Discriminative Accuracy of the CAPTURE Tool for Identifying Chronic Obstructive Pulmonary Disease in US Primary Care Settings

Insufficient Pulmonary Rehabilitation Uptake After Severe Exacerbation of COPD: A Multicentre Study in the South West Region of France

Purpose

Pulmonary rehabilitation (PR) is a type of multidisciplinary care strongly recommended after severe exacerbation of chronic obstructive pulmonary disease (COPD). Recently, a national French study reported a very low rate of PR uptake (8.6%); however, important clinical data were missing. Here, we aimed to identify the main factors associated with insufficient PR uptake after hospitalisation for COPD exacerbation.

Patients and Methods

This multicentre retrospective study included patients hospitalised with COPD exacerbation between 1 January 2017 and 31 December 2018, as identified by both coding and a detailed review of medical records. PR was defined as inpatient care in a specialised centre or unit within 90 days of discharge. Multivariate logistic regression was used to identify associations between PR uptake and patient characteristics, such as comorbidities, non-invasive ventilation (NIV), inhaled treatment, and forced expiratory volume in 1 second (FEV1).

Results

Among the 325 patients admitted for severe COPD exacerbation, 92 (28.3%) underwent PR within 90 days of discharge. In univariate analysis, relative to those who underwent PR, patients without PR had significantly more comorbidities, were less often treated with triple bronchodilator therapy or NIV, and had a higher FEV1. In multivariate analysis, variables independently associated with the lack of PR uptake were the presence of comorbidities (adjusted odds ratio (aOR) = 1.28 [1.10-1.53], p = 0.003) and a higher FEV1 (aOR = 1.04 [1.02-1.06], p < 0.001). There was no significant correlation between PR uptake and departmental PR centre capacity (notably, some departments had no PR facilities).

Conclusion

These data highlight the lack of PR in the early stages of COPD. Collaboration among all healthcare providers involved in patient management is crucial for improved PR uptake.

Early Diagnosis and Treatment of COPD and Asthma - A Randomized, Controlled Trial

BACKGROUND

Many persons with chronic obstructive pulmonary disease (COPD) or asthma have not received a diagnosis, so their respiratory symptoms remain largely untreated.

METHODS

We used a case-finding method to identify adults in the community with respiratory symptoms without diagnosed lung disease. Participants who were found to have undiagnosed COPD or asthma on spirometry were enrolled in a multicenter, randomized, controlled trial to determine whether early diagnosis and treatment reduces health care utilization for respiratory illness and improves health outcomes. Participants were assigned to receive the intervention (evaluation by a pulmonologist and an asthma-COPD educator who were instructed to initiate guideline-based care) or usual care by their primary care practitioner. The primary outcome was the annualized rate of participant-initiated health care utilization for respiratory illness. Secondary outcomes included changes from baseline to 1 year in disease-specific quality of life, as assessed with the St. George Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better health status); symptom burden, as assessed with the COPD Assessment Test (CAT; scores range from 0 to 40, with lower scores indicating better health status); and forced expiratory volume in 1 second (FEV1).

RESULTS

Of 38,353 persons interviewed, 595 were found to have undiagnosed COPD or asthma and 508 underwent randomization: 253 were assigned to the intervention group and 255 to the usual-care group. The annualized rate of a primary-outcome event was lower in the intervention group than in the usual-care group (0.53 vs. 1.12 events per person-year; incidence rate ratio, 0.48; 95% confidence interval [CI], 0.36 to 0.63; P<0.001). At 12 months, the SGRQ score was lower than the baseline score by 10.2 points in the intervention group and by 6.8 points in the usual-care group (difference, -3.5 points; 95% CI, -6.0 to -0.9), and the CAT score was lower than the baseline score by 3.8 points and 2.6 points, respectively (difference, -1.3 points; 95% CI, -2.4 to -0.1). The FEV1 increased by 119 ml in the intervention group and by 22 ml in the usual-care group (difference, 94 ml; 95% CI, 50 to 138). The incidence of adverse events was similar in the trial groups.

CONCLUSIONS

In this trial in which a strategy was used to identify adults in the community with undiagnosed asthma or COPD, those who received pulmonologist-directed treatment had less subsequent health care utilization for respiratory illness than those who received usual care. (Funded by Canadian Institutes of Health Research; UCAP ClinicalTrials.gov number, NCT03148210.).

Spirometric Transition of at Risk Individuals and Risks for Progression to Chronic Obstructive Pulmonary Disease in General Population

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a dynamic disease with a high socioeconomic burden. Using data collected prospectively from the general population, we examined factors related to the transition of at-risk individuals to COPD.

