Choosing wisely: adherence by physicians to recommended use of spirometry in the diagnosis and management of adult asthma

Leveraging the health equity implementation framework to foster an equity focus in medical education

Teaching equitable clinical practice is of critical importance, yet how best to do so remains unknown. Educators utilize implementation science frameworks to disseminate clinical evidence-based practices (EBP). The Health Equity Implementation Framework (HEIF) is one of these frameworks, and it delineates how health equity may be concomitantly assessed and addressed in planning the implementation of an EBP. The HEIF therefore lays a strong foundation to understand and explain barriers and facilitators to implementation through an equity lens, making it well-suited for use by medical educators. Three equity-focused frames of reference within the model include (1) the clinical encounter, (2) societal context, and (3) culturally relevant factors, herein referred to as domains. The HEIF provides a structure for prospective and retrospective assessment of how EBP are taught and ultimately incorporated into clinical practice by trainees, with specific attention to delivering equitable care. We present three examples of common topics in internal medicine, contextualized by the three equity domains of the HEIF. We additionally acknowledge the limitations of this framework as a research tool with complex features that may not be suitable for brief teaching in the clinical environment. We propose a 360-degree learner assessment to ensure implementation of this framework is successful. By encouraging trainees to explore the narrative experiences of their patients and examine their own implicit biases, the HEIF provides a structure to address gaps in knowledge about delivering equitable care.

Agreement between self-reported and registered age at asthma diagnosis in Finland

INTRODUCTION

In epidemiological studies, the age at asthma onset is often defined by patients' self-reported age at diagnosis. The reliability of this report might be questioned. Our objective was to evaluate the agreement between self-reported and registered age at asthma diagnosis and assess features contributing to the agreement.

METHODS

As part of the FinEsS respiratory survey in 2016, randomly selected population samples of 13,435 from Helsinki and 8000 from Western Finland were studied. Self-reported age at asthma diagnosis was compared to age at asthma diagnosis registered in the Finnish register on special reimbursement for asthma medication. The reimbursement right is based on lung function criteria according to GINA and Finnish guidelines. If the difference was less than 5 years, self-reported diagnosis was considered reliable. Features associated with the difference between self-reported and registered age at asthma diagnosis were evaluated.

RESULTS

Altogether 197 subjects from Helsinki and 144 from Western Finland were included. Of these, 61.9% and 77.8%, respectively, reported age at diagnosis reliably. Median difference between self-reported and registered age at diagnoses was - 2.0 years (IQR - 9.0 to 0) in Helsinki and - 1.0 (IQR - 4.3 to 0) in Western Finland indicating earlier self-reported age at diagnosis. More reliable self-report was associated with non-allergic subjects and subjects who reported having asthma diagnosis more recently.

CONCLUSIONS

Agreement between self-reported and registered age at asthma diagnosis was good especially with adult-onset asthma patients. Poor agreement in early-onset asthma could be related to delay in registration due to reimbursement criteria.

Construction of a Diagnostic Algorithm for Diagnosis of Adult Asthma Using Machine Learning with Random Forest and XGBoost

An evidence-based diagnostic algorithm for adult asthma is necessary for effective treatment and management. We present a diagnostic algorithm that utilizes a random forest (RF) and an optimized eXtreme Gradient Boosting (XGBoost) classifier to diagnose adult asthma as an auxiliary tool. Data were gathered from the medical records of 566 adult outpatients who visited Kindai University Hospital with complaints of nonspecific respiratory symptoms. Specialists made a thorough diagnosis of asthma based on symptoms, physical indicators, and objective testing, including airway hyperresponsiveness. We used two decision-tree classifiers to identify the diagnostic algorithms: RF and XGBoost. Bayesian optimization was used to optimize the hyperparameters of RF and XGBoost. Accuracy and area under the curve (AUC) were used as evaluation metrics. The XGBoost classifier outperformed the RF classifier with an accuracy of 81% and an AUC of 85%. A combination of symptom-physical signs and lung function tests was successfully used to construct a diagnostic algorithm on importance features for diagnosing adult asthma. These results indicate that the proposed model can be reliably used to construct diagnostic algorithms with selected features from objective tests in different settings.

Reductions in inhaler greenhouse gas emissions by addressing care gaps in asthma and chronic obstructive pulmonary disease: an analysis

INTRODUCTION

Climate change from greenhouse gas (GHG) emissions represents one of the greatest public health threats of our time. Inhalers (and particularly metred-dose inhalers (MDIs)) used for asthma and chronic obstructive pulmonary disease (COPD), constitute an important source of GHGs. In this analysis, we aimed to estimate the carbon footprint impact of improving three distinct aspects of respiratory care that drive avoidable inhaler use in Canada.

METHODS

We used published data to estimate the prevalence of misdiagnosed disease, existing inhaler use patterns, medication class distributions, inhaler type distributions and GHGs associated with inhaler actuations, to quantify annual GHG emissions in Canada: (1) attributable to asthma and COPD misdiagnosis; (2) attributable to overuse of rescue inhalers due to suboptimally controlled symptoms; and (3) avoidable by switching 25% of patients with existing asthma and COPD to an otherwise comparable therapeutic option with a lower GHG footprint.

RESULTS

We identified the following avoidable annual GHG emissions: (1) ~49 100 GHG metric tons (MTs) due to misdiagnosed disease; (2) ~143 000 GHG MTs due to suboptimal symptom control; and (3) ~262 100 GHG MTs due to preferential prescription of strategies featuring MDIs over lower-GHG-emitting options (when 25% of patients are switched to lower GHG alternatives). Combined, the GHG emission reductions from bridging these gaps would be the equivalent to taking ~101 100 vehicles off the roads each year.

