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Pagano L, McKeough Z, Wootton SL, Chan ASL, Mahadev S, Zwar N, Pallavicini D, Dennis S. Acceptability and barriers of a GP-physiotherapist partnership in the diagnosis and management of COPD in primary care: A qualitative study. Health Expect 2023; 27:e13935. [PMID: 38063819 PMCID: PMC10757211 DOI: 10.1111/hex.13935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/24/2023] [Accepted: 11/27/2023] [Indexed: 01/01/2024] Open
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is commonly diagnosed and managed in primary care but there is evidence that this has been suboptimal, with low confidence expressed in providing interventions requiring behaviour change. The aim of this study was to determine the acceptability of a general practitioner (GP)-physiotherapist partnership in the diagnosis and management of COPD in primary care and to explore the experiences of participants during the implementation of the model. METHODS Semi-structured interviews were conducted with physiotherapists (n = 3), GPs (n = 2), practice nurses (PNs) (n = 2) and patients (n = 12) who had participated in the InNovaTivE Gp-physiotheRapist pArTnErship for copD (INTEGRATED) trial. We sought to explore participants' views about their experiences and perceived benefits, barriers and facilitators to the implementation of this model of care. Interviews were transcribed, coded and thematically analysed. Synthesis of the data was guided by the Theoretical Domains Framework for clinician interviews and the health belief model for patient interviews. RESULTS All clinicians felt that this integrated model helped to optimise care for patients with COPD by facilitating evidence-based practice. GPs and PNs valued the physiotherapist's knowledge and skills relating to diagnosis and management, which was reported to complement their own management and improve patient outcomes. Patients reported a sense of empowerment following their appointments and acknowledged improved self-management skills. However, physiotherapists reported many patients were already engaging in positive health behaviours. Responses were mixed on the effectiveness of the model in facilitating teamwork between clinicians with different perspectives concerning management, communication pathways and logistical issues, such as time and room availability, being cited as barriers. CONCLUSIONS An experienced cardiorespiratory physiotherapist embedded into a small number of primary care practices to work in partnership with GPs for COPD diagnosis and management was acceptable and viewed as beneficial for patients. Barriers relating to logistics and resources remain, which must be addressed to optimise implementation. PATIENT OR PUBLIC CONTRIBUTION Patient input was obtained from qualitative feedback from a prior study conducted by two authors and was used to refine the model of care to determine the added value of a physiotherapist integrated into the primary care team. This feedback was also used to refine the interview guides utilised in this study determine the acceptability of this model of care. We had health service involvement from the rehabilitation service of the local health district who were directly involved in determining study aims and establishing the project around the priorities for their chronic disease integration service. For example, this project aimed to engage with a less severe patient population in primary care who would benefit from pulmonary rehabilitation. The findings from this study will be used to further tailor the model of care to the needs of the public and patients. TRIAL REGISTRATION ACTRN12619001127190.
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Affiliation(s)
- Lisa Pagano
- Sydney School of Health Sciences, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
- Present address:
Australian Institute of Health Innovation, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyNSWAustralia
| | - Zoe McKeough
- Sydney School of Health Sciences, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
| | - Sally L. Wootton
- Sydney School of Health Sciences, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
- Chronic Disease Community Rehabilitation ServiceNorthern Sydney Local Health DistrictSydneyNew South WalesAustralia
| | - Andrew S. L. Chan
- Department of Respiratory and Sleep MedicineRoyal North Shore HospitalSt LeonardsNew South WalesAustralia
- Northern Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Sriram Mahadev
- Department of Respiratory and Sleep MedicineRoyal North Shore HospitalSt LeonardsNew South WalesAustralia
- Northern Clinical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Nicholas Zwar
- Faculty of Health Sciences and MedicineBond UniversityGold CoastQueenslandAustralia
| | | | - Sarah Dennis
- Sydney School of Health Sciences, Faculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
- Ingham Institute for Applied Medical ResearchSydneyNew South WalesAustralia
- South Western Sydney Local Health DistrictLiverpoolNew South WalesAustralia
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Rodwin BA, DeRycke EC, Han L, Bade BC, Brandt CA, Bastian LA, Akgün KM. Characteristics Associated with Spirometry Guideline Adherence in VA Patients Hospitalized with Chronic Obstructive Pulmonary Disease. J Gen Intern Med 2023; 38:619-626. [PMID: 36241942 PMCID: PMC9971396 DOI: 10.1007/s11606-022-07826-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 09/16/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends at least annual spirometry for patients with chronic obstructive pulmonary disease (COPD). Since spirometry acquisition is variable in clinical practice, identifying characteristics associated with annual spirometry may inform strategies to improve care for patients with COPD. METHODS We included veterans hospitalized for COPD at Veterans Health Administration (VHA) facilities from 10/2012 to 09/2015. Our primary outcome was spirometry within 1 year of COPD hospitalization. Patient demographics, health factors, and comorbidities as well as practice and geographic variables were identified using Corporate Data Warehouse; provider characteristics were obtained from the Survey of Healthcare Experiences of Patients. We used logistic regression with a random intercept to account for potential clustering within facilities. RESULTS Spirometry was completed 1 year before or after hospitalization for 20,683/38,148 (54.2%) veterans across 114 facilities. Patients with spirometry were younger, (mean=67.2 years (standard deviation (SD)=9.3) vs. 69.4 (10.3)), more likely non-white (21.3% vs. 19.7%), and more likely to have comorbidities (p<0.0001 for asthma, depression, and post-traumatic stress disorder). Pulmonary clinic visit was most strongly associated with spirometry (odds ratio (OR)=3.14 [95% confidence interval 2.99-3.30]). There was no association for facility complexity. In a secondary analysis including provider-level data (3862 patients), results were largely unchanged. There was no association between primary care provider age, gender, or type (physician vs. advanced practice registered nurse vs. physician assistant) and spirometry. CONCLUSION In a cohort of high-risk COPD patients, just over half completed spirometry within 1 year of hospitalization. Pulmonary clinic visit was most strongly associated with 1-year spirometry, though provider variables were not. Spirometry completion for high-risk COPD patients remains suboptimal and strategies to improve post-hospitalization care for patients not seen in pulmonary clinic should be developed to ensure guideline concordant care.
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Affiliation(s)
- Benjamin A Rodwin
- VA Connecticut Healthcare System, West Haven, CT, USA.
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Eric C DeRycke
- Department of Veterans Affairs, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, USA
| | - Ling Han
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Veterans Affairs, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, USA
| | - Brett C Bade
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Cynthia A Brandt
- Department of Veterans Affairs, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, USA
| | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Veterans Affairs, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Veterans Affairs, Pain Research, Informatics, Multimorbidities, and Education Center, West Haven, USA
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Carlsson L, Holm M, Edlund M, Ekström M, Torén K. Ever Smoking is Not Associated with Performed Spirometry while Occupational Exposure and Respiratory Symptoms are. Int J Chron Obstruct Pulmon Dis 2023; 18:341-348. [PMID: 36960354 PMCID: PMC10029369 DOI: 10.2147/copd.s394832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
Objective Despite recommendations, assessment using spirometry or peak expiratory flow is insufficient in the clinical evaluation of suspected obstructive pulmonary disease. The aim was to investigate factors associated with performing spirometry or peak flow expiratory flow assessment. Methods Randomly selected subjects from the general population aged 50-65 completed a respiratory questionnaire with items about the history of previously performed spirometry or peak expiratory flow. The association between ever having had spirometry or peak expiratory flow performed was analyzed for smoking, age, sex, occupational exposures, dyspnea, wheeze, self-reported physician diagnosed asthma and COPD using multivariable logistic regression models. The results are presented as odds ratios (OR) with 95% confidence intervals (95% CIs). Results Of the 1105 participants, 43.4% (n=479) had a history of previously performed spirometry or peak expiratory flow. Occupational exposure (OR 1.72, [95% CI] 1.30-2.27), wheeze (OR 2.29, 1.41-3.70), and dyspnea (OR 1.70, 1.11-2.60) were associated with previously performed spirometry. Compared to men, women had spirometry or peak expiratory flow performed less often (OR 0.67, 0.51-0.86). Neither current smoking (OR 0.83, 0.57-1.20) or former smoking (OR 1.27, 0.96-1.67) were associated with performed spirometry or peak expiratory flow. Conclusion We found no relation between smoking status and a history of previously performed spirometry or peak expiratory flow in a population-based sample of middle-aged people. This is surprising regarding the strong guidelines which highlight the importance for spirometry surveillance on current smokers due to their increased risk of lung disease. Male sex, respiratory symptoms and occupational exposures to air pollution were associated with previously performed spirometry or peak expiratory flow. The association with occupational exposure may be an effect of pre-employment screening and workplace surveillance, and the findings indicate that females do not receive the same attention regarding spirometry or peak expiratory flow.
