US COPD Coalition are to:

• Promote better care for patients with COPD

• Raise awareness of COPD among patients, health professionals, policy makers, and the public

• Foster communication and networking opportunities

• Promote programs of prevention and early detection of COPD

• Define barriers for program implementation

• Stimulate research

• Seek a cure for COPD

Organizations participate as partners in the US COPD Coalition by providing information about the COPD programs of their organization on the Coalition website (www.uscopd.com). The US COPD Coalition Partner Organizations contributing to the National COPD Conference are listed in the Appendix.

First National COPD Conference

To begin to address the goals and objectives of the US COPD Coalition in an organized and timely manner, it was recommended that a National COPD Conference be conducted. A program committee was formed (Appendix) and sponsors identified (Appendix). The agenda was formulated around the DHHS Healthy People 2010 program [[5]], focus area 24 Respiratory Diseases, to promote respiratory health through better prevention, detection, treatment, and education efforts. The specific goals for chronic obstructive pulmonary disease (COPD) in this DHHS program include:

• 24‐9. Reduce the proportion of adults whose activity is limited due to chronic lung and breathing problems.

• 24‐10. Reduce deaths from chronic obstructive pulmonary disease (COPD) among adults.

The conference program (Appendix) included plenary sessions, roundtables, workshops, and abstracts. Ninety‐eight abstracts were submitted; fifty were selected for presentation in one of three different sessions.

This conference summary describes the actions and recommendations from plenary speakers, roundtable presentations, and discussions during the conference organized by major topic areas. The actions and recommendations presented in this summary do not necessarily represent a consensus among participants. Additional background material provided by roundtable faculty can be found on the US COPD Coalition website (www.uscopd.org).

Specific Actions and Recommendations

Goals for the US COPD Coalition

1. The US COPD Coalition should develop a sustainable structure with a decision‐making process and business plan to match a realistic rolling 2–3 year strategy. Goals and priorities should be identified for each year.

2. A major priority is to raise awareness of COPD using sophisticated marketing techniques. COPD is common, chronic, and fatal, yet is unknown to most of the US population. It is not considered an “urgent” condition and therefore gets less attention than a diagnosis of cancer, heart attack or stroke. There is an absolute priority need to develop a clear, consistent message that can take the form of a large multi‐faceted awareness campaign. Practical themes and compelling COPD messages tailored to different constituencies (including minority and low income populations) are essential to raise awareness of COPD among different groups, e.g., health professionals, decision makers, providers, payers, lay public and patients. Coalition Partner Organizations should be encouraged to use consistent messages and talk about COPD whenever, and wherever, there is an opportunity. Patient advocacy groups should be included as an essential part of the awareness campaign.

3. Twenty percent of COPD in the US occurs in non‐smokers, and by itself this is a major public health problem. Separating the problem of COPD from the problem of smoking should reinforce the need to stop smoking but disassociate images of COPD from smoking. This should lower the stigma of COPD and the reluctance of patients to share symptoms and concerns with their physician.

4. Coalition Partner Organizations should become aware of government‐sponsored programs that include, or could be expanded to include, projects related to COPD. An example is the DHHS program, Steps to a Healthier US, [[6]] that supports public‐private partnerships to help people to adopt health lifestyles that contribute directly to the prevention of chronic diseases, including COPD. Goals include health education training, media campaigns, walking challenges, and smoking cessation programs.

5. Prevalence, morbidity, mortality, and cost statistics for COPD are impressive, as is the fact that COPD is now as common in women as in men in the US. This compelling information should be made visible to politicians, and to other decision makers. Several approaches were suggested, including linking to “Project 435,” a strategy that could provide information about COPD at the local (district) level and provide an excellent opportunity to actively involve individuals with COPD. An Internet Advocacy model that incorporates video units into online messaging targeted at local, state, and national policy makers may also be an effective approach. Individuals and organizations should be involved in national political debates on health care access for patients with COPD and should encourage incorporation of questions related to COPD in national surveys.

6. A strategy for raising awareness of COPD among members of Congress, both at the National and State levels, would be to form a Congressional COPD Caucus. Each year, one or two visible and important tasks could be developed for the Congressional COPD Caucus with goals and targets set for successful accomplishments. Political actions could include funding for COPD research, improving air quality (indoor/outdoor), tobacco control, use of oxygen on planes (FAA regulations), and Medicare reimbursement for spirometry, rehabilitation, prescription drugs, and supplemental oxygen. Patient experiences and testimonials are invaluable to inform policymakers and the public on the impact of chronic COPD.