CONCLUSIONS

Our analysis shows that the carbon savings from addressing misdiagnosis and suboptimal disease control are comparable to those achievable by switching one in four patients to lower GHG-emitting therapeutic strategies. Behaviour change strategies required to achieve and sustain delivery of evidence-based real-world care are complex, but the added identified incentive of carbon footprint reduction may in itself prove to be a powerful motivator for change among providers and patients. This additional benefit can be leveraged in future behaviour change interventions.

Ever Smoking is Not Associated with Performed Spirometry while Occupational Exposure and Respiratory Symptoms are

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.

Addressing sex and gender to improve asthma management

Sex (whether one is 'male' or 'female', based on biological characteristics) and gender (defined by socially constructed roles and behaviors) influence asthma diagnosis and management. For example, women generally report more severe asthma symptoms than men; men and women are exposed to different asthma-causing triggers; men tend to be more physically active than women. Furthermore, implicit, often unintended gender bias by healthcare professionals (HCPs) is widespread, and may result in delayed asthma diagnosis, which can be greater in women than men. The sex and gender of the HCP can also impact asthma management. Pregnancy, menstruation, and menopause can all affect asthma in several ways and may be associated with poor asthma control. This review provides guidance for considering sex- and gender-associated impacts on asthma diagnosis and management and offers possible approaches to support HCPs in providing personalized asthma care for all patients, regardless of their sex or gender.

Design of the Reducing Diagnostic Error to Improve Patient Safety (REDEfINE) in COPD and asthma study: A cluster randomized comparative effectiveness trial

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.

Structural Inequities in Medicine that Contribute to Racial Inequities in Asthma Care

Structural inequities in medicine have been present for centuries in the United States, but only recently are these being recognized as contributors to racial inequities in asthma care and asthma outcomes. This chapter provides a systematic review of structural factors such as racial bias in spirometry algorithms, the history of systemic racism in medicine, workforce/pipeline limitations to the presence of underrepresented minority health care providers, bias in research funding awards, and strategies to solve these problems.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework

BACKGROUND

Although guidelines have long recommended objective pulmonary function testing to diagnose asthma and chronic obstructive lung disease (COPD), many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side-effects, and delays actual diagnosis.

RESEARCH QUESTION

What are the barriers and enablers to lung function testing for asthma and/or COPD in primary care?

STUDY DESIGN AND METHODS

We searched the literature for qualitative and quantitative studies reporting barriers and/or enablers to in-office or out-of-office lung function testing for diagnosing asthma and/or COPD, in primary care. Two reviewers independently screened abstracts and full texts; assessed methodological quality using the Mixed Methods Appraisal Tool; and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual.

RESULTS

We identified 7988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, 3 were qualitative, and 3 used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in- and out-of-office settings. We identified more reported barriers (e.g. lack of knowledge of the usefulness of spirometry) than enablers (e.g. skills for performing reliable spirometry). Barriers mapped to 9 (of a possible 14) TDF domains (for both in- and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing.

INTERPRETATION

Barriers to objective testing for airways disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behaviour change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD should now be developed and tested.

The Asthma Toolkit Bootcamp to Improve Rural Primary Care for Pediatric Asthma

BACKGROUND

Children with asthma living in rural areas receive most of their care from primary care providers who have variable knowledge of evidence-based guideline management.

OBJECTIVE

To test the capacity of the Asthma Toolkit Bootcamp program to improve primary care provider guidelines adherence and reduce health care utilization in rural children with asthma.

METHODS

The Asthma Toolkit Bootcamp program provided intensive training in National Heart, Lung, and Blood Institute guidelines-based asthma care, evaluated within a RE-AIM implementation science framework. All primary care practices serving pediatric patients in rural La Plata County, Colorado, received (1) online instruction, (2) full-day training, and (3) follow-up, in-practice training 1 month later. Training focused on spirometry use, severity and control assessment, medication management, asthma action plan utilization, and adoption of a standardized visit protocol.

RESULTS

RE-AIM evaluation determined successful enrollment of practices in La Plata County (Reach) and provider uptake of evidence-based practices including spirometry (Adoption). Pediatric asthma patients receiving spirometry increased from 22% pretraining to 86% posttraining; severity assessment from 47% to 88%; and action plans from 40% to 86%. Significant improvements in health care utilization were observed among trained practices including a 10% decrease in emergency department visits, 35% decrease in hospital admissions, and 29% decrease in oral corticosteroid prescriptions (Effectiveness). Comparison practices showed no significant reductions in health care utilization. Participating providers reported that having the training in their own community, intense practice, a team-based approach, and cost-free materials including the spirometer and patient education materials were particularly helpful.

CONCLUSIONS

The Asthma Toolkit Bootcamp improved pediatric asthma care given by rural providers and reduced health care utilization among their patients.

Physician-Patient Concordance in the Assessment of Asthma Control

BACKGROUND

Discordance between physicians' and patients' perceptions of asthma control may negatively impact symptom control, treatment, and outcomes.

OBJECTIVE

To evaluate concordance between physicians' and patients' perceptions of overall asthma control and the association between perceived overall control and individual components of control.

METHODS

U.S. survey data (Dec 2015-Feb 2016; Apr-Aug 2018) from the Respiratory Disease Specific Programme were analyzed. Physicians recorded patient disease characteristics and their perception of patients' asthma control. Patients' perception of control was assessed using the Asthma Control Test; responses were compared with level of symptom control per the Global Initiative for Asthma criteria and Work Productivity and Impairment questionnaire responses. Agreement and association were assessed by weighted kappa (κ) and Spearman rho (ρ), respectively.