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Affiliation(s)
- Linnea Carlsson
- Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Occupational and Environmental Medicine, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Correspondence: Linnea Carlsson, Occupational and Environmental Medicine, Department of Medicine, Sahlgrenska University Hospital, PO Box 414, Gothenburg, SE 405 30, Sweden, Email
| | - Mathias Holm
- Occupational and Environmental Medicine, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Edlund
- Occupational and Environmental Medicine, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
| | - Kjell Torén
- Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Discipline of Occupational and Environmental Health, University of KwaZulu-Natal, Durban, South Africa
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Design of the Reducing Diagnostic Error to Improve Patient Safety (REDEfINE) in COPD and asthma study: A cluster randomized comparative effectiveness trial. Contemp Clin Trials 2022; 123:106971. [PMID: 36280032 DOI: 10.1016/j.cct.2022.106971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 01/27/2023]
Abstract
Although spirometry is a simple, portable test and recommended for the diagnosis of asthma and chronic obstructive pulmonary disease (COPD), it is not routinely used in the primary care setting. Minorities and underserved populations are less likely to have spirometry assessment, leading to both over and misdiagnosis of asthma and COPD. Because dyspnea is a common symptom across multiple diseases, use of spirometry as a diagnostic tool is important. Missed, delayed, or misdiagnosis of asthma and COPD, which are considered diagnostic errors (DE), can lead to poor quality of care, increased morbidity and mortality, and increased costs to patients and health systems. Barriers to the use of spirometry have been identified at clinician/clinic and health systems levels. The REDEFINE program is designed to overcome identified barriers to spirometry use in primary care by utilizing health promoters (HPs) who perform spirometry within primary care clinics and work collaboratively with clinicians to incorporate the results at the point of care without interrupting clinic workflow. The REDEFINE trial is a comparative effectiveness study comparing outcomes of the REDEFINE program with usual care (UC) in primary care patients determined to be at increased risk of DE for asthma and COPD. The primary outcome will be all-cause hospitalizations. The secondary outcomes will be the proportion of accurate diagnosis of COPD, asthma, or asthma-COPD overlap based on initial diagnosis and spirometry and all cause and respiratory-related acute outpatient care and emergency department visits. In this report, we describe the design and methods for the REDEFINE trial. Trial registration: NCT03137303https://clinicaltrials.gov/ct2/show/NCT03137303?term=REDEFINE&draw=2&rank=1.
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Pagano L, McKeough Z, Wootton S, Zwar N, Dennis S. Accuracy of the COPD diagnostic questionnaire as a screening tool in primary care. BMC PRIMARY CARE 2022; 23:78. [PMID: 35421929 PMCID: PMC9010070 DOI: 10.1186/s12875-022-01685-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The COPD Diagnostic Questionnaire (CDQ) was developed to identify people who would benefit from spirometry testing to confirm Chronic Obstructive Pulmonary Disease (COPD). The aim of this study was to determine the usefulness of a cut-off score of 16.5 on the CDQ in identifying those at increased risk of obstruction, in a mixed population of people 'at risk' of COPD and those with an 'existing' COPD diagnosis. METHODS People 'at risk' of COPD (aged > 40 years, current/ex-smoker) and those with 'existing' COPD were identified from four general practices and invited to participate. Participants completed the CDQ and those with a CDQ score ≥ 16.5 were categorised as having intermediate to increased likelihood of airflow obstruction. Pre and post-bronchodilator spirometry determined the presence of airway obstruction (FEV1/FVC ratio < 0.7). Sensitivity, specificity and accuracy of the CDQ was determined compared to spirometry as the gold standard. RESULTS One hundred forty-one participants attended an initial assessment ('at risk' = 111 (79%), 'existing' COPD = 30 (21%)). A cut-off score of 16.5 corresponded to a sensitivity of 81%, specificity of 36% and accuracy of 50%, in the entire mixed population. The area under the ROC curve was 0.59 ± 0.50 indicating low diagnostic accuracy of the CDQ. Similar results were found in the 'existing' COPD group alone. CONCLUSION Whilst a cut-off score of 16.5 on the CDQ may result in a large number of false positives, clinicians may still wish to use the CDQ to refine who receives spirometry due to its high sensitivity. TRIAL REGISTRATION ANZCTR, ACTRN12619001127190. Registered 12 August 2019 - Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx.
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Affiliation(s)
- Lisa Pagano
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
| | - Zoe McKeough
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
| | - Sally Wootton
- Chronic Disease Community Rehabilitation Service, Northern Sydney Local Health District, Sydney, Australia
| | - Nicholas Zwar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Sarah Dennis
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia.
- Ingham Institute for Applied Medical Research, Liverpool, Australia.
- South Western Sydney Local Health District, Liverpool, Australia.
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Baldomero AK, Kunisaki KM, Bangerter A, Nelson DB, Wendt CH, Fortis S, Hagedorn H, Dudley RA. Beyond Access: Factors Associated With Spirometry Underutilization Among Patients With a Diagnosis of COPD in Urban Tertiary Care Centers. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2022; 9:538-548. [PMID: 36040836 PMCID: PMC9718583 DOI: 10.15326/jcopdf.2022.0303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Rationale Many patients with suspected chronic obstructive pulmonary disease (COPD) do not undergo spirometry to confirm the diagnosis. Underutilization is often attributed to barriers to accessing spirometry. Objective Our objective wasto identify factors associated with spirometry underutilization for patients who are less likely to face access barriers related to travel, insurance, and availability of spirometry. Methods A retrospective analysis was conducted of patients enrolled in the Veterans Health Administration and living in urban areas with a new diagnosis of COPD between 2012 to 2015, reducing out-of-pocket cost and travel barriers, respectively. We included only patients whose primary care clinic was located in an academically affiliated tertiary level facility with spirometry available. We used logistic regression to estimate associations between patient characteristics and receipt of spirometry within 2 years before or after COPD diagnosis. Results Of 24,300 patients, 59.7% had spirometry. Compared to patients <55 years, patients 75-84 years had an adjusted odds ratio (aOR) of undergoing spirometry of 0.80 (95% confidence interval [CI]:0.72-0.90), while patients ≥85 years had an aOR of 0.47 (95%CI: 0.40-0.54). Compared to patients with a Charlson Comorbidity Index (CCI) ≥3, patients with a CCI of 0 had an aOR of 0.60 (95%CI:0.54-0.67). Patients who had not seen a pulmonary specialist had lower odds of receiving spirometry (aOR 0.38 [95%CI:0.35-0.41]). Conclusion Spirometry underutilization persists among patients who are less likely to have access barriers related to travel, insurance, and availability of spirometry. Spirometry underutilization is associated with older age, not having received pulmonary care, and having fewer comorbidities. COPD care quality initiatives will need to address these factors.