7. The image of COPD among health care providers, the public and patients with the disease needs to be modified to more accurately reflect strides that have been made in our understanding of the management of COPD. Changing the image of COPD from a pessimistic image to an optimistic image will help to eliminate the stigma and prejudice that is so often associated with the diagnosis of COPD. Emphasizing that COPD can be treated can replace the common nihilistic attitude demonstrated by many health care providers with one of responsibility.

COPD and Public Health

1. There is presently a large gulf between the visibility and funding that is given to other chronic diseases, such as heart disease, asthma and diabetes, and that given to COPD, Public health officials in the US need to be informed about the prevalence, morbidity, mortality and cost statistics for COPD.

2. DHHS should be held accountable for meeting the COPD goals in the Healthy People 2010 program through implementation of specific initiatives. Visibility should be given to accomplishments, as well as to lack of progress.

3. Programs to assure better, and more accurate diagnosis of COPD should be implemented. This is particularly important as current practice fails to effectively utilize readily available, highly efficient and inexpensive technology. In order to detect COPD, primary care providers should perform an office spirometry test for patients > 45 years old who report smoking cigarettes (current or previous smokers) or anyone of any age who has one of the cardinal symptoms of COPD: chronic cough, excess mucus (sputum) production, dyspnea on mild exertion out of proportion to age, or wheeze.

4. Economic and social analyses of the costs and impact of COPD should include considerations of the effect of COPD on work ability, efficiency, and job choice as well as the effect of occupational exposures on COPD risk.

5. Acute exacerbations in patients with COPD lead to significant mortality and significant financial burden associated with hospitalization, and intensive, emergency, and outpatient care. Semantic issues regarding definition of an exacerbation and the definition of treatment failure confound interpretation of the available literature and highlight the need for an accepted, robust definition and a transferable index of severity stratification. At present, there are no severity assessment criteria, although a complex of clinical, physical examination, and selected laboratory parameters could be utilized to generate a comprehensive stratification system. A prospective validation of such a system would be required.

Health Care Systems and Chronic Disease Care

The present health care system in the US grew out of a need to manage acute diseases, rather than chronic diseases. As the age structure of the US population changes and more men and women are living into the chronic disease age range, the treatment paradigm needs to be redesigned. For COPD (and most chronic illnesses) there are increasingly effective, but complex, therapies, and increasingly effective behavioral/educational interventions but these are not reaching those in need. The current model of healthcare delivery leads to very fragmented care, especially for those with a chronic disease. Current care delivery models lack the ability to implement/discuss issues related to quality of life.

1. A well‐structured Medicare COPD disease management program is required. COPD patients need a continuous (and coordinated) healing relationship with a care team and a practice system organized to assure:

   • Effective Treatment (clinical, behavioral, supportive)

   • Information and support for their self‐management

   • Systematic follow‐up and assessment tailored to clinical severity

   • Linkages to services and supports in the community

   • End of life care consistent with preferences

2. Americans with Chronic Illness Experience—a Quality Chasm (IOM report) [[7]]—indicates that the current care systems in the US are oriented to acute illness and focus on symptoms and laboratory results. The role of the patient and the family in management is not emphasized and too often, non‐pharmacologic treatments are ignored. The most effective strategy is to create a practice system that assures guideline adherence, better uses non‐physician team members, relies on planned encounters and active follow‐up, provides ongoing self‐management support, and uses information systems to monitor, remind, and plan care.

3. To implement a chronic disease care model, there is growing agreement that a comprehensive system change must take place but this will require resources. An evaluation program must determine whether generic chronic disease approaches will be as effective as disease‐specific ones. Examples of questions that must be addressed include: Will coverage of recommended services alone change practice? Will financial rewards encourage real system change or gaming/fraud? Will only a “paperless” office raise quality? If less costly information systems improve quality, how might these systems be disseminated? Would a model that involves primary‐specialty‐hospital care collaboration that has proven effective in New Zealand be possible in the U.S.? Are we providing teaching practice models and teaching supportive of high quality COPD care?

4. From the perspective of the Health Care Provider, the goals are to minimize the cost of care for chronic conditions while at the same time, maintaining and improving quality. However, there are considerable system constraints with competition for scarce resources among many different chronic diseases and treatments and the requirement to stay within budget for a given year. Treatments for COPD need to be considered in terms of their effectiveness and, given resource constraints, their cost‐effectiveness. At present, COPD is under recognized by health plans and careful choices must be made when asking health plans to shift scarce resources to major treatment initiatives. Cost effectiveness analysis offers a methodology for prioritizing among treatments across the different stages of COPD and thus could focus on treatments that give the best health improvement for the expenditure.

