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Mountain R, Duan KI, Johnson KM. Benefit-Harm Analysis of Earlier Initiation of Triple Therapy for Prevention of Acute Exacerbation in Patients with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2024; 21:1139-1146. [PMID: 38578813 DOI: 10.1513/annalsats.202311-990oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/04/2024] [Indexed: 04/07/2024] Open
Abstract
Rationale: Reducing the risk of exacerbation is a fundamental goal in managing stable chronic obstructive pulmonary disease (COPD). Guidelines recommend triple therapy (inhaled corticosteroids, long-acting muscarinic antagonists, and long-acting β-agonists) only as a stepup from dual therapy (long-acting muscarinic antagonists and long-acting β-agonists) for patients at continued high risk of exacerbation, because of the trade-off of an increased risk of pneumonia associated with inhaled corticosteroid-containing therapies. However, there is little evidence on the optimum timing of initiating triple therapy. Objectives: To perform a benefit-harm analysis to evaluate the net benefit of earlier initiation of triple therapy for the prevention of acute exacerbations in patients with COPD compared with standard timing recommended in current guidelines. Methods: We used a validated whole-disease microsimulation model of COPD in the Canadian general population aged ⩾40 years to determine the benefit versus harm of earlier initiation of triple therapy over a 20-year time horizon compared with standard care. We assessed net change in quality-adjusted life-years (QALYs) from the reduction in risk of acute exacerbations and the increased risk of treatment-related pneumonia in subgroups of patients with COPD defined by exacerbation history, symptoms, and disease severity. Model parameters were determined from clinical trials and other published literature. Key parameters were varied in one-way sensitivity analysis. Results: In patients at high risk of acute exacerbation (54.7% female; mean age, 74.0 yr; 68% Global Initiative for Chronic Obstructive Lung Disease grades I and II), earlier initiation of triple therapy was associated with a net QALY gain of 4.8 per 100 patients with COPD over 20 years compared with standard care. The net QALY gain increased to 5.9 per 100 patients in the subgroup of patients with a high symptom burden (modified Medical Research Council dyspnea scale score, >1). Earlier initiation remained net beneficial in all subgroup and sensitivity analysis scenarios. Conclusions: Modeling suggests that earlier initiation of triple therapy is likely to be net beneficial for patients at high risk of acute exacerbation, with an even greater benefit to patients with a high symptom burden. Further clinical research is needed to verify these findings in empirical studies.
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Affiliation(s)
- Rachael Mountain
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Kevin I Duan
- Division of Respiratory Medicine, Department of Medicine, and
| | - Kate M Johnson
- Division of Respiratory Medicine, Department of Medicine, and
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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2
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Aaron SD, Montes de Oca M, Celli B, Bhatt SP, Bourbeau J, Criner GJ, DeMeo DL, Halpin DMG, Han MK, Hurst JR, Krishnan JK, Mannino D, van Boven JFM, Vogelmeier CF, Wedzicha JA, Yawn BP, Martinez FJ. Early Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease: The Costs and Benefits of Case Finding. Am J Respir Crit Care Med 2024; 209:928-937. [PMID: 38358788 DOI: 10.1164/rccm.202311-2120pp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/14/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Shawn D Aaron
- The Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Maria Montes de Oca
- Universidad Central de Venezuela, Caracas, Venezuela
- Hospital Centro Médico de Caracas, Caracas, Venezuela
| | | | - Surya P Bhatt
- Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jean Bourbeau
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Dawn L DeMeo
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David M G Halpin
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - MeiLan K Han
- Division of Pulmonary & Critical Care, University of Michigan, Ann Arbor, Michigan
| | - John R Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Jamuna K Krishnan
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, New York
| | - David Mannino
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, University of Groningen, Groningen, The Netherlands
| | - Claus F Vogelmeier
- Philipps-Universität Marburg, German Center for Lung Research, Marburg, Germany
| | - Jadwiga A Wedzicha
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Barbara P Yawn
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota; and
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3
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Vaezi A, Mirsaeidi M. Proposing the potential of utilizing the CAT score for early detection of COPD in asymptomatic patients, shifting towards a patient-centered approach: A review. Medicine (Baltimore) 2024; 103:e37715. [PMID: 38608107 PMCID: PMC11018188 DOI: 10.1097/md.0000000000037715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/04/2024] [Indexed: 04/14/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) constitutes a significant public health challenge, with delayed diagnosis and underdiagnosis being pervasive issues. The United States Preventive Service Task Force recommends restricting COPD screening to symptomatic smokers, a focus that has exhibited limitations, leading to delayed diagnoses, and imposing a substantial burden on patients, their families, and the healthcare system. This paper explores an alternative approach, highlighting the potential utility of the COPD assessment test (CAT) score as a prescreening tool. A CAT score of 10 or higher could serve as an appropriate threshold for further diagnostic procedures, given its robust correlation with pulmonary function test parameters and is valuable capacity to quantify patients' symptoms. The utilization of CAT as a prescreening tool in primary care signifies a transition towards a more patient-centered and comprehensive approach to COPD diagnosis and care.