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Affiliation(s)
- Arianne K. Baldomero
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States,Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, United States,Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States
| | - Ken M. Kunisaki
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States,Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ann Bangerter
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States
| | - David B. Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States
| | - Chris H. Wendt
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States,Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, United States
| | - Spyridon Fortis
- Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa, United States,Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, United States
| | - Hildi Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States
| | - R. Adams Dudley
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States,Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, United States,Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, United States
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Comorbid Anxiety and Depression, Though Underdiagnosed, Are Not Associated with High Rates of Low-Value Care in Patients with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 18:442-451. [PMID: 33306930 DOI: 10.1513/annalsats.201912-877oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with chronic obstructive pulmonary disease (COPD) and anxiety or depression experience more symptoms and exacerbations than patients without these comorbidities. Failure to provide beneficial COPD therapies to appropriate patients (underuse) and provision of potentially harmful therapies to patients without an appropriate indication (overuse) could contribute to respiratory symptoms and exacerbations. Anxiety and depression are known to affect the provision of health services for other comorbid conditions; therefore, underuse or overuse of therapies may explain the increased risk of severe symptoms among these patients.Objectives: To determine whether diagnosed anxiety and depression, as well as significant anxiety and depression symptoms, are associated with underuse and overuse of appropriate COPD therapies.Methods: We analyzed data from a multicenter prospective cohort study of 2,376 participants (smokers and control subjects) enrolled between 2010 and 2015. We identified two subgroups of participants, one at risk for inhaled corticosteroid (ICS) overuse and one at risk for long-acting bronchodilator (LABD) underuse based on the 2011 Global Initiative for Chronic Obstructive Lung Disease statement. Our primary outcomes were self-reported overuse and underuse. Our primary exposures of interest were self-reported anxiety and depression and significant anxiety and depression symptoms. We adopted a propensity-score method with inverse probability of treatment weighting adjusting for differences in prevalence of confounders and performed inverse probability of treatment weighting logistic regression to evaluate all associations between the exposures and outcomes.Results: Among the 1,783 study participants with COPD confirmed by spirometry, 667 (37.4%) did not have an indication for ICS use, whereas 985 (55.2%) had an indication for LABD use. Twenty-five percent (n = 167) of patients reported ICS use, and 72% (n = 709) denied LABD use in each subgroup, respectively. Neither self-reported anxiety and depression nor significant anxiety and depression symptoms were associated with overuse or underuse. At least 50% of patients in both subgroups with significant symptoms of anxiety or depression did not report a preexisting mental health diagnosis.Conclusions: Underuse of LABDs and overuse of ICSs are common but are not associated with comorbid anxiety or depression diagnosis or symptoms. Approximately one-third of individuals with COPD experience anxiety or depression, and most are undiagnosed. There are significant opportunities to improve disease-specific and patient-centered treatment for individuals with COPD.
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Pagano L, McKeough Z, Wootton S, Crone S, Pallavicini D, Chan ASL, Mahadev S, Zwar N, Dennis S. The feasibility of an innovative GP-physiotherapist partnership to identify and manage chronic obstructive pulmonary disease (INTEGRATED): study protocol. Pilot Feasibility Stud 2020; 6:138. [PMID: 32983555 PMCID: PMC7513496 DOI: 10.1186/s40814-020-00680-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) contributes significantly to mortality, hospitalisations and health care costs worldwide. There is evidence that the detection, accurate diagnosis and management of COPD are currently suboptimal in primary care. Physiotherapists are well-trained in cardiorespiratory management and chronic care but are currently underutilised in primary care. A cardiorespiratory physiotherapist working in partnership with general practitioners (GPs) has the potential to improve quality of care for people with COPD. METHODS A prospective pilot study will test the feasibility of an integrated model of care between GPs and physiotherapists to improve the diagnosis and management of people with COPD in primary care. Four general practices will be selected to work in partnership with four physiotherapists from their local health district. Patients at risk of developing COPD or those with a current diagnosis of COPD will be invited to attend a baseline assessment with the physiotherapist, including pre- and post-bronchodilator spirometry to identify new cases of COPD or confirm a current diagnosis and stage of COPD. The intervention for those with COPD will involve the physiotherapist and GP working in partnership to develop and implement a care plan involving the following tailored to patient need: referral to pulmonary rehabilitation (PR), physical activity counselling, medication review, smoking cessation, review of inhaler technique and education. Process outcomes will include the number of people invited and reviewed at the practice, the proportion with a new diagnosis of COPD, the number of patients eligible and referred to PR and the number who attended PR. Patient outcomes will include changes in symptoms, physical activity levels, smoking status and self-reported exacerbations. DISCUSSION If feasible, we will test the integration of physiotherapists within the primary care setting in a cluster randomised controlled trial. If the model improves health outcomes for the growing numbers of people with COPD, then it may provide a GP-physiotherapist model of care that could be tested for other chronic conditions. TRIAL REGISTRATION ANZCTR, ACTRN12619001127190. Registered on 12 August 2019-retrospectively registered.
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Affiliation(s)
- Lisa Pagano
- Discipline of Physiotherapy, University of Sydney, Sydney, Australia
| | - Zoe McKeough
- Discipline of Physiotherapy, University of Sydney, Sydney, Australia
| | - Sally Wootton
- Discipline of Physiotherapy, University of Sydney, Sydney, Australia
- Chronic Disease Community Rehabilitation Service, Northern Sydney Local Health District, St Leonards, Australia
| | - Stephen Crone
- Chronic Disease Community Rehabilitation Service, Northern Sydney Local Health District, St Leonards, Australia
| | | | - Andrew S. L. Chan
- Royal North Shore Hospital, St Leonards, Australia
- Northern Clinical School, University of Sydney, Sydney, Australia
| | - Sriram Mahadev
- Royal North Shore Hospital, St Leonards, Australia
- Northern Clinical School, University of Sydney, Sydney, Australia
| | - Nicholas Zwar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Sarah Dennis
- Discipline of Physiotherapy, University of Sydney, Sydney, Australia
- Ingham Institute for Applied Medical Research, Liverpool, Australia
- South Western Sydney Local Health District, Liverpool, Australia
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Lidcombe, NSW 2141 Australia
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Tran D, Lim M, Vogrin S, Jayaram L. Point of Care Portable Spirometry in the Diagnosis and Treatment of Inpatients with Chronic Obstructive Pulmonary Disease. Lung 2020; 198:143-150. [PMID: 31894409 DOI: 10.1007/s00408-019-00314-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Spirometry is required to accurately diagnose chronic obstructive pulmonary disease (COPD). Following an acute exacerbation, it is recommended that spirometry be performed after a delay of 4-6 weeks to allow stability and a measure of 'baseline' lung function. However, poor attendance at these appointments can occur, leading to an inability to confirm the diagnosis of COPD or assess the severity of airflow obstruction. Portable spirometry (PS) is a proven surrogate device that may provide a convenient method to address these issues. The purpose of this study was to compare PS values, obtained prior to hospital discharge to laboratory-based spirometry (LS) results undertaken 4 weeks later. METHODS Thirty-three eligible inpatients with a clinically determined exacerbation of COPD were recruited. Patients underwent PS prior to discharge and LS 4 weeks later. RESULTS Reliability of PS values at discharge compared with outpatient LS 4 weeks later was excellent (intraclass correlation coefficient > 0.9). The PS confirmed a new diagnosis of COPD at the bedside in 29% of patients and excluded COPD in 6% at both time points. Patients were found to have a similar severity of airflow obstruction on both PS and LS, with clinical stability maintained between visits. The PS and LS may be used interchangeably for earlier diagnosis of COPD. PS at the point of discharge from hospital offers a unique opportunity to diagnose and facilitate COPD management from hospital to primary care.
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Affiliation(s)
- Donald Tran
- The University of Melbourne, Melbourne, Australia.,Department of Medicine, Respiratory & Sleep Disorders, Western Health, Melbourne, Australia
| | - Melvin Lim
- Department of Medicine, Respiratory & Sleep Disorders, Western Health, Melbourne, Australia
| | - Sara Vogrin
- The University of Melbourne, Melbourne, Australia
| | - Lata Jayaram
- The University of Melbourne, Melbourne, Australia. .,Department of Medicine, Respiratory & Sleep Disorders, Western Health, Melbourne, Australia.
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Morgan E, Lazear J. Implementation of Pulmonary Function Testing in Rural Primary Care. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2018.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fisk M, McMillan V, Brown J, Holzhauer-Barrie J, Khan MS, Baxter N, Roberts CM. Inaccurate diagnosis of COPD: the Welsh National COPD Audit. Br J Gen Pract 2019; 69:e1-e7. [PMID: 30559109 PMCID: PMC6301368 DOI: 10.3399/bjgp18x700385] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/20/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The diagnosis of chronic obstructive pulmonary disease (COPD) is confirmed with spirometry demonstrating persistent airflow obstruction. AIM To evaluate the clinical characteristics and management of patients in primary care on COPD registers with spirometry incompatible with COPD. DESIGN AND SETTING A primary care audit of Welsh COPD Read-Coded patient data from the Quality and Outcomes Framework (QOF) COPD register in Wales. METHOD Patients on the QOF COPD register with incompatible spirometry (post-bronchodilator forced expiratory lung volume in 1 second/forced vital capacity [FEV1/FVC] ratio ≥0.70) were compared with those with compatible spirometry (FEV1/FVC <0.70). RESULTS This audit included 63% of Welsh practices contributing 48 105 patients. Only 19% (n = 8957) of patients were post-bronchodilator FEV1/FVC Read-Coded and were included in this study. Of these, 75% (n = 6702) had compatible spirometry and 25% (n = 2255) did not. Patients with incompatible spirometry were more likely female (P = 0.009), never-smokers (P<0.001), had higher body mass index (P<0.001), and better mean FEV1 (P<0.001). Medical Research Council (MRC) breathlessness scores, exacerbation frequency, and asthma co-diagnosis were similar between groups. Patients in both groups were just as likely to receive inhaled corticosteroid (ICS) and long-acting beta-agonists (LABAs), but patients with incompatible spirometry were less likely to receive long-acting muscarinic antagonists (LAMAs) (P<0.001) or LABA/ICS (P = 0.002) combinations. CONCLUSION Patients on the COPD QOF register with spirometry incompatible with COPD are symptomatic and managed using significant resources. If quality of care and effective resource use are to be improved, focus must be given to correct diagnosis in this group.