5. The effectiveness of disease management programs for COPD should be evaluated and, if found effective, their value should be demonstrated for employers and payers to embrace and fund.

6. To be effective, strategies influencing affordability are likely to require partnerships between payers, providers, and other stakeholders. Dissemination of practice guidelines, technology assessment, tort reforms, and efforts to influence physician supply all would be more effective if participants in the US healthcare system collaborated. To increase interest in partnering, it is important to agree on a single (or a few) disease management strategie(s) for COPD, and stress behavior change, consumer‐driven care, and prudent medication use. Ongoing relationships between vendors, payers and providers should be encouraged for feedback on value/collaboration in program revision.

7. It is important to increase awareness of the effectiveness of pulmonary rehabilitation among patients with COPD, physicians (both primary care and specialists) and policy makers, including Medicare. Principles of pulmonary rehabilitation should be incorporated into disease management programs for the chronic care of patients with COPD. Efforts should be made to encourage third party payers to support pulmonary rehabilitation as an important component of COPD treatment. The need to make pulmonary rehabilitation strategies more widely understood, and more easily implemented, particularly in “home based” situations, should be a priority.

8. Patients with severe COPD are often not adequately monitored when at home. The absence of adequate home monitoring contributes to increased utilization of health care resources including physician offices, emergency departments, skilled nursing facilities, and acute care facilities. Approaches are needed for home‐use monitoring linked to computer‐based transmission to health providers.

Setting Clinical Standards/Quality of Care

Clinical standards can impact on the content of community practice, patient care outcome, health system costs, health system priorities as well as health system metrics. Accountability measures are best if they are supported by strong evidence, are relevant, have actions that can be easily taken, are meaningful to all audiences and drive change.

1. Obstacles to quality of care for COPD patients include access to care, legal issues, operational issues and social acceptability. There is a need to bring more awareness to medical standards for COPD management but, in setting measurable clinical standards, quality of care must be defined reasonably with the recognition that there will be different approaches to standards in different settings. If standards cannot be measured, they cannot be monitored.

2. Pathways to impact guidelines include both education and behavior change. Performance measures need to be developed that do not micromanage but force answers to critical questions. Good performance measures are based on guidelines, but not all guidelines translate to performance measures. This is dependent on validity of evidence and clarity of statements. Accountability measures are best if they are supported by strong evidence, clinically relevant, have actions that can be easily taken, are meaningful to all audiences and drive change. Clinical standards can impact on the content of community practice, patient care outcome, health system costs, health system priorities as well as health system metrics.

3. Because CME and didactic programs appear to have little impact on changing behavior, more effective strategies should be implemented, such as reminder systems, standing orders, clinical pathways or protocols, opinion leaders and physician champions, and self‐monitoring and feedback.

4. Quality measures should be developed and included in national quality assessment programs such as those of JCAHO, HEDIS and CMS. This could greatly raise the urgency of dealing with COPD in practice and may facilitate the critical need to reimburse for services that the patients need and cannot currently afford.

COPD Diagnosis and Detection

1. There must be scientifically agreed upon criteria for the definition of COPD and then a collaborative effort to develop a simple, low cost, quick, reliable method of diagnosis, one that will allow primary care physicians, nurses and other health personnel in offices or in public health/community‐health settings, to accurately diagnose COPD. Health professionals need to be educated on parameters of a correct diagnosis and appropriate treatment for COPD. The scientific reasoning and evidence leading to a diagnosis of COPD needs to be provided in a manner that the public can easily understand.

2. Early diagnosis of COPD will require the development and use of cost effective assessments of those at risk in primary care practice. A practical and feasible list of indications for spirometry should be developed that will lead people to request and expect testing. This could be modeled after other successful campaigns, such as chest pain in heart disease (MI), the stroke awareness campaign, or the campaign to screen for diabetes in high‐risk patients. To encourage providers to use spirometry, an easily understandable algorithm for interpretation and action should be developed, and reimbursement issues should be addressed to remove the economic barriers to doing spirometry.