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Affiliation(s)
- Atefeh Vaezi
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, FL
| | - Mehdi Mirsaeidi
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Florida, Jacksonville, FL
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4
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Bhatt SP, Casaburi R, Agusti A, Celli BR, Miller BE, Putcha N, Rommes J, Dransfield MT. Chronic obstructive pulmonary disease: hiding in plain sight, a Statement from the COPD Foundation Medical and Scientific Advisory Committee. THE LANCET. RESPIRATORY MEDICINE 2023; 11:1041-1043. [PMID: 38030371 DOI: 10.1016/s2213-2600(23)00436-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Richard Casaburi
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Alvar Agusti
- University of Barcelona, Respiratory Institute, Clinic Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | | | | | - Nirupama Putcha
- Johns Hopkins University School of Medicine, Pulmonary and Critical Care Medicine, Baltimore, MD, USA
| | | | - Mark T Dransfield
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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5
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Mountain R, Kim D, Johnson KM. Budget impact analysis of adopting primary care-based case detection of chronic obstructive pulmonary disease in the Canadian general population. CMAJ Open 2023; 11:E1048-E1058. [PMID: 37935489 PMCID: PMC10635706 DOI: 10.9778/cmajo.20230023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND An estimated 70% of Canadians with chronic obstructive pulmonary disease (COPD) have not received a diagnosis, creating a barrier to early intervention, and there is growing interest in the value of primary care-based opportunistic case detection for COPD. We sought to build on a previous cost-effectiveness analysis by evaluating the budget impact of adopting COPD case detection in the Canadian general population. METHODS We used a validated discrete-event microsimulation model of COPD in the Canadian general population aged 40 years and older to assess the costs of implementing 8 primary care-based case detection strategies over 5 years (2022-2026) from the health care payer perspective. Strategies varied in eligibility criteria (based on age, symptoms or smoking history) and testing technology (COPD Diagnostic Questionnaire [CDQ] or screening spirometry). Costs were determined from Canadian studies and converted to 2021 Canadian dollars. Key parameters were varied in one-way sensitivity analysis. RESULTS All strategies resulted in higher total costs compared with routine diagnosis. The most cost-effective scenario (the CDQ for all patients) had an associated total budget expansion of $423 million, with administering case detection and subsequent diagnostic spirometry accounting for 86% of costs. This strategy increased the proportion of individuals diagnosed with COPD from 30.4% to 37.8%, and resulted in 4.6 million referrals to diagnostic spirometry. Results were most sensitive to uptake in primary care. INTERPRETATION Adopting a national COPD case detection program would be an effective method for increasing diagnosis of COPD, dependent on successful uptake. However, it will require prioritisation by budget holders and substantial additional investment to improve access to diagnostic spirometry.