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Affiliation(s)
- Marie Fisk
- Experimental Medicine and Immunotherapeutics (EMIT) Department, University of Cambridge, Cambridge
| | | | - James Brown
- Royal Free London NHS Foundation Trust and UCL Respiratory, Division of Medicine, University College London, London
| | | | | | - Noel Baxter
- National COPD Audit Programme Primary Care Workstream, Royal College of Physicians, London
| | - C Michael Roberts
- National COPD Audit Programme; associate director, Clinical Effectiveness and Evaluation Unit, Care Quality Improvement Department, Royal College of Physicians, London
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12
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Nida, Lone KP. Plasma surfactant protein-A levels in apparently healthy smokers, stable and exacerbation COPD patients. Pak J Med Sci 2018; 34:934-939. [PMID: 30190756 PMCID: PMC6115589 DOI: 10.12669/pjms.344.13951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: To compare the plasma level of surfactant protein-A in apparently healthy smokers, stable and exacerbation Chronic Obstructive Pulmonary Disease (COPD) patients. Methods: This was a comparative study conducted from January, 2015 to March, 2016. This study was conducted on 87 subjects of both gender and age between 30-70 years. Of the total 87 subjects; 29 subjects were “healthy smokers” selected from general population as control group. Another 29 were “stable COPD” patients free of exacerbation since last six weeks. Lastly, another 29 subjects were “exacerbated COPD” patients with 7-10 days of exacerbation. COPD was diagnosed on the basis of relevant history and spirometry showing post bronchodilator FEV1/FVC <0.70. Surfactant Protein-A level (ng/ml) was estimated by a specific solid phase enzyme linked immunosorbent assay (ELISA) using automated EIA analyzer. Results: The SP-A levels, determined by competitive ELISA, was significantly higher (P<0.025) in healthy smokers (44.19±39.17 ng/ml) and exacerbated (43.86±40.17) than the stable COPD (25.89±18.85) patients. The lung function parameters (FEV1, FVC and FEV1/ FVC) were lower in COPD patients compared to healthy smokers and were related to the duration of smoking. Conclusion: Current smokers and exacerbated patients had higher values of SP-A protein than stable COPD patients since they had stopped smoking.
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Affiliation(s)
- Nida
- Nida, Department of Physiology & Cell Biology, The University of Health Sciences, Khayaban-e-Jamia, Lahore, Pakistan
| | - Khalid Parvez Lone
- Khalid Parvez Lone, Department of Physiology & Cell Biology, The University of Health Sciences, Khayaban-e-Jamia, Lahore, Pakistan
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13
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Nardini S, Annesi-Maesano I, Simoni M, Ponte AD, Sanguinetti CM, De Benedetto F. Accuracy of diagnosis of COPD and factors associated with misdiagnosis in primary care setting. E-DIAL (Early DIAgnosis of obstructive lung disease) study group. Respir Med 2018; 143:61-66. [PMID: 30261994 DOI: 10.1016/j.rmed.2018.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 08/03/2018] [Accepted: 08/12/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and results in both substantial and increasing socioeconomic burden. Guidelines on COPD encourage primary care physicians to detect the disease at an early stage. Our main aim was to evaluate the accuracy of the diagnosis of COPD at the primary health care. METHODS 6466 patients were randomly selected in 22 Italian primary care practices (46% males, mean age 56 ± 16 years) and were asked about respiratory symptoms and risk for any chronic respiratory disease including COPD. After a prior evaluation, 701 patients (51% males, mean age 59 ± 15 years) were sent by General Practitioners (GPs) to Pulmonary Units (PU) for confirming the diagnosis. The agreement in diagnosing COPD between GPs and pulmonary diseases specialists was assessed by using Cohen's kappa (k) statistic. RESULTS Lack of precision in COPD diagnosis resulted in 13% of over-diagnosis and 59% of under-diagnosis. GPs were quite good in correctly excluding the patients who did not have COPD (specificity = 87%), but less good in diagnosing the patients with COPD (sensitivity = 41%). The risk of under-diagnosis was higher in people with age >62 years and in current/ex-smokers, when compared to no COPD, whereas it was higher in subject <62 years old and in those with no previous spirometry when compared to correctly diagnosed COPD. CONCLUSION Our results confirm that COPD misdiagnosis is common in primary care and that under-diagnosis is a major problem. It is necessary to enhance COPD diagnosis and to reduce misdiagnosis in primary care settings.
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Affiliation(s)
- Stefano Nardini
- Division of Respiratory Medicine, Vittorio Veneto Hospital, Vittorio Veneto, Italy
| | - Isabella Annesi-Maesano
- Epidemiology of Allergic and Respiratory Diseases Department (EPAR), Sorbonne Université, INSERM, Pierre Louis Institute of Epidemiology and Public Health, Saint-Antoine Medical School, Paris, France.
| | - Marzia Simoni
- Epidemiology of Allergic and Respiratory Diseases Department (EPAR), Sorbonne Université, INSERM, Pierre Louis Institute of Epidemiology and Public Health, Saint-Antoine Medical School, Paris, France
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14
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Adekunle AO, Watson T, Schreuder FM. Pulmonary rehabilitation: Uptake and completion profile of patients with chronic obstructive pulmonary disease. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2017. [DOI: 10.12968/ijtr.2017.24.9.385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims: Pulmonary rehabilitation is effective in the management of chronic obstructive pulmonary disease patients; however, 33% of patients referred for pulmonary rehabilitation do not start the programme. This study examines the relationship between participation in outpatient pulmonary rehabilitation and baseline measures of disease severity and psychosocial variables in chronic obstructive pulmonary disease patients. Methods: In an observational study and before their first outpatient pulmonary rehabilitation appointment, chronic obstructive pulmonary disease patients completed outcome measures of depression (Brief Assessment Depression Card), social support (Duke Social Support Index), multidimensional health locus of control and chronic obstructive pulmonary disease severity (Medical Research Council dyspnoea scale). Data on attendance at the pulmonary rehabilitation appointments were obtained from the pulmonary rehabilitation register. Results: A total of 51 patients (mean age 77.2 years, male=20), completed the study. Results indicated that the if the patient has depression, there was a moderate, but statistically significant association (P=0.02) with the uptake of pulmonary rehabilitation. There was no significant correlation between uptake status and any of the domains of multidimensional health locus of control, Duke Social Support Index or Medical Research Council dyspnea score (P>0.005). Conclusion: Patients with chronic obstructive pulmonary disease and depression are less likely to take up a referral to pulmonary rehabilitation compared to those without depression. Social support, multidimensional health locus, and chronic obstructive pulmonary disease severity does not have a relationship with the uptake or completion of outpatient pulmonary rehabilitation.