RESULTS

The study included 1,288 patients. Concordance between physician-perceived and patient-perceived asthma control in the prior 4 weeks was moderate (κ = 0.4951). Association between physicians' overall perception of asthma control and patients' overall Asthma Control Test score was also moderate (ρ = 0.5450). However, 61.5% of patients with self-reported, well-controlled asthma had shortness of breath 1 to 2 times/wk, 45.6% had 1 to 2 night-time awakenings/wk, and patients reported a mean (SD) daily activity impairment of 17.5% (16.2%). Only 21.8% of patients with self-reported, well-controlled asthma were classified as such by Global Initiative for Asthma symptom criteria.

CONCLUSIONS

Patients' self-assessment of overall control does not accurately characterize the true level of control; thus, patients and physicians may benefit from working together to assess the individual components of asthma control to achieve better disease management, treatment decisions, and improved outcomes.

How Frequently Is Asthma Objectively Demonstrated before Starting a Biologic? Quality Assessment of a Group Practice of Allergists and Immunologists

Worldwide, asthma-related healthcare cost remains a major burden. Individuals with severe asthma account for 50% of that cost. Although they are expensive, biologics such as anti-IL5 and anti-IgE agents promise cost-effectiveness when judiciously used to decrease asthma-related hospitalization and the debilitating side effects of systemic corticosteroids. Before considering biologics to treat patients with asthma, current guidelines recommend confirmation of asthma and control of comorbid diseases. Diagnostic confirmation of asthma can be challenging among individuals with severe asthma. In this quality assessment study, we determined the frequency of objective asthma confirmation and addressing of comorbidities prior to starting biologics at a group practice of allergists and immunologists. We surveyed our specialty providers to understand habit(s) leading to the observed results. We identified 40 adult patients who started on biologic modifiers for asthma over the past 5 years. Only 58% of these patients had a proper diagnosis of asthma. Providers underutilized several diagnostic methods that may prove useful in confirming asthma diagnosis in this patient population. The factors contributing to poor asthma control were rarely addressed. A sense of urgency to initiate biologics was the primary reason for the observed results. Further interventions are needed to improve asthma diagnosis and management prior to the initiation of biologic therapeutics.

Use of National Asthma Guidelines by Allergists and Pulmonologists: A National Survey

BACKGROUND

Little is known about specialist-specific variations in guideline agreement and adoption.

OBJECTIVE

To assess similarities and differences between allergists and pulmonologists in adherence to cornerstone components of the National Asthma Education and Prevention Program's Third Expert Panel Report.

METHODS

Self-reported guideline agreement, self-efficacy, and adherence were assessed in allergists (n = 134) and pulmonologists (n = 99) in the 2012 National Asthma Survey of Physicians. Multivariate models were used to assess if physician and practice characteristics explained bivariate associations between specialty and "almost always" adhering to recommendations (ie, ≥75% of the time).

RESULTS

Allergists and pulmonologists reported high guideline self-efficacy and moderate guideline agreement. Both groups "almost always" assessed asthma control (66.2%, standard error [SE] 4.3), assessed school/work asthma triggers (71.3%, SE, 3.9), and endorsed inhaled corticosteroids use (95.5%, SE 2.0). Repeated assessment of the inhaler technique, use of asthma action/treatment plans, and spirometry were lower (39.7%, SE 4.0; 30.6%, SE 3.6; 44.7%, SE 4.1, respectively). Compared with pulmonologists, more allergists almost always performed spirometry (56.6% vs 38.6%, P = .06), asked about nighttime awakening (91.9% vs 76.5%, P = .03) and emergency department visits (92.2% vs 76.5%, P = .03), assessed home triggers (70.5% vs 52.6%, P = .06), and performed allergy testing (61.8% vs 21.3%, P < .001). In multivariate analyses, practice-specific characteristics explained differences except for allergy testing.

CONCLUSIONS

Overall, allergists and pulmonologists adhere to the asthma guidelines with notable exceptions, including asthma action plan use and inhaler technique assessment. Recommendations with low implementation offer opportunities for further exploration and could serve as targets for increasing guideline uptake.

Spirometry Utilization Among Patients with Asthma

OBJECTIVE

To examine predictors of spirometry use at a tertiary academic health system and association between receipt of spirometry and outcomes.

PATIENTS AND METHODS

We conducted a retrospective cohort study of adult patients with an ICD-9 CM diagnostic code for asthma and a 2014 outpatient visit in either a community health center or private practice associated with a tertiary academic medical center. The main outcome was receipt of spirometry during a 2007-2015 "exposure period." We secondarily examined future hospitalizations and emergency department (ED) visits during a follow-up period (2016-2019).

RESULTS

In a sample of 394 patients, the majority were white (48%; n=188) and female (72%; n=284). Mean (SD) age was 52 years. Approximately half (185, 47%) of the patients received spirometry and 25% (n=97) saw a specialist during the exposure period. Nearly, 88% (n=85) of patients who saw a specialist received spirometry. More than half of the cohort (220/394, 56%) had an ED visit or admission during the follow-up period. Of these, 168 (76.4%) had not seen a specialist and 111 (50.5%) had not received spirometry within the exposure period. We saw no association between spirometry in the exposure window and future ED visit or hospitalization.

CONCLUSION

In a cohort of patients at a tertiary medical center, spirometry was underused. We observed a strong association between seeing a specialist and use of spirometry, suggesting a need to better incorporate spirometry into routine primary care for patients with asthma. Among 220 patients who had an asthma-related hospitalization or ED visit in 2016-2019, the majority had no record of receiving spirometry and no documentation indicating a prior specialist visit.