METHODS

We used the Korean Genome Epidemiology Study (KoGES) database, defining pre-COPD based on respiratory symptoms and radiological abnormalities suggestive of COPD; the preserved ratio impaired spirometry (PRISm) was defined as a forced expiratory volume in 1s (FEV1)/forced vital capacity ratio≥70% and FEV1<80%, as predicted by spirometry. We determined group differences in the rate of lung function decline, risk of future airflow obstruction (AFO).

RESULTS

The study included 4762 individuals, and longitudinal analysis revealed distinct trends in pulmonary function indicators. Compared to the normal group, the pre-COPD group showed a more rapid decline in lung function, while the PRISm group showed a slower decline. In the pre-COPD and PRISm groups, 4.4% and 3.5%, and 13.6% and 10.8%, respectively, of patients had progressed to COPD at the first and second visits. Pre-COPD and PRISm contributed to an earlier time to first AFO, but consideration of comorbid cardiovascular disease weakened this relationship in the PRISm group. Multivariate logistic regression showed that pre-COPD and PRISm are significant risk factors for future development of COPD (OR 1.80, p<0.001; OR 4.26, p<0.001, respectively).

CONCLUSION

Pre-COPD and PRISm patients showed different trends in lung function changes over time and both were significant risk factors for future development of COPD.

Exacerbation-like events in the 12 months prior to identification of chronic respiratory conditions in a primary care population

Initial chronic obstructive lung disease (COPD) pharmacotherapy is based on symptom burden and exacerbation history. Inclusion of inhaled cortico-steroids (ICS) is recommended only for those with a history of exacerbations. This brief report highlights that among individuals with previously unrecognized COPD about 1 in 5 have one or more exacerbation-like events and about 1 in 10 have two or more events in the prior 12 months whether or not they self-report concomitant asthma. Closer attention to prior exacerbation-like event history might lead to more guideline concordant care. In addition, there are two other groups that have impaired but non-obstructive spirometry, some with significant respiratory symptom burden who have frequencies of exacerbation-like events similar to those meeting COPD spirometry criteria. To date we have little guidance for treatment of these individuals.

The COPD Foundation on Its Twentieth Anniversary

This article does not contain an abstract.

Screening performance of COPD-PS scale, COPD-SQ scale, peak expiratory flow, and their combinations for chronic obstructive pulmonary disease in the primary healthcare in Haicang District, Xiamen City

Objectives

This study aimed to evaluate the screening performance of COPD-PS questionnaire, COPD-SQ questionnaire, peak expiratory flow (PEF), COPD-PS questionnaire combined with PEF, and COPD-SQ questionnaire combined with PEF for chronic obstructive pulmonary disease (COPD).

Methods

This was a cross-sectional study. We distributed self-designed surveys and COPD screening scales (COPD-PS questionnaire and COPD-SQ questionnaire) to residents who underwent physical examination in five community health centers in Haicang District, Xiamen City, from February 2023 to May 2023, and measured their lung function and PEF with a portable device. We used logistic regression to obtain the coefficients of COPD-PS questionnaire, COPD-SQ questionnaire, and PEF, and plotted the receiver operating characteristic curves of each tool for diagnosing COPD and moderate-to-severe COPD. We evaluated and compared the optimal cut-off points and scores of sensitivity, specificity, Youden index, and area under the curve (AUC) values, and assessed the screening efficiency of different methods.

Results

Of the 3,537 residents who completed the COPD-SQ questionnaire, COPD-PS questionnaire, and spirometry, 840 were diagnosed with COPD. We obtained the coefficients of COPD-PS questionnaire combined with peak expiratory flow (PEF), and COPD-SQ questionnaire combined with PEF, by logistic regression as -0.479-0.358 × PEF +0.321 × COPD-PS score and - 1.286-0.315 × PEF +0.125 × COPD-SQ score, respectively. The sensitivity of diagnosing COPD by COPD-SQ questionnaire, COPD-PS questionnaire, PEF, COPD-PS questionnaire combined with PEF, and COPD-SQ questionnaire combined with PEF were 0.439, 0.586, 0.519, 0.586, 0.612 respectively, and the specificity were 0.725, 0.621, 0.688, 0.689, 0.663 respectively, with ROC values of 0.606 (95%CI: 0.586-0.626), 0.640 (0.619-0.661), 0.641 (0.619-0.663), 0.678 (0.657-0.699), 0.685 (0.664-0.706) respectively. The sensitivity of diagnosing GOLD II and above by COPD-SQ questionnaire, COPD-PS questionnaire, PEF, COPD-PS questionnaire combined with PEF, and COPD-SQ questionnaire combined with PEF were 0.489, 0.620, 0.665, 0.630, 0.781 respectively, and the specificity were 0.714, 0.603, 0.700, 0.811, 0.629 respectively, with ROC values of 0.631 (95%CI: 0.606-0.655), 0.653 (0.626-0.679), 0.753 (0.730-0.777), 0.784 (0.762-0.806), 0.766 (0.744-0.789) respectively.