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Affiliation(s)
- Ademola O Adekunle
- Principal researcher, Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Tim Watson
- Professor of physiotherapy, Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Fiona M Schreuder
- Senior Lecturer, Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
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15
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Tumin D, Jackson EJ, Hayes D. Medicaid expansion and chronic obstructive pulmonary disease among low‐income adults in the United States. CLINICAL RESPIRATORY JOURNAL 2017; 12:1398-1406. [DOI: 10.1111/crj.12668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 06/28/2017] [Accepted: 07/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Dmitry Tumin
- Department of PediatricsThe Ohio State UniversityColumbus Ohio
- Center for Epidemiology of Organ Failure and TransplantationNationwide Children's HospitalColumbus Ohio
- Department of Anesthesiology and Pain MedicineNationwide Children's HospitalColumbus Ohio
| | - Edwin J. Jackson
- Department of Internal MedicineThe Ohio State UniversityColumbus Ohio
| | - Don Hayes
- Department of PediatricsThe Ohio State UniversityColumbus Ohio
- Center for Epidemiology of Organ Failure and TransplantationNationwide Children's HospitalColumbus Ohio
- Department of Internal MedicineThe Ohio State UniversityColumbus Ohio
- Department of SurgeryThe Ohio State UniversityColumbus Ohio
- Section of Pulmonary MedicineNationwide Children's HospitalColumbus Ohio
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16
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Elbehairy AF, Parraga G, Webb KA, Neder JA, O’Donnell DE. Mild chronic obstructive pulmonary disease: why spirometry is not sufficient! Expert Rev Respir Med 2017; 11:549-563. [DOI: 10.1080/17476348.2017.1334553] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Amany F. Elbehairy
- Department of Medicine, Queen’s University and Kingston General Hospital, Kingston, ON, Canada
- Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Grace Parraga
- Department of Medical Biophysics, Robarts Research Institute, Western University, London, Canada
| | - Katherine A. Webb
- Department of Medicine, Queen’s University and Kingston General Hospital, Kingston, ON, Canada
| | - J Alberto Neder
- Department of Medicine, Queen’s University and Kingston General Hospital, Kingston, ON, Canada
| | - Denis E. O’Donnell
- Department of Medicine, Queen’s University and Kingston General Hospital, Kingston, ON, Canada
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17
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Skinner TR, Scott IA, Martin JH. Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen Med 2016; 9:137-46. [PMID: 27284262 PMCID: PMC4881921 DOI: 10.2147/ijgm.s96741] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Misdiagnosis, either over- or underdiagnosis, exposes older patients to increased risk of inappropriate or omitted investigations and treatments, psychological distress, and financial burden. Objective To evaluate the frequency and nature of diagnostic errors in 16 conditions prevalent in older patients by undertaking a systematic literature review. Data sources and study selection Cohort studies, cross-sectional studies, or systematic reviews of such studies published in Medline between September 1993 and May 2014 were searched using key search terms of “diagnostic error”, “misdiagnosis”, “accuracy”, “validity”, or “diagnosis” and terms relating to each disease. Data synthesis A total of 938 articles were retrieved. Diagnostic error rates of >10% for both over- and underdiagnosis were seen in chronic obstructive pulmonary disease, dementia, Parkinson’s disease, heart failure, stroke/transient ischemic attack, and acute myocardial infarction. Diabetes was overdiagnosed in <5% of cases. Conclusion Over- and underdiagnosis are common in older patients. Explanations for over-diagnosis include subjective diagnostic criteria and the use of criteria not validated in older patients. Underdiagnosis was associated with long preclinical phases of disease or lack of sensitive diagnostic criteria. Factors that predispose to misdiagnosis in older patients must be emphasized in education and clinical guidelines.
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Affiliation(s)
- Thomas R Skinner
- Department of Internal Medicine, Sunshine Coast Health Service District, Nambour Hospital, Nambour, QLD, Australia
| | - Ian A Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia; Southern School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jennifer H Martin
- Southern School of Medicine, University of Queensland, Brisbane, QLD, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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18
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Han MK, Martinez CH, Au DH, Bourbeau J, Boyd CM, Branson R, Criner GJ, Kalhan R, Kallstrom TJ, King A, Krishnan JA, Lareau SC, Lee TA, Lindell K, Mannino DM, Martinez FJ, Meldrum C, Press VG, Thomashow B, Tycon L, Sullivan JL, Walsh J, Wilson KC, Wright J, Yawn B, Zueger PM, Bhatt SP, Dransfield MT. Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective. THE LANCET RESPIRATORY MEDICINE 2016; 4:473-526. [PMID: 27185520 DOI: 10.1016/s2213-2600(16)00094-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 12/21/2022]
Abstract
The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.
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Affiliation(s)
- MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Carlos H Martinez
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - David H Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, and VA Puget Sound Health Care System, US Department of Veteran Affairs, Seattle, WA, USA; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Jean Bourbeau
- McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard Branson
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital & Health Sciences System, University of Illinois, Chicago, IL, USA
| | - Suzanne C Lareau
- University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL, USA
| | | | - David M Mannino
- Department of Preventive Medicine and Environmental Health, University of Kentucky, Lexington, KY, USA
| | - Fernando J Martinez
- Department of Internal Medicine, Weill Cornell School of Medicine, New York, NY, USA
| | - Catherine Meldrum
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - Valerie G Press
- Section of Hospital Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Byron Thomashow
- Division of Pulmonary, Critical Care and Sleep Medicine, Columbia University Medical Center, New York, NY, USA
| | - Laura Tycon
- Palliative and Supportive Institute, Pittsburgh, PA, USA
| | | | | | - Kevin C Wilson
- Boston University School of Medicine, Boston, MA, USA; American Thoracic Society, New York, NY, USA
| | - Jean Wright
- Carolinas HealthCare System, Charlotte, NC, USA
| | - Barbara Yawn
- Family and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Patrick M Zueger
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, and UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
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José BPDS, Camargos PAM, Cruz Filho ÁASD, Corrêa RDA. Diagnostic accuracy of respiratory diseases in primary health units. Rev Assoc Med Bras (1992) 2015; 60:599-612. [PMID: 25650863 DOI: 10.1590/1806-9282.60.06.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 03/24/2014] [Indexed: 11/22/2022] Open
Abstract
Respiratory diseases are responsible for about a fifth of all deaths worldwide and its prevalence reaches 15% of the world population. Primary health care (PHC) is the gateway to the health system, and is expected to resolve up to 85% of health problems in general. Moreover, little is known about the diagnostic ability of general practitioners (GPs) in relation to respiratory diseases in PHC. This review aims to evaluate the diagnostic ability of GPs working in PHC in relation to more prevalent respiratory diseases, such as acute respiratory infections (ARI), tuberculosis, asthma and chronic obstructive pulmonary disease (COPD). 3,913 articles were selected, totaling 30 after application of the inclusion and exclusion criteria. They demonstrated the lack of consistent evidence on the accuracy of diagnoses of respiratory diseases by general practitioners. In relation to asthma and COPD, studies have shown diagnostic errors leading to overdiagnosis or underdiagnosis depending on the methodology used. The lack of precision for the diagnosis of asthma varied from 54% underdiagnosis to 34% overdiagnosis, whereas for COPD this ranged from 81% for underdiagnosis to 86.1% for overdiagnosis. For ARI, it was found that the inclusion of a complementary test for diagnosis led to an improvement in diagnostic accuracy. Studies show a low level of knowledge about tuberculosis on the part of general practitioners. According to this review, PHC represented by the GP needs to improve its ability for the diagnosis and management of this group of patients constituting one of its main demands.
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Affiliation(s)
- Bruno Piassi de São José
- UFMG Pneumology Outpatient Clinic, Hospital das Clínicas, Federal University of Minas Gerais Medical School, Belo Horizonte, MG, Brazil
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A clinical study of COPD severity assessment by primary care physicians and their patients compared with spirometry. Am J Med 2015; 128:629-37. [PMID: 25595469 DOI: 10.1016/j.amjmed.2014.12.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/18/2014] [Accepted: 12/18/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Primary care physicians often do not use spirometry to confirm the diagnosis of chronic obstructive pulmonary disease. This project was designed to see how well physicians' impressions about their patients' chronic obstructive pulmonary disease severity correlate with the severity of airflow obstruction measured by spirometry and to assess whether spirometry results subsequently changed the physicians' opinions about chronic obstructive pulmonary disease severity and treatment. METHODS We performed a multicenter, cross-sectional, observational study conducted in 83 primary care clinics from across the United States. A total of 899 patients with a clinical diagnosis of chronic obstructive pulmonary disease completed a questionnaire and spirometry testing. Physicians completed a questionnaire and case report forms. Concordance among physician ratings, patient ratings, and spirometry results was evaluated. RESULTS Physicians' chronic obstructive pulmonary disease severity ratings before spirometry were accurate for only 30% of patients with evaluable spirometry results, and disease severity in 41% of patients was underestimated. Physicians also underestimated severity compared with patients' self-assessment among 42% of those with evaluable results. After spirometry, physicians changed their opinions on the severity for 30% of patients and recommended treatment changes for 37%. Only 75% of patients performed at least 1 high-quality spirometry test; however, the physicians' opinions and treatment decisions were similar regardless of suboptimal test results. CONCLUSIONS Without performing spirometry, physicians are likely to underestimate their patients' chronic obstructive pulmonary disease severity or inadequately characterize their patients' lung disease. Spirometry changed the physicians' clinical impressions and treatments for approximately one third of these patients; thus, spirometry is a valuable tool for chronic obstructive pulmonary disease management in primary care.