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Affiliation(s)
- Rachael Mountain
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences (Mountain, Johnson), University of British Columbia, Vancouver, BC; Centre for Health Informatics, Computing, and Statistics (Mountain), Lancaster Medical School, Lancaster University, Lancaster, UK; Faculty of Medicine (Kim) and Division of Respiratory Medicine, Department of Medicine (Johnson), University of British Columbia, Vancouver, BC
| | - Dexter Kim
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences (Mountain, Johnson), University of British Columbia, Vancouver, BC; Centre for Health Informatics, Computing, and Statistics (Mountain), Lancaster Medical School, Lancaster University, Lancaster, UK; Faculty of Medicine (Kim) and Division of Respiratory Medicine, Department of Medicine (Johnson), University of British Columbia, Vancouver, BC
| | - Kate M Johnson
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences (Mountain, Johnson), University of British Columbia, Vancouver, BC; Centre for Health Informatics, Computing, and Statistics (Mountain), Lancaster Medical School, Lancaster University, Lancaster, UK; Faculty of Medicine (Kim) and Division of Respiratory Medicine, Department of Medicine (Johnson), University of British Columbia, Vancouver, BC
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Zhao L, Zhao Q. Knowledge, attitude, and practice toward disease prevention among a high-risk population for chronic obstructive pulmonary disease: A cross-sectional study. Int J Nurs Sci 2023; 10:238-244. [PMID: 37128490 PMCID: PMC10148251 DOI: 10.1016/j.ijnss.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/08/2023] [Accepted: 03/19/2023] [Indexed: 04/07/2023] Open
Abstract
Objective This study aimed to describe the current situation of knowledge, attitude, and practice (KAP) of chronic obstructive pulmonary disease (COPD) prevention among a high-risk population for COPD. Methods A cross-sectional survey was conducted. A total of 241 participants at risk of COPD were selected who visited the respiratory outpatient department of a Class A tertiary hospital in Chongqing, China from January to December 2021. A self-developed COPD prevention KAP assessment was used for evaluation which included knowledge (21 items), attitude (9 items), and practice (9 items) three dimension, 39 items. Results The average overall KAP score was 68.29 ± 12.91, with scores for the knowledge, attitude, and practice dimension was 68.75 ± 18.07, 71.13 ± 15.09 and 65.00 ± 20.93, respectively. Among the people at risk of COPD, 76.8% experienced a moderate level of KAP toward COPD prevention, while 22.0% were at a poor level. Significant differences in the KAP scores were based on gender, educational level, occupation, type of medical insurance, smoking, and passive smoking status (P < 0.05). The male COPD high-risk group has better KAP toward COPD prevention than the female group (P < 0.05). The knowledge and attitude of COPD prevention present worse in people with a high risk of COPD aged 70 or above, primary school and below educational level, and farmers (P < 0.05). Smoking and passive smoking groups have higher recognition of the knowledge but the lower practice of COPD prevention (P < 0.05). Conclusion The participants with a high risk of COPD had a moderate level of KAP for COPD prevention, in which the understanding and action on vaccination and lung function test was weak, but an active attitude for health. It is necessary to implement tailored health education interventions to their characteristics to reduce the incidence and development of COPD.
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Affiliation(s)
- Lulu Zhao
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Nursing, The People’s Hospital of Dazu, Chongqing, China
| | - Qinghua Zhao
- Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Corresponding author.
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Bhatt SP, Balte PP, Schwartz JE, Jaeger BC, Cassano PA, Chaves PH, Couper D, Jacobs DR, Kalhan R, Kaplan R, Lloyd-Jones D, Newman AB, O’Connor G, Sanders JL, Smith BM, Sun Y, Umans JG, White WB, Yende S, Oelsner EC. Pooled Cohort Probability Score for Subclinical Airflow Obstruction. Ann Am Thorac Soc 2022; 19:1294-1304. [PMID: 35176216 PMCID: PMC9353954 DOI: 10.1513/annalsats.202109-1020oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/16/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Early detection of chronic obstructive pulmonary disease (COPD) is a public health priority. Airflow obstruction is the single most important risk factor for adverse COPD outcomes, but spirometry is not routinely recommended for screening. Objectives: To describe the burden of subclinical airflow obstruction (SAO) and to develop a probability score for SAO to inform potential detection and prevention programs. Methods: Lung function and clinical data were harmonized and pooled across nine U.S. general population cohorts. Adults with respiratory symptoms, inhaler use, or prior diagnosis of COPD or asthma were excluded. A probability score for prevalent SAO (forced expiratory volume in 1 second/forced vital capacity < 0.70) was developed via hierarchical group-lasso regularization from clinical variables in strata of sex and smoking status, and its discriminative accuracy for SAO was assessed in the pooled cohort as well as in an external validation cohort (NHANES [National Health and Nutrition Examination Survey] 2011-2012). Incident hospitalizations and deaths due to COPD (respiratory events) were defined by adjudication or administrative criteria in four of nine cohorts. Results: Of 33,546 participants (mean age 52 yr, 54% female, 44% non-Hispanic White), 4,424 (13.2%) had prevalent SAO. The incidence of respiratory events (Nat-risk = 14,024) was threefold higher in participants with SAO versus those without (152 vs. 39 events/10,000 person-years). The probability score, which was based on six commonly available variables (age, sex, race and/or ethnicity, body mass index, smoking status, and smoking pack-years) was well calibrated and showed excellent discrimination in both the testing sample (C-statistic, 0.81; 95% confidence interval [CI], 0.80-0.82) and in NHANES (C-statistic, 0.83; 95% CI, 0.80-0.86). Among participants with predicted probabilities ⩾ 15%, 3.2 would need to undergo spirometry to detect one case of SAO. Conclusions: Adults with SAO demonstrate excess respiratory hospitalization and mortality. A probability score for SAO using commonly available clinical risk factors may be suitable for targeting screening and primary prevention strategies.