Conclusion

Our study found that the accuracy of COPD screening by COPD-SQ questionnaire and COPD-PS questionnaire can be improved by combining the results of PEF. The screening performance of COPD-SQ questionnaire combined with PEF is relatively better. In future research, further studies are needed to optimize the performance of screening tools and understand whether their use will affect clinical outcomes.

Comparative analysis between PUMA and CAPTURE questionnaires for chronic obstructive pulmonary disease (COPD) screening in smokers

Chronic obstructive pulmonary disease (COPD) presents a significant global challenge, impacting health systems, economies, and societies. Its prevalence is anticipated to rise owing to an aging demographic. Although the PUMA and CAPTURE questionnaires are available for COPD screening, their comparative effectiveness has not been studied in Indonesia. The aim of this study was to evaluate the effectiveness of the PUMA and CAPTURE questionnaires as screening tools for COPD among smokers. A cross-sectional study was conducted at Universitas Sumatera Utara Hospital and H. Adam Malik General Hospital, Medan, Indonesia, from December 2022 to February 2023. Smokers aged over 40 or above with a history of smoking more than 100 cigarettes in their lifetime and no previous COPD diagnosis were included in the study. To collect the responses to PUMA and CAPTURE questionnaire, face-to-face interviews were conducted, followed by a spirometry test. A total of 76 smokers were included in the study; the predominant age group was 51-60 years (36.8%), with the majority being male (81.6%). Most participants began smoking at ages 15-20 years (65.8%) and had been smoking for 20-30 years (36.8%) at a moderate intensity (44.8%). Spirometry tests indicated obstructive patterns in 50 participants, with 17 classified as severe obstruction. At a cut-off score of ≥6, the PUMA questionnaire yielded a sensitivity of 72.55% and a specificity of 84%. In contrast, the CAPTURE questionnaire, with a cut-off score of ≥4, exhibited a sensitivity of 70.83% and a specificity of 64.29%. These results imply that the PUMA questionnaire could be more efficient in COPD screening compared to the CAPTURE questionnaire.

Impact of Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma on Symptoms, Quality of Life, Healthcare Use, and Work Productivity

Rationale: A significant proportion of individuals with chronic obstructive pulmonary disease (COPD) and asthma remain undiagnosed. Objectives: The objective of this study was to evaluate symptoms, quality of life, healthcare use, and work productivity in subjects with undiagnosed COPD or asthma compared with those previously diagnosed, as well as healthy control subjects. Methods: This multicenter population-based case-finding study randomly recruited adults with respiratory symptoms who had no previous history of diagnosed lung disease from 17 Canadian centers using random digit dialing. Participants who exceeded symptom thresholds on the Asthma Screening Questionnaire or the COPD Diagnostic Questionnaire underwent pre- and post-bronchodilator spirometry to determine if they met diagnostic criteria for COPD or asthma. Two control groups, a healthy group without respiratory symptoms and a symptomatic group with previously diagnosed COPD or asthma, were similarly recruited. Measurements and Main Results: A total of 26,905 symptomatic individuals were interviewed, and 4,272 subjects were eligible. Of these, 2,857 completed pre- and post-bronchodilator spirometry, and 595 (21%) met diagnostic criteria for COPD or asthma. Individuals with undiagnosed COPD or asthma reported greater impact of symptoms on health status and daily activities, worse disease-specific and general quality of life, greater healthcare use, and poorer work productivity than healthy control subjects. Individuals with undiagnosed asthma had symptoms, quality of life, and healthcare use burden similar to those of individuals with previously diagnosed asthma, whereas subjects with undiagnosed COPD were less disabled than those with previously diagnosed COPD. Conclusions: Undiagnosed COPD or asthma imposes important, unmeasured burdens on the healthcare system and is associated with poor health status and negative effects on work productivity.

Early detection of chronic obstructive pulmonary disease in primary care: a randomised controlled trial

BACKGROUND

Worldwide, chronic obstructive pulmonary disease (COPD) remains largely underdiagnosed.

AIM

To assess whether the use of Global Initiative for Chronic Obstructive Lung Disease (GOLD) questions and COPD coordination, either alone or combined, would detect new COPD cases in primary care.

DESIGN AND SETTING

GPs in Brittany, France, systematically enrolled patients aged 40-80 years over a 4-month period in this French multicentre cluster randomised controlled study.