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Mapel DW, Roberts MH. Management of asthma and chronic obstructive pulmonary disease with combination inhaled corticosteroids and long-acting β-agonists: a review of comparative effectiveness research. Drugs 2015; 74:737-55. [PMID: 24797158 PMCID: PMC4030099 DOI: 10.1007/s40265-014-0214-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The value of combination therapy with inhaled corticosteroids and long-acting β-agonists (ICS/LABA) is well recognized in the management of asthma and chronic obstructive pulmonary disease (COPD). Despite differences in the pharmacological properties between two well-established ICS/LABA products (budesonide/formoterol and fluticasone/salmeterol), data from randomized clinical trials (RCTs) and meta-analyses suggest that these two products perform similarly under RCT conditions. In contrast, a few recently reported real-world comparative effectiveness studies have suggested that there are substantial differences between ICS/LABA combination treatments in terms of clinical and healthcare outcomes in patients with asthma or COPD. The purpose of this article is to provide a brief review of the benefits, as well as the limitations, of comparative effectiveness research (CER) in the therapeutic area of asthma and COPD. We conducted a structured literature review of the current CER studies on ICS/LABA combinations in asthma and COPD. These articles were then used to illustrate the unique challenges of CER studies, providing a summary of study results and limitations. We focus particularly on difficult biases and confounding factors that may be introduced before, during, and after the initiation of therapy. Beyond being a review of these two ICS/LABA combination treatments, this article is intended to help those who wish to assess the quality of CER published projects in asthma and COPD, or guide investigators who wish to design new CER studies for chronic respiratory disease treatments.
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Affiliation(s)
- Douglas W Mapel
- Lovelace Clinic Foundation, 2309 Renard Place SE, Albuquerque, NM, 87106, USA,
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22
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Collins BF, Feemster LC, Rinne ST, Au DH. Factors predictive of airflow obstruction among veterans with presumed empirical diagnosis and treatment of COPD. Chest 2015; 147:369-376. [PMID: 25079684 PMCID: PMC4314814 DOI: 10.1378/chest.14-0672] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/07/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite guideline recommendations, patients suspected of having COPD often are treated empirically instead of undergoing spirometry to confirm airflow obstruction (AFO). Accurate diagnosis and treatment are essential to provide high-quality, value-oriented care. We sought to identify predictors associated with AFO among patients with and treated for COPD prior to performance of confirmatory spirometry. METHODS We identified a cohort of veterans with spirometry performed at Pacific Northwest Department of Veterans Affairs medical centers between 2003 and 2007. We included only patients with empirically diagnosed COPD in the 2 years prior to spirometry who were also taking inhaled medication to treat COPD in the 1 year prior to spirometry. We used relative risk regression analysis to identify predictors of AFO. RESULTS Among patients empirically treated for COPD (N = 3,209), 62% had AFO. Risk factors such as older age, prior smoking status, and underweight status were associated with AFO on spirometry. In contrast, comorbidities often associated with somatic symptoms were associated with absence of AFO and included congestive heart failure, depression, diabetes, obesity, and sleep apnea. CONCLUSIONS Comorbidities associated with somatic complaints of dyspnea were associated with a lower risk of having airflow limitations, suggesting that empirical diagnosis and treatment of COPD may lead to inappropriate treatment of individuals who do not have AFO.
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Affiliation(s)
- Bridget F Collins
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Laura C Feemster
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Seppo T Rinne
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - David H Au
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
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van Dijk W, Tan W, Li P, Guo B, Li S, Benedetti A, Bourbeau J. Clinical relevance of fixed ratio vs lower limit of normal of FEV1/FVC in COPD: patient-reported outcomes from the CanCOLD cohort. Ann Fam Med 2015; 13:41-8. [PMID: 25583891 PMCID: PMC4291264 DOI: 10.1370/afm.1714] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The way in which spirometry is interpreted can lead to misdiagnosis of chronic obstructive pulmonary disease (COPD) resulting in inappropriate treatment. We compared the clinical relevance of 2 criteria for defining a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC): the fixed ratio and the lower limit of normal. METHODS We analyzed data from the cross-sectional phase of the population-based Canadian Cohort of Obstructive Lung Disease (CanCOLD) study. We determined associations of the spirometric criteria for airflow limitation with patient-reported adverse outcomes, including respiratory symptoms, disability, health status, exacerbations, and cardiovascular disease. Sensitivity analyses were used to explore the impact of age and severity of airflow limitation on these associations. RESULTS We analyzed data from 4,882 patients aged 40 years and older. The prevalence of airflow limitation was 17% by fixed ratio and 11% by lower limit of normal. Patients classified as having airflow limitation by fixed ratio only had generally small, nonsignificant increases in the odds of adverse outcomes. Patients having airflow limitation based on both fixed ratio and lower limit of normal had larger, significant increases in odds. But strongest associations were seen for patients who had airflow limitation by both fixed ratio and lower limit of normal and also had a low FEV1, defined as one less than 80% of the predicted value. CONCLUSIONS Our results suggest that use of the fixed ratio alone may lead to misdiagnosis of COPD. A diagnosis established by both a low FEV1/FVC (according to fixed ratio and/or lower limit of normal) and a low FEV1 is strongly associated with clinical outcomes. Guidelines should be reconsidered to require both spirometry abnormalities so as to reduce overdiagnosis of COPD.
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Affiliation(s)
- Wouter van Dijk
- Department of Primary and Community Care, Radboud University, Nijmegen Medical Centre, Nijmegen, the Netherlands Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - Wan Tan
- UBC James Hogg Research Centre, Providence Heart and Lung Institute, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Pei Li
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - Best Guo
- UBC James Hogg Research Centre, Providence Heart and Lung Institute, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Summer Li
- UBC James Hogg Research Centre, Providence Heart and Lung Institute, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
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Small M, Higgins V, Lees A, Johns N, Mastrangelo A, Nazareth T, Turner SJ. Physician-Patient Concordance in Pharmacological Management of Patients with COPD. COPD 2015; 12:473-83. [PMID: 26244570 PMCID: PMC4776681 DOI: 10.3109/15412555.2014.995287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A retrospective analysis of a cross-sectional, multicenter survey was conducted in United States (US) medical practices to evaluate the concordance between patients with COPD and their physicians on disease-specific characteristics. Associations between patient and disease-related characteristics with monotherapy, dual therapy, or triple therapy prescribed as COPD maintenance regimens were also examined. Eligible physicians completed patient record forms (PRFs) for up to 6 consecutive patients with COPD. Patients for whom a PRF was completed were invited to complete a patient self-completion (PSC) survey consisting of questions similar to those on the PRF, as well as several validated measures to assess the impact of COPD on patients' lives. A total of 469 patients completed a PSC that was matched with the PRF completed by their physician, forming the sample for the concordance analysis. Moderate agreement (kappa (κ) = 0.41-0.60) was observed for 79% of measures, with the lowest concordance rating corresponding to hemoptysis (κ = 0.22). There were few differences in demographic or clinical characteristics between patients prescribed monotherapy and dual therapy. Triple therapy rather than monotherapy or dual therapy was more often prescribed for patients with greater frequency of symptoms, negative impact of COPD on daily life and interpersonal relationships, and respiratory impairment based on the most recent FEV1. Diverse factors influence US physicians' perceptions of disease and treatment choices, including patient symptoms, quality of life, and disease impact. Our results highlight that concordance between physicians and patients regarding symptoms and physical function may contribute to optimal management of COPD.