Cost-effectiveness of implementing objective diagnostic verification of asthma in the United States

BACKGROUND

Asthma diagnosis in the community is often made without objective testing.

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of implementing a stepwise objective diagnostic verification algorithm among patients with community-diagnosed asthma in the United States.

METHODS

We developed a probabilistic time-in-state cohort model that compared a stepwise asthma verification algorithm on the basis of spirometry testing and a methacholine challenge test against the current standard of care over 20 years. Model input parameters were informed from the literature and with original data analyses when required. The target population was US adults (≥15 years old) with physician-diagnosed asthma. The final outcomes were costs (in 2018 dollars) and quality-adjusted life years (QALYs), discounted at 3% annually. Deterministic and probabilistic analyses were undertaken to examine the effect of alternative assumptions and uncertainty in model parameters on the results.

RESULTS

In a simulated cohort of 10,000 adults with diagnosed asthma, the stepwise algorithm resulted in removal of the diagnosis of 3,366. This was projected to be associated with savings of $36.26 million in direct costs and a gain of 4,049.28 QALYs over 20 years. Extrapolating these results to the US population indicated an undiscounted potential savings of $56.48 billion over 20 years. The results were robust against alternative assumptions and plausible changes in values of input parameters.

CONCLUSION

Implementation of a simple diagnostic testing algorithm to verify asthma diagnosis might result in substantial savings and improvement in patients' quality of life.

Direct costs of overdiagnosed asthma: a longitudinal, population-based cohort study in British Columbia, Canada

OBJECTIVES

A current diagnosis of asthma cannot be objectively confirmed in many patients with physician-diagnosed asthma. Estimates of resource use in overdiagnosed cases of asthma are necessary to measure the burden of overdiagnosis and to evaluate strategies to reduce this burden. We assessed differences in asthma-related healthcare resource use between patients with a confirmed asthma diagnosis and those with asthma ruled out.

DESIGN

Population-based, prospective cohort study.

SETTING

Participants were recruited through random-digit dialling of both landlines and mobile phones in the province of British Columbia, Canada.

PARTICIPANTS

We included 345 individuals ≥12 years of age with a self-reported physician diagnosis of asthma. The diagnosis of asthma was reassessed at the end of 12 months of follow-up using a structured algorithm, which included a bronchodilator reversibility test, methacholine challenge test, and if necessary medication tapering and a second methacholine challenge test.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported annual asthma-related direct healthcare costs (2017 Canadian dollars), outpatient physician visits and medication use from the perspective of the Canadian healthcare system.

RESULTS

Asthma was ruled out in 86 (24.9%) participants. The average annual asthma-related direct healthcare costs for participants with confirmed asthma were $C497.9 (SD $C677.9) and for participants with asthma ruled out, $C307.7 (SD $C424.1). In the adjusted analyses, a confirmed diagnosis was associated with higher direct healthcare costs (relative ratio (RR)=1.60, 95% CI 1.14 to 2.22), increased rate of specialist visits (RR=2.41, 95% CI 1.05 to 5.40) and reliever medication use (RR=1.62, 95% CI 1.09 to 2.35), but not primary care physician visits (p=0.10) or controller medication use (p=0.11).

CONCLUSIONS

A quarter of individuals with a physician diagnosis of asthma did not have asthma after objective re-evaluation. These participants still consumed a significant amount of asthma-related healthcare resources. The population-level economic burden of asthma overdiagnosis could be substantial.

Factors Associated with Physician-Patient Discordance in the Perception of Asthma Control

BACKGROUND

Physicians' perception of asthma control has a direct impact on treatment options and patients' outcomes.

OBJECTIVE

To analyze the differences between patients and their physicians in the perception of asthma control. Moreover, factors associated with this discordance were explored.

METHODS

A multicenter, cross-sectional survey was conducted in patients visiting primary or secondary facilities for routine asthma reviews. Before the review, patients completed the 5-iteam Asthma Control Questionnaire (ACQ) under the supervision of a medical staff. Physicians recorded their perception of the patients' asthma control without viewing the ACQ results. After the review, physicians completed the demographic and clinical data.

RESULTS

A total of 1697 patients were included. ACQ results showed that asthma was well controlled in 52.2% of the patients, but physicians perceived that 79.6% of patients were well controlled. The concordance analyzed by the kappa index was weak (0.27). The discordant physician-patient pairs had significantly worse ACQ scores than the concordant pairs (P < .0001), but the use of neither inhaled corticosteroids nor other controller medications showed any differences between the groups. In a multivariate model, ACQ score of 0.75 or more and lack of lung function assessment within the previous 6 months were independently associated with the physician-patient discordance in the perception of asthma control.

CONCLUSIONS

The subjective perception of the physicians did not show a good agreement with the patients' asthma control based on validated ACQ scores, with increased rates of discordance among patients whose asthma was not well controlled and patients who had not received lung function assessment.

Advances in spirometry testing for lung function analysis

Introduction: Spirometry, the most common lung function test, is used to evaluate individuals with respiratory complaints or known respiratory disease. However, its underutilization and the misinterpretation of its parameters are causes for concern. Areas covered: This review describes new spirometry-derived metrics, new reference equations, recent recommendations for presentation of results, recent spirometry-based prevalence studies, and technological advances in spirometry equipment. Expert opinion: The underutilization of spirometry can be overcome by increasing access to portable, hand-held, and user-friendly spirometers, together with strategies that increase awareness of the importance of spirometry. New metrics derived from spirometry, together with traditional spirometric criteria, can identify individuals with structural lung disease and respiratory morbidity. Some problems with the reference equations were solved by the Global Lung Function Initiative (GLI), which covers a wider age range and more ethnic groups and provides limits of normality using the z-score. Despite these advantages, the GLI equations lack data from large populations (especially those from Africa, South Asia, and Latin America) and greater representation of older people. Another disadvantage attributed to the GLI is the lack of predicted values for peak expiratory flow and other airflows, limiting the interpretation of the maximal expiratory flow-volume curve.