3. Before there are changes in pulmonary function, patients may experience symptoms which are usually the cause for patients to seek health care. Thus, it was recommended that health care providers routinely assess respiratory related symptoms. This assessment should include the presence or absence of symptoms as well as their intensity, distress, frequency/duration and quality (descriptors). This assessment should not focus on only one symptom but rather, multiple symptoms simultaneously. At present, there are few symptom measures available for use in clinical practice that would be appropriate for the COPD patient, and these tools need to be developed to describe the full symptom experience including early symptoms and other changes indicative of COPD, intensity, distress, frequency/duration and quality.

4. Excellent diagnostic equipment already exists but its simplicity needs to be improved to remove the barrier to incorporating spirometry into primary care. Issues that need to be considered include accuracy and precision of the spirometer and its software, proper selection of the lower limits reference range, appropriate selection of reference values, a good interpretive scheme, and quality control.

COPD Prevention

Prevention of COPD will require not only aggressive control of tobacco smoking but also control of adverse occupational and environmental exposures.

1. Campaigns to emphasize the impact of smoking cessation should continue. Cigarettes should be made more costly and less accessible through implementation of statewide tobacco control programs. Efforts should be made to encourage or require third party payers to support treatments for smoking cessation as a component of COPD treatment. There is evidence that workplace based efforts that combine health protection (hazard control) with health promotion (smoking cessation programs) are most effective in reducing risk and increasing acceptance of tobacco control.

2. Scientific information about COPD prevention should be made available to the public in a manner that can easily be understood and used in ways that will enhance and lengthen lives. Creative approaches to alert young people to the potential of COPD and its causes should be developed. Information for older persons and their family caregivers should be provided to make them aware of the symptoms of COPD to discuss with health care providers.

3. Epidemiologic studies provide compelling, consistent evidence that exposure to a wide range of minerals, metals, organic dusts, fumes, chemical vapors, and smoke are associated with increased risk of COPD. Thus, adverse exposures in the workplace are a significant cause or contributor to the burden of COPD. The combination of tobacco smoking and occupational exposures is particularly hazardous. Improved data collection and reporting, for example the inclusion of usual industry and occupation on all death certificates and improved monitoring and tracking of disease occurrence, would be of great value. Increasing resources devoted to COPD prevention in the workplace, targeting interventions, and evaluating the effectiveness of those interventions are required.

4. A wide range of individuals/organizations have a role to play in controlling and preventing COPD caused by occupational and environmental exposures including workers and their representatives, employers and their associations, government agencies, politicians, health care providers, professional associations, pharmaceutical companies, device/equipment companies, researchers, insurers, lawyers, and affected or at‐risk individuals. Effective control requires attention to the social, legal, political, and economic environment.

COPD Research

1. Basic and clinical research is needed to develop new and effective disease modifying therapies that will decrease the relentless loss of lung function, restore lung function and lengthen lifespan. This will only be accomplished if the biological basis of COPD is understood and therapies developed that interrupt the disease process. Areas of research that should be encouraged related to COPD include: classic protein, cell, and molecular biology; expression profiling and proteomics; genetic engineering; animal models; human genetics; and pharmacogenetics.

2. Currently, screening is likely to require development of symptom checklists and more widespread availability of spirometry in primary care practices. In the future it is hoped that biomarkers and genetic markers may be available.

3. Increased research attention should be given to the occupational and environmental causes and contributors to COPD, to improve understanding of risk factors and effective interventions, including improving the national data sources available for such research, such as incorporation of spirometry into future rounds of NHANES and inclusion of industry and occupation on all death certificate.

4. Health services research funding is necessary to develop and evaluate the role of chronic disease management programs for COPD, and to determine the necessary elements and best timing for pulmonary rehabilitation. Research is also required to study the application of pulmonary rehabilitation to patient populations including, but not limited to, underserved communities, lower socio‐economic and education groups.

5. Many questions related to exacerbations in COPD remain: What is the nature of the treatment failures that are closely associated with health care utilization and impairment in quality of life? Why do some patients fail to recover from an exacerbation? What is the optimal format for staging exacerbation severity? Potential host factors associated with a greater likelihood of treatment failures, including smoking status, clinical phenotype, and the time from previous exacerbations should be examined. The role of self‐management (‘home hospitalization’) in the management of exacerbations needs to be evaluated and empowering COPD patients with patient‐oriented disease management approaches should be investigated to determine if this evolving field would lead to major improvement in management. Are we measuring the correct end‐points for testing the effect of various interventions? Should the time to next exacerbation, bacterial eradication, days to resolution of symptoms, markers of inflammation, or other novel end‐points be routinely examined in trials of exacerbation management? How much emphasis should be placed on interventions that may prevent exacerbations, for example, drugs, diet, antioxidants, immune stimulators, and anti‐cytokines? A generally accepted study format for examining exacerbation prevention was felt to be an important component for future study but will depend heavily on a robust, yet straightforward, definition of an exacerbation. Research on the optimal treatment of COPD exacerbations as a component that adversely affects quality of life should be encouraged.