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Affiliation(s)
- Surya P. Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine
- Lung Health Center, and
| | - Pallavi P. Balte
- Division of General Medicine, Columbia University Medical Center, New York, New York
| | - Joseph E. Schwartz
- Division of General Medicine, Columbia University Medical Center, New York, New York
- Department of Psychiatry and Behavioral Health, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Byron C. Jaeger
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patricia A. Cassano
- Division of Nutritional Sciences, Weill Cornell Medical College, Ithaca, New York
| | - Paulo H. Chaves
- Benjamin Leon Center for Geriatric Research and Education, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - David Couper
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - David R. Jacobs
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Ravi Kalhan
- Division of Pulmonary and Critical Care Medicine and
| | - Robert Kaplan
- Albert Einstein College of Medicine, New York, New York
| | - Donald Lloyd-Jones
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | | | - George O’Connor
- Division of Pulmonary, Allergy, Sleep, and Critical Care, Boston University, Boston, Massachusetts
| | - Jason L. Sanders
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | - Jason G. Umans
- Georgetown Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Wendy B. White
- Undergraduate Training and Education Center, Tougaloo College, Tougaloo, Mississippi; and
| | - Sachin Yende
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Elizabeth C. Oelsner
- Division of General Medicine, Columbia University Medical Center, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York
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Bhatt SP, O'Connor GT. Screening for Chronic Obstructive Pulmonary Disease: Challenges and Opportunities. JAMA 2022; 327:1768-1770. [PMID: 35536275 DOI: 10.1001/jama.2022.3823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham
| | - George T O'Connor
- Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
- Associate Editor, JAMA
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Riesco-Miranda JA, Solano-Reina S, Rábade-Castedo C, de Granda-Orive JI, Pastor-Esplá E, García-Rueda M, Callejas-Gonzalez FJ, Azpeitia-Anadón Á, Mas S, Jiménez-Ruiz CA. Certified Smoking Cessation Units in Spain: High Potential for Detection of Undiagnosed Chronic Obstructive Pulmonary Disease and Profile of Newly Diagnosed Cases. Int J Chron Obstruct Pulmon Dis 2021; 16:443-450. [PMID: 33658774 PMCID: PMC7920505 DOI: 10.2147/copd.s289097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/07/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Smokers attending smoking cessation units (SCUs) may offer a unique opportunity for early recognition of undiagnosed chronic obstructive pulmonary disease (COPD). We aimed at assessing the impact of SCUs on the early diagnosis of COPD and describing the clinical and smoking profile of newly-diagnosed COPD cases at SCUs certified by the Spanish Society of Respiratory Diseases and Thoracic Surgery (SEPAR). PATIENTS AND METHODS A multicenter cross-sectional observational cohort study (DIPREPOQ study) was performed in eight SEPAR-certified SCUs in Spain. Adult current smokers with no previously diagnosed respiratory disease and having one o more respiratory symptoms were included. Lung functional tests were performed and previously undiagnosed COPD cases were identified and characterized based on national guidelines. RESULTS Out of 401 individuals newly attending the SCUs, 252 participants were included and 73 (28.9%) met the definition of previously undiagnosed COPD. A characterization of patients with COPD being newly recognized in SCUs showed: age (mean±SD) 61±9 years; men 59%; active work status 53.1%; functional class I/II dyspnea 82.8%, GOLD state mild/moderate/severe 57%/31%/12%; non-exacerbators 90%, CAT 14±4; emphysema in X-rays 40%. Most common co-morbidities were cardiovascular and psychiatric (anxiety and depression) ones. Usual smoking history included a lengthy smoking history (41±9 years) and a current consumption of 24±9 cigarettes/day. CONCLUSIONS AND IMPLICATIONS Consistently certified SCUs can have a substantial contribution to early diagnosis of COPD. A typical profile of newly detected cases is reported, with most patients being men at their early sixties, with mild symptoms and with high and lengthy smoking history. Our study reports a high usefulness of lung functional tests to detect undiagnosed COPD in appropriately selected participants attending SCUs at a large national scale, using a standardized methodology. This is likely to be facilitated by the certification of SCUs using well-defined requirements by national scientific societies.
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Affiliation(s)
| | | | - Carlos Rábade-Castedo
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - José-Ignacio de Granda-Orive
- Servicio de Neumología, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Esther Pastor-Esplá
- Servicio de Neumología, Hospital Universitario San Juan de Alicante, Alicante, Spain
| | | | | | | | - Silvia Mas
- Universidad Pompeu Fabra, Barcelona, Spain
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