Diagnosis and management of asthma, COPD and asthma-COPD overlap among primary care physicians and respiratory/allergy specialists: A global survey

INTRODUCTION

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a heterogenous condition with clinical features shared by both asthma and COPD.

OBJECTIVES

This online global survey of respiratory/allergy specialists and primary care practitioners (PCPs) was performed to understand current clinical approaches to the differential diagnosis and management of asthma, COPD and ACO.

METHODS

Respondents were recruited through: (a) a global online physician respondent community (49,980 PCPs and 7205 specialists); (b) market research agents; (c) experts; (d) professional societies; (e) colleague invitation. Respondents were presented with a survey including hypothetical clinical scenarios of diagnostic uncertainty to identify management approaches.

RESULTS

891 responses (447 PCPs and 444 specialists) were collected across 13 countries. Reported features used for diagnosis of asthma and COPD were consistent with practice guidelines, but there was variability in those selected for ACO diagnosis. Features typically selected by specialists focused on spirometry/history, while PCPs focused on previous treatment/symptoms. Most respondents could correctly diagnose patients with features of ACO; however, features selected for theoretical diagnosis were often different to those selected in the case scenarios. Additionally, treatment selection was often inconsistent with guidelines, with over half of respondents not recommending inhaled corticosteroids in a patient with ACO and dominant features of asthma.

CONCLUSION

While most PCPs and respiratory/allergy specialists can reach a working diagnosis of ACO, there remains uncertainty around which diagnostic features are most important and what constitutes optimal management. It is imperative that clinical studies including patients with ACO are initiated, allowing the generation of evidence-based management strategies.

Family medicine physician teachers and residents' intentions to prescribe and interpret spirometry: a descriptive cross-sectional study

Background: Spirometry is the best test to demonstrate airway obstruction, but remains underused in primary care. Objectives: We assessed, among family medicine physician teachers and residents, their intention to prescribe spirometry in patients suspected of chronic obstructive pulmonary disease and their intention to interpret the results. This evaluation is based on the theoretical framework proposed by Godin et al. for the study of factors influencing healthcare professionals' behavior. Methods: Participants of this descriptive cross-sectional study were recruited from eight Family medicine units (FMUs) of Laval University's network. They completed a 23-item self-administered questionnaire measuring their intention to prescribe and to interpret spirometry as well as some determinants of this intention (beliefs about capabilities, beliefs about consequences, social influence and moral norm). Answers to each of the items were scored on a Likert scale (score 1 to 7) where a higher score indicated a greater agreement with the statement. Results: Of the 284 eligible physicians, 104 were included. The mean score ± standard deviation of physicians' intention to prescribe spirometry (6.6 ± 0.7) was higher than to interpret the results (5.8 ± 1.5). Mean scores for all determinants of intention measured were also higher for prescription than for interpretation of spirometry. Conclusion: The results suggest that participants have a very strong intention to prescribe spirometry. Although the intention to interpret the results is positive, it is weaker than for the prescription of the test. Further studies will be needed to assess the barriers to spirometry interpretation.

Primary care clinician adherence with asthma guidelines: the National Asthma Survey of Physicians

Background and objectives: Although primary care clinicians provide >60% of U.S. asthma care, no nationally representative study has examined variation in adherence among primary care groups to four cornerstone domains of the Expert Panel Report-3 asthma guidelines: assessment/monitoring, patient education, environmental assessment, and medications. We used the 2012 National Asthma Survey of Physicians: National Ambulatory Medical Care Survey to compare adherence by family/general medicine practitioners (FM/GM), internists, pediatricians and Community Health Center mid-level clinicians (CHC). Methods: Adherence was self-reported (n = 1355 clinicians). Adjusted odds of almost always adhering to each recommendation (≥75% of the time) were estimated controlling for clinician/practice characteristics, and agreement and self-efficacy with guideline recommendations. Results: A higher percentage of pediatricians adhered to most assessment/monitoring recommendations compared to FM/GM and other groups (e.g. 71.6% [SE 4.0] almost always assessed daytime symptoms versus 50.6% [SE 5.1]-51.1% [SE 5.8], t-test p < 0.05) but low percentages from all groups almost always performed spirometry (6.8% [SE 2.0]-16.8% [SE 4.7]). Pediatricians were more likely to provide asthma action/treatment plans than FM/GM and internists. Internists were more likely to assess school/work triggers than pediatricians and CHC (environmental assessment). All groups prescribed inhaled corticosteroids for daily control (84.0% [SE 3.7]-90.7% [SE 2.5]) (medications). In adjusted analyses, pediatric specialty, high self-efficacy and frequent specialist referral were associated with high adherence. Conclusions: Pediatricians were more likely to report high adherence than other clinicians. Self- efficacy and frequent referral were also associated with adherence. Adherence was higher for history-taking recommendations and lower for recommendations involving patient education, equipment and expertise.