6. Translational research on COPD treatments should be encouraged. Identification of intermediate end‐points and biomarkers are essential for the effective and efficient translation of basic research findings to clinically relevant outcomes. Large, simple clinical trials that are clinically relevant should be conducted in order to optimize COPD treatments using currently existing therapies. There needs to be increased numbers of participants in COPD clinical trials; participation should be encouraged by education of patients as well as expansion of current COPD research groups. Patient‐driven protocols should be investigated for the management of COPD, not just exacerbations of COPD.

7. The development of optimal approaches to prevent smoking uptake and encourage cessation among groups that have so far proved resistant to these strategies, such as teenagers, young adults, and certain minority groups should be a major agenda for COPD research.

8. The impact of testing for alpha 1‐antitrypsin should be examined in individuals undergoing CT scans as part of cancer screening trials (which would identify smokers with and without CT evidence of emphysema and with and without alpha 1‐antitrypsin deficiency).

9. Research should be undertaken to evaluate the role of community‐based health care coalitions for COPD. These programs are needed in order to share or leverage information and experiences, carry out needs assessment, do policy analysis and priority setting, advocate, provide and/or improve services directly, coordinate services provided by member organizations, raise money or improve marketing capacity, reduce risk, and increase rate of implementation or translation into local action.

10. Cooperation between industry and government should be encouraged in order to promote research of new COPD treatments. Cooperation between CMS and NIH‐NHLBI was highly effective in establishing the value and limitations of Lung Volume Reduction Surgery (LVRS) and should be encouraged as a model for future research in COPD.

Summary

An important outcome of this first National COPD Conference was the creation of a meaningful bridge between the professional caregiver and the patients themselves. Participants had the opportunity to interact not only with individuals from a wide spectrum of the health care community, but also with the many articulate patient advocates who attended the meeting. Beyond compassion, the patient advocates were focused on society, and resonated with the human rights impact of COPD. An important message is the critical need to involve the patient community in establishing the public policy priorities, in the development of tactics and strategy and in involvement in the implementation of programs and evaluations. Although discrimination and right to work represent some of the concerns of individuals with COPD, they do not reflect the comprehensive nature and complexity of patient issues.

US COPD Coalition Partner Organizations Contributing to the National COPD Conference

Alpha‐1 Association, Alpha‐1 Foundation, American Academy of Family Physicians, American Association for Respiratory Care, American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians‐American Society of Internal Medicine, American Institute for Life‐Threatening Illness, Emphysema/COPD Composite Program, American Lung Association, American Thoracic Society, Asthma/Emphysema Self‐Help Group, Center for Medicare and Medicaid Services, DHHS, COPD‐Alert, COPD Resource Network, Emphysema Foundation for Our Right to Survive (EFFORTS), Global Initiative for Chronic Obstructive Lung Disease, The James P. Mara Center for Lung Disease, National Association for Medical Direction of Respiratory Care, National Center for Environmental Health, CDC, DHHS, National Emphysema Foundation, National Home Oxygen Patients Association, National Institute for Occupational Safety and Health, CDC, DHHS, National Lung Health Education Program, National Medical Association, Pulmonary Education and Research Foundation (PERF), SPRY Foundation

National COPD Conference Program Committee

Dennis E. Doherty. M.D., co‐chair Lexington, KY, James P. Kiley, Ph.D., co‐chair Bethesda, MD, Bartolome R. Celli, M.D. Boston, MA, Audrey Gift, Ph.D., East Lansing, MI, David M. Mannino, M.D., Atlanta, GA, Fernando J. Martinez, M.D., Ann Arbor, MI, Janet Maurer, M.D., Hartford, CT, Sydney R. Parker, Ph.D., Northbrook, IL, Thomas L. Petty, M.D., Denver, CO, Stephen I. Rennard, M.D. Omaha, NE, Andrew L. Ries, M.D., M.P.H., San Diego, CA, James K. Stoller, M.D., M.S. Cleveland, OH, Bryon Thomashow, M.D., New York, NY, Elisabeth L. Righter, M.D., Beaver Creek, OH, Vicky Shrader, RRT, CPFT, Hanover, PA.