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Affiliation(s)
- Mark Small
- Adelphi Real World, Adelphi Mill, Bollington, Cheshire, United Kingdom
| | - Victoria Higgins
- Adelphi Real World, Adelphi Mill, Bollington, Cheshire, United Kingdom
| | - Adam Lees
- Adelphi Real World, Adelphi Mill, Bollington, Cheshire, United Kingdom
| | - Nicola Johns
- Adelphi Real World, Adelphi Mill, Bollington, Cheshire, United Kingdom
| | | | - Tara Nazareth
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Stuart J. Turner
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
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Prieto-Centurion V, Rolle AJ, Au DH, Carson SS, Henderson AG, Lee TA, Lindenauer PK, McBurnie MA, Mularski RA, Naureckas ET, Vollmer WM, Joese BJ, Krishnan JA. Multicenter study comparing case definitions used to identify patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2014; 190:989-95. [PMID: 25192554 DOI: 10.1164/rccm.201406-1166oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Clinical trials in chronic obstructive pulmonary disease (COPD) usually require evidence of airflow obstruction and clinical risk factors. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes or patient-reported physician diagnoses are often used for epidemiologic studies and performance improvement programs. OBJECTIVES To evaluate agreement between these case definitions for COPD and to assess the comparability of study populations identified as having COPD not using the clinical trial reference standard. METHODS We recruited patients from the COPD Outcomes-based Network for Clinical Effectiveness and Research Translation multicenter clinical registry in a cross-sectional study. Demographics, clinical, and post-bronchodilator spirometry data were collected at an in-person study visit. The kappa statistic (κ) was used to evaluate agreement. A multivariable logistic regression model was used to identify patient characteristics associated with meeting the trial reference standard. MEASUREMENTS AND MAIN RESULTS A total of 998 (82.8%) of 1,206 study participants met at least one case definition for COPD (of the 998: 91% using ICD-9 codes, 73% using patient-reported physician diagnosis, 56% using trial reference standard); agreement between case definitions was poor (κ = 0.20-0.26). Lack of airflow obstruction was the principal (89%) reason patients identified as having COPD did not meet the trial reference standard. Patients who were black (vs. white), obese (vs. normal weight), or had depression (vs. not) were less likely to meet the trial reference standard (odds ratio [95% CI], 0.37 [0.26-0.53], 0.51 [0.34-0.75], 0.53 [0.40-0.71], respectively). CONCLUSIONS Findings highlight concerns about the applicability of findings in clinical trials to patients meeting other case definitions for COPD.
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Luize AP, Menezes AMB, Perez-Padilla R, Muiño A, López MV, Valdivia G, Lisboa C, Montes de Oca M, Tálamo C, Celli B, Nascimento OA, Gazzotti MR, Jardim JR. Assessment of five different guideline indication criteria for spirometry, including modified GOLD criteria, in order to detect COPD: data from 5,315 subjects in the PLATINO study. NPJ Prim Care Respir Med 2014; 24:14075. [PMID: 25358021 PMCID: PMC4373468 DOI: 10.1038/npjpcrm.2014.75] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/04/2014] [Accepted: 08/05/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Spirometry is the gold standard for diagnosing chronic obstructive pulmonary disease (COPD). Although there are a number of different guideline criteria for deciding who should be selected for spirometric screening, to date it is not known which criteria are the best based on sensitivity and specificity. AIMS Firstly, to evaluate the proportion of subjects in the PLATINO Study that would be recommended for spirometry testing according to Global initiative for Obstructive Lung Disease (GOLD)-modified, American College of Chest Physicians (ACCP), National Lung Health Education Program (NLHEP), GOLD and American Thoracic Society/European Respiratory Society (ATS/ERS) criteria. Secondly, we aimed to compare the sensitivity, specificity, and positive predictive and negative predictive values, of these five different criteria. METHODS Data from the PLATINO study included information on respiratory symptoms, smoking and previous spirometry testing. The GOLD-modified spirometry indication criteria are based on three positive answers out of five questions: the presence of cough, phlegm in the morning, dyspnoea, age over 40 years and smoking status. RESULTS Data from 5,315 subjects were reviewed. Fewer people had an indication for spirometry (41.3%) according to the GOLD-modified criteria, and more people had an indication for spirometry (80.4%) by the GOLD and ATS/ERS criteria. A low percentage had previously had spirometry performed: GOLD-modified (14.5%); ACCP (13.2%); NLHEP (12.6%); and GOLD and ATS/ERS (12.3%). The GOLD-modified criteria showed the least sensitivity (54.9) and the highest specificity (61.0) for detecting COPD, whereas GOLD and ATS/ERS criteria showed the highest sensitivity (87.9) and the least specificity (20.8). CONCLUSION There is a considerable difference in the indication for spirometry according to the five different guideline criteria. The GOLD-modified criteria recruit less people with the greatest sum of sensitivity and specificity.
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Affiliation(s)
- Ana P Luize
- Respiratory Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Rogelio Perez-Padilla
- Respiratory Division, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Adriana Muiño
- Respiratory Division, Universidad de la República, Montevideo, Uruguay
| | | | - Gonzalo Valdivia
- Respiratory Division, Pontifícia Universidad Católica de Chile, Santiago, Chile
| | - Carmem Lisboa
- Respiratory Division, Pontifícia Universidad Católica de Chile, Santiago, Chile
| | | | - Carlos Tálamo
- Respiratory Division, Universidad Central de Venezuela, Caracas, Venezuela
| | - Bartolomé Celli
- Brighans Women´s Hospital, Harvard University, Boston, MA, USA
| | | | - Mariana R Gazzotti
- Respiratory Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José R Jardim
- Respiratory Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Lewis A, Bruton A, Donovan-Hall M. Uncertainty prior to pulmonary rehabilitation in primary care: A phenomenological qualitative study in patients with chronic obstructive pulmonary disease. Chron Respir Dis 2014; 11:173-180. [PMID: 24980128 DOI: 10.1177/1479972314539981] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pulmonary rehabilitation (PR) is recommended for patients functionally restricted by chronic obstructive pulmonary disease (COPD). However, attendance and adherence to PR remains suboptimal. No previous research has explored COPD patient experiences during the key period from referral to initiation of PR in the United Kingdom. This research aimed to explore the lived experience of COPD patients referred to PR programmes prior to participation. COPD participants were recruited from referrals to two community PR programmes. Semi-structured interviews with COPD participants occurred following PR referral, but prior to programme initiation. Data were analyzed using applied interpretive phenomenology. Twenty-five COPD participants aged 42-90 were interviewed. 'Uncertainty' affected participants throughout their lived experience of COPD that negatively impacted illness perceptions, PR perceptions and increased participant's panic and anger. Participants who perceived COPD less as a chronic condition and more as a cyclical process experienced fewer feelings of panic or anger. The experience of uncertainty was disabling for these COPD participants. Recognition of the role that uncertainty plays in patients with COPD is the first step towards developing interventions focused on reducing this uncertainty, thereby reducing the burden of the disease for the individual patient and facilitating PR attendance.
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Affiliation(s)
- Adam Lewis
- Faculty of Health Sciences, University of Southampton, UK Solent NHS Trust, UK Respiratory Care Team, Virgin Care, Peach Portacabins, Bournewood House, St Peters Hospital, Chertsey, UK
| | - Anne Bruton
- Faculty of Health Sciences, University of Southampton, UK
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28
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Nishi SPE, Wang Y, Kuo YF, Goodwin JS, Sharma G. Spirometry use among older adults with chronic obstructive pulmonary disease: 1999-2008. Ann Am Thorac Soc 2013; 10:565-73. [PMID: 24053440 PMCID: PMC3960963 DOI: 10.1513/annalsats.201302-037oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 07/31/2013] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Clinical practice guidelines recommend spirometry to diagnose chronic obstructive pulmonary disease (COPD) and facilitate management. National trends in spirometry use in older adults with newly diagnosed COPD are not known. OBJECTIVES To examine the rate and beneficiary characteristics associated with spirometry use in subjects with newly diagnosed COPD between 1999 and 2008. METHODS We examined newly diagnosed beneficiaries with COPD using a 5% Medicare population from 1999 to 2008. A new COPD diagnosis required two outpatient visits or one hospitalization with primary International Classification of Diseases, 9th edition code 491.xx, 492.xx, or 496 occurring at least 30 days apart with none in the prior 12 months. The primary measurement was spirometry performed within 365 days (±) of the first claim with a COPD diagnosis. MEASUREMENTS AND MAIN RESULTS Between 1999 and 2008, 64,985 subjects were newly diagnosed with COPD. Of these, 35,739 (55%) had spirometry performed within 1 year before or after the initial diagnosis of COPD. Spirometry use increased from 51.3% in 1999 to 58.3% in 2008 (P < 0.001). Subjects with younger age, men, whites, those with higher socioeconomic status, and those with a greater number of comorbidities were more likely to have spirometry. In a multivariable analysis, compared with 1999, subjects diagnosed in 2008 had 10% higher odds (odds ratio, 1.10; 95% confidence interval, 1.06-1.13) of having spirometry performed. CONCLUSIONS Despite an increase in the use of spirometry over time in newly diagnosed older adults with COPD, spirometry use remains low. Clinical practice guidelines and educational efforts should focus on increasing the use of spirometry to diagnose and manage COPD.