Approaches to Asthma Diagnosis in Children and Adults

Although the hallmark features of asthma include reversible airflow obstruction, airway eosinophilia, and symptoms of recurrent wheeze associated with breathlessness and cough, it is a heterogeneous disease. The extent of the pathophysiological abnormalities are variable between patients. Despite this, until recently, asthma diagnosis had been made very simplistically predominantly from a clinical history and examination, and often a trial of medication such as short acting bronchodilators. The limitations of this approach have become increasingly apparent with evidence of inappropriate over diagnosis, under diagnosis and misdiagnosis. Although there is no gold standard single test to make a diagnosis of asthma, there are several objective tests that can be used to support the diagnosis including physiological measures such as obstructive spirometry associated with bronchodilator reversibility and airway hyperresponsiveness. In addition, non-invasive tests of airway inflammation such as exhaled nitric oxide or peripheral blood eosinophils are important to identify those with an allergic or eosinophilic phenotype. Diagnostic guidelines reflect the importance of using objective tests to support a diagnosis of asthma, however practical application in the clinic may not be straightforward. The focus of this review is to discuss the need to undertake objective tests in all patients to support asthma diagnosis and not just rely on clinical features. The advantages, challenges and limitations of performing tests of lung function and airway inflammation in the clinic, the difficulties related to training and interpretation of results will be explored, and the utility and relevance of diagnostic tests will be compared in adults and children.

Colorado Asthma Toolkit Implementation Improves Some Process Measures of Asthma Care

BACKGROUND

The Colorado Asthma Toolkit Program (CATP) has been shown to improve processes of care with less evidence demonstrating improved outcomes.

OBJECTIVE

To model the association between pre-and-post-CATP status and asthma-related process and outcome measures among patients ages 5 to 64 years receiving care in safety-net primary care practices.

METHODS

This is an implementation study involving secondary prepost analysis of existing structured clinical, administrative, and claims data. Nine primary care practices in a federally qualified health center network implemented the CATP. Processes of care and health and utilization outcomes were evaluated prepost implementation in a cohort of patients with asthma using generalized linear mixed models.

RESULTS

The study cohort included 2678 patients age 5 to 64 years with at least one visit to one of the 9 participating practices during the study period (March 12, 2010 to December 1, 2012). A comparison of 12 months pre- and post-CATP implementation showed improvement in some process measures of asthma care associated with the intervention, including the rate of asthma-severity measurement, although no change in 2 Health care Effectiveness Data and Information Set measures: asthma medication ratio and medication management for people with asthma. We also found no change in asthma outcomes measured across multiple domains: exacerbations, utilization, symptom scores, and pulmonary physiology measures.

CONCLUSIONS

Implementation of the CATP in a primary care setting led to some improved processes of asthma care, but no changes in measured outcomes. Recommendations for future work include supplemental follow-up training including case review.

Current challenges in health information technology-related patient safety

We identify and describe nine key, short-term, challenges to help healthcare organizations, health information technology developers, researchers, policymakers, and funders focus their efforts on health information technology-related patient safety. Categorized according to the stage of the health information technology lifecycle where they appear, these challenges relate to (1) developing models, methods, and tools to enable risk assessment; (2) developing standard user interface design features and functions; (3) ensuring the safety of software in an interfaced, network-enabled clinical environment; (4) implementing a method for unambiguous patient identification (1-4 Design and Development stage); (5) developing and implementing decision support which improves safety; (6) identifying practices to safely manage information technology system transitions (5 and 6 Implementation and Use stage); (7) developing real-time methods to enable automated surveillance and monitoring of system performance and safety; (8) establishing the cultural and legal framework/safe harbor to allow sharing information about hazards and adverse events; and (9) developing models and methods for consumers/patients to improve health information technology safety (7-9 Monitoring, Evaluation, and Optimization stage). These challenges represent key "to-do's" that must be completed before we can expect to have safe, reliable, and efficient health information technology-based systems required to care for patients.

Misdiagnosis of asthma and COPD and underuse of spirometry in primary care unselected patients

BACKGROUND

The diagnosis of both asthma and chronic obstructive pulmonary disease (COPD) consists of a combination of classical symptoms and signs, and the evidence of consistent lung function abnormalities. Spiromety has been reported to be underused, possibly for practical difficulties in accessing to a lung function lab. This may lead to misdiagnosis of both asthma and COPD. We aimed to evaluate the frequency of spirometry use and the concordance between doctor-diagnosed asthma and COPD and spirometric patterns, in an unselected cohort of patients sent by general practitioners to perform a spirometry.

METHODS

The first 300 patients consecutively enrolled patients performed spirometry and bronchodilator test with salbutamol 400 mcg. Demographic, clinical and lung function data have been collected.

RESULTS

128 patients (42.7%) declared a doctor-diagnosed asthma and 75 (25%) a doctor-diagnosis of COPD; the remaining subjects never had received any respiratory diagnosis. Only 112 patients with doctor-diagnosed asthma (55.2%) and 114 (56.2%) with doctor-diagnosed COPD have ever performed a spirometry in their entire life (average time since the last spirometry was about 47.0 months). Eighty-nine (69.5%) and 10 (13.3%) patients with respectively doctor-diagnosed asthma and COPD had concordant spirometric patterns with their known diseases.

DISCUSSION

we described a worrying lack of use of spirometry and a high proportion of misdiagnosis, in patients with suspect chronic airway inflammatory diseases and cared by primary care physicians. Novel strategies to overcome this situation include should be implemented to give a better care to our patients.

Ability of Exhaled Nitric Oxide to Discriminate for Airflow Obstruction Among Frequent Exacerbators of Clinically Diagnosed Asthma

OBJECTIVE

Fraction of exhaled nitric oxide (FE_NO) has been proposed as a non-invasive biomarker for allergic inflammation seen in asthma. Many asthmatics in clinical practice have never had spirometry and recent data report misdiagnoses in patients with physician diagnosed (PD) asthma. The aim of this study was to assess the ability of FE_NO to discriminate between those with and without airflow obstruction (AO) among patients with PD-asthma.