METHOD

GPs were randomly allocated to one of four groups: control (standard of care), GOLD questions (adapted from symptoms and risk factors identified by GOLD), COPD coordination, and GOLD questions with COPD coordination. New cases of COPD were those confirmed by spirometry: post-bronchodilator forced expiratory volume in 1 second over forced vital capacity of <0.7.

RESULTS

In total, 11 430 consultations were conducted by 47 GPs, who enrolled 3162 patients who did not have prior diagnosed asthma or COPD. Among these, 802 (25%) were enrolled in the control, 820 (26%) in the GOLD questions, 802 (25%) in the COPD coordination, and 738 (23%) in the GOLD questions with COPD coordination groups. In the control group, COPD was not evoked, and no spirometry was prescribed. All new cases of COPD diagnosed (n = 24, 0.8%) were in the intervention groups, representing 6.8% of patients who performed spirometry. Statistically significantly more new cases of COPD were detected with COPD coordination (P = 0.01).

CONCLUSION

Interventions that can be easily implemented, such as the GOLD questions and COPD coordination, can identify new cases of COPD. Studies are needed to identify the most appropriate case-finding strategies for GPs to detect COPD in primary care for each country.

Use of CAPTURE to Identify Individuals Who May or May Not Require Treatment for Chronic Obstructive Pulmonary Disease

Rationale: The CAPTURE tool (Chronic Obstructive Pulmonary Disease [COPD] Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk) was developed to identify patients with undiagnosed COPD with an FEV1 <60% predicted or risk of exacerbation as treatment criteria. Objectives: To test the ability of CAPTURE to identify patients requiring treatment because of symptoms or risk of exacerbation or hospitalization. Methods: Data were from COMPASS (Clinical, Radiological and Biological Factors Associated with Disease Progression, Phenotypes and Endotypes of COPD in China), a prospective study of COPD, chronic bronchitis without airflow limitation (postbronchodilator FEV1/FVC ratio ≥0.70), and healthy never-smokers. CAPTURE was tested as questions alone and with peak expiratory flow measurement. Sensitivity, specificity, and positive and negative predicted values (PPV and NPV) were calculated for COPD Assessment Test (CAT) scores ⩾10 versus <10, modified Medical Research Council (mMRC) scores ⩾2 versus <2, and at least one moderate exacerbation or hospitalization in the previous year versus none. Measurements and Main Results: Patients with COPD (n = 1,696) had a mean age of 65 ± 7.5 years, and 90% were male, with a postbronchodilator FEV1 of 66.5 ± 20.1% predicted. Control participants (n = 307) had a mean age of 60.2 ± 7.0 years, and 65% were male, with an FEV1/FVC ratio of 0.78 ± 0.04. CAPTURE using peak expiratory flow showed the best combination of sensitivity and specificity. Sensitivity and specificity were 68.5% and 64.0%, respectively, to detect a CAT score ⩾10; 85.6% and 61.0% to detect an mMRC score ⩾2; 63.5% and 55.6% to detect at least one moderate exacerbation; and 70.2% and 59.4% to detect at least one hospitalization. PPVs ranged from 15.6% (moderate exacerbations) to 47.8% (CAT score). NPVs ranged from 80.8% (CAT score) to 95.6% (mMRC score). Conclusions: CAPTURE has good sensitivity to identify patients with COPD who may require treatment because of increased symptoms or risk of exacerbations or hospitalization, including those with an FEV1 >60% predicted. High NPV values show that CAPTURE can also exclude those who may not require treatment. Clinical trial registered with www.clinicaltrials.gov (NCT04853225).

Pathogenesis and management of emphysema in people with HIV

INTRODUCTION

Since early in the HIV epidemic, emphysema has been identified among people with HIV (PWH) and has been associated with increased mortality. Smoking cessation is key to risk reduction. Health maintenance for PWH and emphysema should ensure appropriate vaccination and lung cancer screening. Treatment should adhere to inhaler guidelines for the general population, but inhaled corticosteroid (ICS) should be used with caution. Frontiers in treatment include targeted therapeutics. Major knowledge gaps exist in the epidemiology of and optimal care for PWH and emphysema, particularly in low and middle-income countries (LMIC).

AREAS COVERED

Topics addressed include risk factors, pathogenesis, current treatment and prevention strategies, and frontiers in research.

EXPERT OPINION

There are limited data on the epidemiology of emphysema in LMIC, where more than 90% of deaths from COPD occur and where the morbidity of HIV is most heavily concentrated. The population of PWH is aging, and age-related co-morbidities such as emphysema will only increase in salience. Over the next 5 years, the authors anticipate novel trials of targeted therapy for emphysema specific to PWH, and we anticipate a growing body of evidence to inform optimal clinical care for lung health among PWH in LMIC.