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Affiliation(s)
- Shawn P. E. Nishi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Yue Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
| | - Yong-Fang Kuo
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Galveston, Texas
| | - James S. Goodwin
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Galveston, Texas
| | - Gulshan Sharma
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Galveston, Texas
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van Dijk WD, Gupta N, Tan WC, Bourbeau J. Clinical relevance of diagnosing COPD by fixed ratio or lower limit of normal: a systematic review. COPD 2013; 11:113-20. [PMID: 23862613 DOI: 10.3109/15412555.2013.781996] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Different spirometric criteria in diagnosing COPD have been advocated by different groups, debilitating adequate diagnosis and treatment of COPD. We reviewed the clinical relevance of fixed ratio and lower limit of normal (LLN) in diagnosing COPD and explored if modifying factors may affect their clinical relevance. METHODS Two reviewers independently searched PubMed and Embase for papers that compared both criteria on any clinically relevant outcome, published before June 1st, 2012, without any language restriction. Two reviewers independently extracted the study characteristics, including study design, population characteristics and diagnostic criteria used, and summarized the results of clinical relevance. Study quality was assessed by scoring forms for bias and level of evidence. RESULTS Of 394 studies retrieved, 11 studies were included, with a median of 1,258 participants. Although both criteria appeared related with various clinically relevant outcomes, we were unable to prefer one criterion over the other, with various performances of the criteria for different outcomes. Should the criteria disagree on diagnosis, an alternative diagnosis should be suspected, in particular in those (elderly) with less severe airflow limitation for whom the LLN appears a better criterion. The fixed ratio appears to perform better in subjects with more severe airflow limitation. CONCLUSION In diagnosing COPD, severity of airflow limitation appears an important factor for choosing whether the fixed ratio or LLN. Disagreement between the criteria is suggestive for an alternative diagnosis. Future studies on clinical relevance should further reveal the criterion of choice, in order to improve adequate diagnosis and consequent treatments.
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Affiliation(s)
- Wouter D van Dijk
- 1Department of Primary and Community Care, Radboud University Nijmegen Medical Centre , Nijmegen , the Netherlands
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30
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Prieto Centurion V, Huang F, Naureckas ET, Camargo CA, Charbeneau J, Joo MJ, Press VG, Krishnan JA. Confirmatory spirometry for adults hospitalized with a diagnosis of asthma or chronic obstructive pulmonary disease exacerbation. BMC Pulm Med 2012; 12:73. [PMID: 23217023 PMCID: PMC3538708 DOI: 10.1186/1471-2466-12-73] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 11/29/2012] [Indexed: 11/16/2022] Open
Abstract
Background Objective measurement of airflow obstruction by spirometry is an essential part of the diagnosis of asthma or COPD. During exacerbations, the feasibility and utility of spirometry to confirm the diagnosis of asthma or chronic obstructive pulmonary disease (COPD) are unclear. Addressing these gaps in knowledge may help define the need for confirmatory testing in clinical care and quality improvement efforts. This study was designed to determine the feasibility of spirometry and to determine its utility to confirm the diagnosis in patients hospitalized with a physician diagnosis of asthma or COPD exacerbation. Methods Multi-center study of four academic healthcare institutions. Spirometry was performed in 113 adults admitted to general medicine wards with a physician diagnosis of asthma or COPD exacerbation. Two board-certified pulmonologists evaluated the spirometry tracings to determine the proportion of patients able to produce adequate quality spirometry data. Findings were interpreted to evaluate the utility of spirometry to confirm the presence of obstructive lung disease, according to the 2005 European Respiratory Society/American Thoracic Society recommendations. Results There was an almost perfect agreement for acceptability (κ = 0.92) and reproducibility (κ =0.93) of spirometry tracings. Three-quarters (73%) of the tests were interpreted by both pulmonologists as being of adequate quality. Of these adequate quality tests, 22% did not present objective evidence of obstructive lung disease. Obese patients (BMI ≥30 kg/m2) were more likely to produce spirometry tracings with no evidence of obstructive lung disease, compared to non-obese patients (33% vs. 8%, p = 0.007). Conclusions Adequate quality spirometry can be obtained in most hospitalized adults with a physician diagnosis of asthma or COPD exacerbation. Confirmatory spirometry could be a useful tool to help reduce overdiagnosis of obstructive lung disease, especially among obese patients.
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Loerbroks A, Jiang CQ, Thomas GN, Adab P, Zhang WS, Lam KBH, Bosch JA, Cheng KK, Lam TH. COPD and Depressive Symptoms: Findings from the Guangzhou Biobank Cohort Study. Ann Behav Med 2012; 44:408-15. [DOI: 10.1007/s12160-012-9389-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Rahaghi FF, Sandhaus RA, Brantly ML, Rouhani F, Campos MA, Strange C, Hogarth DK, Eden E, Stocks JM, Krowka MJ, Stoller JK. The prevalence of alpha-1 antitrypsin deficiency among patients found to have airflow obstruction. COPD 2012; 9:352-8. [PMID: 22506682 DOI: 10.3109/15412555.2012.669433] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Alpha-1 antitrypsin deficiency (AATD) is a genetic disease that may be manifested by chronic obstructive pulmonary disease. Despite professional society guidelines that recommend broad testing of at-risk individuals, fewer than 10% of affected individuals have been identified. The goals of this study were to estimate the frequency of abnormal AAT genotypes among patients found to have fixed airflow obstruction and to assess the feasibility of having Pulmonary Function Laboratory personnel administer the study. METHODS Nineteen medical centers in the United States participated in the study. Eligible patients (> GOLD II, FEV(1)/FVC ratio < 0.7, with post-bronchodilator FEV(1)<80% predicted) were offered testing for AATD by the Pulmonary Function Laboratory personnel at the time of pulmonary function testing. RESULTS A total of 3,457 patients were tested, of whom 3152 were eligible. Deficient patients (ZZ, SZ) constituted 0.63% of subjects, while 10.88% were carriers (MS, MZ). Neither demographic (except African-American race) nor post-bronchodilator pulmonary function variables (FEV(1), FVC, FEV(1)/FVC ratio, TLC, and FEV(1)/FVC) allowed us to predict AAT heterozygote or deficiency status. CONCLUSIONS The prevalence of AATD among patients undergoing pulmonary function tests with fixed airflow obstruction was 0.63%. Pulmonary Function Laboratory personnel effectively conducted the study.
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Affiliation(s)
- Franck F Rahaghi
- Cleveland Clinic Florida, Pulmonary and Critical Care, Weston, Florida 33332, USA.
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Practical management problems of stable chronic obstructive pulmonary disease in the elderly. Curr Opin Pulm Med 2012; 17 Suppl 1:S43-8. [PMID: 22209930 DOI: 10.1097/01.mcp.0000410747.20958.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) is one of the most prevalent and increasing health problems in the elderly on a worldwide scale. The management of COPD in older patients presents practical diagnostic and treatment issues, which are reviewed with reference to the stable stage of the disease. RECENT FINDINGS In the diagnostic approach of COPD in the elderly the use of spirometry is recommended, but both patient conditions (such as inability to correctly perform it due to fatigue, lack of coordination, and cognitive impairment) and metrics characteristics should be taken into account for the test performance. It has been demonstrated in population studies that the use of the fixed ratio determines a substantial overdiagnosis of COPD in the oldest patients. Other parameters have been suggested [such as the evaluation of Lower Limit of Normality (LLN) for the FEV1/FVC ratio], which may be useful to guide the diagnosis. Several nonpharmacologic - such as smoking cessation, vaccination, physical activity, and pulmonary rehabilitation, nutrition, and eventually invasive ventilation - and pharmacologic interventions have been shown to improve outcomes and have been reviewed. Effective management of COPD in older adults should always consider the ability of patients to properly use inhalers and the involvement of caregivers or family members as a useful support to care, especially when treating cognitively impaired patients. Especially in the older population, timely identification and treatment of comorbidities are also crucial, but evidence in this area is still lacking and clinical practice guidelines do not take comorbidities into account in their recommendations. SUMMARY The Global Initiative for Obstructive Lung Disease has recommended criteria for diagnosis and management of COPD in the general population. On the contrary, available evidence suggests practical limitations in diagnostic approach and intervention strategies in older patients with stable COPD that need to be further studied for a translation into clinical practice guidelines.
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