METHODS

Frequent exacerbators of PD-asthma (with 2 or more asthma exacerbations leading to emergency room visit or hospitalization within last 12 months) were enrolled. All patients underwent diagnostic evaluations including spirometry, FE_NO testing and serum immunoglobulin (IgE) and eosinophils. Serial spirometry and methacholine challenge testing (MCT) were performed as indicated. AO was defined by a decreased FEV1/FVC ratio (< 70% and/or < LLN), or a positive MCT.

RESULTS

Of the 222 patients with PD-asthma, AO was found in 136 (vs. 86 without AO). 81.6% of patients with AO and 66.2% without AO completed FE_NO testing. There was no significant difference in the mean FE_NO levels among patients with or without AO (40.8 vs. 30.4 ppb, P = 0.10). Likewise, there was no difference in the serum IgE levels and serum eosinophils.

CONCLUSIONS

Our analyses suggest that FE_NO levels do not help discriminate between those with and without AO in patients with PD-asthma. Patients who experience symptoms of asthma may have elevated FE_NO levels above the suggested cut points of 20-25 ppb. Objective confirmation of AO should be considered in all patients with PD-asthma, irrespective of FE_NO levels.

A Nasal Brush-based Classifier of Asthma Identified by Machine Learning Analysis of Nasal RNA Sequence Data

Asthma is a common, under-diagnosed disease affecting all ages. We sought to identify a nasal brush-based classifier of mild/moderate asthma. 190 subjects with mild/moderate asthma and controls underwent nasal brushing and RNA sequencing of nasal samples. A machine learning-based pipeline identified an asthma classifier consisting of 90 genes interpreted via an L2-regularized logistic regression classification model. This classifier performed with strong predictive value and sensitivity across eight test sets, including (1) a test set of independent asthmatic and control subjects profiled by RNA sequencing (positive and negative predictive values of 1.00 and 0.96, respectively; AUC of 0.994), (2) two independent case-control cohorts of asthma profiled by microarray, and (3) five cohorts with other respiratory conditions (allergic rhinitis, upper respiratory infection, cystic fibrosis, smoking), where the classifier had a low to zero misclassification rate. Following validation in large, prospective cohorts, this classifier could be developed into a nasal biomarker of asthma.

Clinician Agreement, Self-Efficacy, and Adherence with the Guidelines for the Diagnosis and Management of Asthma

BACKGROUND

The 2007 Guidelines for the Diagnosis and Management of Asthma provide evidence-based recommendations to improve asthma care. Limited national-level data are available about clinician agreement and adherence to these guidelines.

OBJECTIVE

To assess clinician-reported adherence with specific guideline recommendations, as well as agreement with and self-efficacy to implement guidelines.

METHODS

We analyzed 2012 National Asthma Survey of Physicians data for 1412 primary care clinicians and 233 asthma specialists about 4 cornerstone guideline domains: asthma control, patient education, environmental control, and pharmacologic treatment. Agreement and self-efficacy were measured using Likert scales; 2 overall indices of agreement and self-efficacy were compiled. Adherence was compared between primary care clinicians and asthma specialists. Logistic regression models assessed the association of agreement and self-efficacy indices with adherence.

RESULTS

Asthma specialists expressed stronger agreement, higher self-efficacy, and greater adherence with guideline recommendations than did primary care clinicians. Adherence was low among both groups for specific core recommendations, including written asthma action plan (30.6% and 16.4%, respectively; P < .001); home peak flow monitoring, (12.8% and 11.2%; P = .34); spirometry testing (44.7% and 10.8%; P < .001); and repeated assessment of inhaler technique (39.7% and 16.8%; P < .001). Among primary care clinicians, greater self-efficacy was associated with greater adherence. For specialists, self-efficacy was associated only with increased odds of spirometry testing. Guideline agreement was generally not associated with adherence.

CONCLUSIONS

Agreement with and adherence to asthma guidelines was higher for specialists than for primary care clinicians, but was low in both groups for several key recommendations. Self-efficacy was a good predictor of guideline adherence among primary care clinicians but not among specialists.

Novel Interprofessional Mentoring Intervention to Improve Spirometry in Primary Care: Uptake, Feedback, and Effects on Behavioral Intention

INTRODUCTION

Little is known about the nature and effects of mentoring interventions on evidence-based clinician behaviors. We sought to design and evaluate a novel mentorship-based intervention to improve the usage of spirometry in primary care.

METHODS

This was a prospective one-year study of a pragmatic intervention across Canadian primary care sites. We established mentor-mentee pods, each including physician and nurse/allied health mentors and mentees, and enabled communication through a secure online portal; email; telephone; teleconference; videoconference; fax; and/or in person. We measured (1) change in intention to perform spirometry (through a questionnaire based on the theory of planned behavior, administered before and after the intervention); (2) mentoring uptake; and (3) feedback/satisfaction.

RESULTS

Twenty-five of 90 (28%) nurse/allied health and 23/68 (34%) physician mentees consented across seven sites. There were no statistically significant changes in behavioral intention after the intervention. Mentors logged 56.5 hours, with most preferred communication modalities being in person (6/11; 55%) and email (4/11; 36%). Mentees most commonly used email (9/18; 50%), followed by in-person communication (6/18; 33%). Mentees were highly satisfied with the experience, and most (89%) would participate in a similar program again.