National COPD Conference Sponsors

The following sponsors provided unrestricted educational grants in support of the conference activities: Altana, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Pfizer. Dr. Sree Nair (Emphysema Foundation) and Dr. Neil Schacter also provided unrestricted support. Several US COPD Coalition Partner Organizations provided support that allowed many of their members to attend.

National COPD Conference Agenda

SESSION I: Plenary Speakers—COPD: A Public Health Priority (Chairs: Claude Lenfant, MD, Sree Nair, MD)

• COPD and its Impact on Public Health: Setting/Meeting Goals—Cristina Beato, M.D., Acting Assistant Secretary for Health, PHS, DHHS

• COPD: Challenges for the Family Physician—James Martin, MD, President, American Academy of Family Physicians, San Antonio, TX

• COPD: Challenges for Public Health—Roger J. Bulger, M.D., President and Chief Executive Officer, Association of Academic Health Centers, Washington D.C.

• COPD: Challenges for the Pulmonary Physician—Homer Boushey, MD, President, American Thoracic Society, San Francisco, CA

Session I: Roundtables

• A. Occupational/environmental aspects of COPD—J. Balmes, W. Beckett, D. Mannino, G. Wagner

• B. Symptom management: Factors affecting recognition of COPD symptoms: S. Rennard, B. Yawn

• C. Leveraging community partnerships/raising awareness—M. Ader, E. Gantz McKay, J. Kirkwood, S. Parker, A. Patel

Session I: Workshop—Diagnosis/Spirometry (ATS responsibility)—H. Boushey, chair, A. Sonia Buist, R. Crapo, P. Enright, B. Make, S. Stoloff

Session I: Abstracts—COPD Mechanisms and Experimental Approaches

SESSION II: Plenary Speakers—Setting Goals to Effect Change…Making an Impact on COPD: (Chairs: William Voight, Pamela DeNardo)

• Health Care Systems: A Reality Check with Chronic Disease Care—Ed Wagner, MD, Seattle, WA

• Role of Private Insurance—Janet Maurer, MD, CIGNA Health Care, Hartford, CT. Setting Clinical Standards/Quality of Care—William K. Sullivan, MD, Deputy Chief Medical Officer, CMS, DHHS

• Role of Patient Groups—John W. Walsh, Alpha‐1 Foundation, Miami FL

Session II: Roundtables

• D. Recognition and management of exacerbations: C. Camargo, R. Irwin, F. Martinez

• E. Assessing high risk populations—R. Sandhaus, J. Stoller

• F. Costs associated with COPD—S. Ramsey, J. Addiego

Session II: Workshop—Education/Templates for Hospital, Community Programs (ACCP responsibility)—S. Parker, chair, M. Ader, M. Fletcher, B. Make, A. Patel, A. Ries

Session II: Abstracts—Patients' View of COPD

SESSION III: Plenary Speakers—Prevention and Treatment: New Directions (Chairs, John Tooker, MD, James Kiley, PhD)

• Prevention and Treatment: Setting New Goals—Stephen Shapiro, MD., Boston, MA

• Setting Practice Standards for COPD—William E. Golden, MD, Little Rock, AK

• Quality of Care: Measuring Performance, Improving Quality—Barbara Paul, MD, Director, Quality Measurement/Health Assessment Group, Center for Beneficiary Choices, CMS, DHHS

• Improving the Quality of Care: Lessons from Community‐Based Programs—Dennis E. Doherty, MD, Lexington, KY

Session III: Roundtables

• G. COPD prevention, raising awareness—D. Abrams, A. Gift, R. Kaplan

• H. Rehabilitation home/hospital—B. Carlin, B. Make, A. Ries

• I. New approaches to COPD management—B. Celli, B, Thomashow, R. Wise

• J. Public Policy/Advocacy—G. Ewart, L. Marcus, M. O'Day, P. Porte

Session III: Workshop—Home Monitoring/Telemedicine (AARC responsibility)—S. Giordano, chair, T. Kallstrom, J. Lewarski, L. Marshall

Session III: Abstracts—Understanding COPD Occurrence and Evaluating Available Treatments

Session IV: Obtaining the goals of HP 2010…why not? (Chairs, H. Boushey, MD, R. Irvine, MD)

• Diagnostic Challenges—Robert Crapo, MD, Salt Lake City, UT

• Medical Challenges—James D. Crapo, MD, Denver, CO

• Legislative Challenges—Senator Michael Crapo, Rep., Idaho. Private/Patient Partnership to Increase Awareness—Russell Morgan, MD, President SPRY Foundation, Washington DC