DISCUSSION

A mentorship-based intervention can successfully engage physicians, nurses, and allied health practitioners through multiple communication platforms. Email seems to be an important medium for this activity. Such interventions can be highly satisfying and may affect certain constructs underlying mentees' behavioral intentions. Such a program can be replicated across diseases, and future research should measure effects on behavior, patient outcomes, and the sustainability of effects.

Action plans for COPD: strategies to manage exacerbations and improve outcomes

COPD is the third-largest killer in the world, and certainly takes a toll on the health care system. Recurrent COPD exacerbations accelerate lung-function decline, worsen mortality, and consume over US$50 billion in health care spending annually. This has led to a tide of payment reforms eliciting interest in strategies reducing preventable COPD exacerbations. In this review, we analyze and discuss the evidence for COPD action plan-based self-management strategies. Although action plans may provide stabilization of acute symptomatology, there are several limitations. These include patient-centered attributes, such as comprehension and adherence, and nonadherence of health care providers to established guidelines. While no single intervention can be expected independently to translate into improved outcomes, structured together within a comprehensive integrated disease-management program, they may provide a robust paradigm.

Office spirometry correlates with laboratory spirometry in patients with symptomatic asthma and COPD

OBJECTIVES

Spirometry remains underutilized in the evaluation of obstructive lung disease. While office spirometry (OS) has been compared to formal laboratory-based spirometry (LS) in healthy subjects, the correlation has never been formally assessed in patients with symptomatic obstructive lung disease. The aim of this study was to investigate the correlation in this population.

METHODS

We used a retrospective study design to analyze spirometry data from patients that underwent both OS and LS. Two flow sensing office (portable) spirometers were used and compared with laboratory-based (body plethymosgraph) spirometer. Accuracy and reliability were assessed using Bland Altman analysis.

RESULTS

Among 185 patients with symptomatic obstructive lung disease, 129 had undergone both OS and LS. Of these, 107 patients had both tests performed less than 90 days apart and were included in final analyses. Mean age was 54 years with mean FEV1 of 1.97 L (65% predicted). Ninety-two patients had airflow obstruction, as determined by a FEV1/FVC ratio of <70%. We found significant correlation in the values between OS and LS for both FEV1 and FVC (r = 0.937 and 0.90, respectively, P < 0.001). Eighty-seven percent of patients had a concordant spirometry in terms of airflow obstruction. Correlation was independent of the office spirometer (and hence the Flow-sensing mechanism) used.

CONCLUSIONS

In patients with known asthma and chronic obstructive pulmonary disease (COPD), OS is accurate and reliable when compared to formal laboratory-based spirometry. Routine use of OS should be encouraged to improve spirometry utilization and healthcare outcomes in patients with Asthma and COPD.

Deficits in allergy knowledge among physicians at academic medical centers

BACKGROUND

Allergic conditions have high prevalence in the general population. Misconceptions regarding the diagnosis and management of allergic disease among physicians can lead to suboptimal clinical care.

OBJECTIVE

To determine the extent of allergy-related knowledge deficits among physicians.

METHODS

Pediatric and internal medicine resident and attending physicians from 2 separate academic medical centers were asked to answer an anonymous electronic survey. Survey questions addressed 7 different allergy content areas.

RESULTS

Four hundred eight physicians completed surveys (23.9% response rate). Respondents had few correct answers (mean ± SD 1.91 ± 1.43). Pediatric respondents had a larger number of correct answers compared with medicine-trained physicians (P < .001). No individual answered every survey question correctly, and 50 respondents (12.3%) had no correct answer. Three hundred seventy-eight respondents (92.6%) were unable to provide correct answers for at least 50% of survey questions. Level of residency training and prior rotation through an allergy and immunology elective correlated with a larger number of correct responses (P < .01). Only 1 survey question had an overall correct response rate higher than 50% (n = 261, 64%). Correct response rate was lower than 30% for 7 of the 9 possible questions.

CONCLUSION

There are significant knowledge deficits in many areas of allergy-related content among pediatric and internal medicine physicians and across all levels of training and specialty. Given the prevalence of allergic conditions, the potential implications of a negative impact on clinical care are staggering.

Benefits of an asthma education program provided at primary care sites on asthma outcomes

BACKGROUND

Although it is a key-recommendation of all recent asthma guidelines, self-management education is still insufficiently offered in primary care settings.

AIMS OF THE STUDY

To demonstrate the benefits of an educational program offered at the site of primary care (Family Medicine Clinics- FMC) by trained asthma educators on patient outcomes and healthcare use.

METHODS

This was a one-year pre-post intervention study. Patients with a diagnosis of mild to moderate asthma were enrolled from six FMC. After an initial encounter by the educator, an assessment of educational needs and a spirometry were done, followed by 3 follow-up visits at 4-6 weeks, 4-6 months and one year. Expiratory flows, asthma control criteria, knowledge about asthma, adherence to medication and healthcare and medication use were assessed at each visit.

RESULTS

Data from 124 asthma patients (41M/83F), aged 55 ± 18 years, were analyzed. After initiating the intervention, there was a progressive increase in asthma knowledge and an improvement in medication adherence. The number of unscheduled visits for respiratory problems went from 137 to 33 (P < 0.0001), the number of antibiotic treatments from 112 to 33 (P = 0.0002) and the number of oral corticosteroids treatments from 26 to 8 (NS). Marked improvements were observed in regard to inhaler technique and provision of a written action plan.

CONCLUSION

This study shows that an educational intervention applied at the site of primary care can result in significant improvements in patient asthma outcomes and reduce unscheduled visits and inappropriate use of medications such as antibiotics.