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Wang C, Siff J, Greco PJ, Warren E, Thornton JD, Tarabichi Y. The Impact of an Electronic Health Record Intervention on Spirometry Completion in Patients with Chronic Obstructive Pulmonary Disease. COPD 2022; 19:142-148. [PMID: 35392743 PMCID: PMC9202241 DOI: 10.1080/15412555.2022.2049736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/07/2022] [Accepted: 02/25/2022] [Indexed: 11/12/2022]
Abstract
Spirometry is necessary to diagnose chronic obstructive pulmonary disease (COPD), yet a large proportion of patients are diagnosed and treated without having received testing. This study explored whether the effects of interventions using the electronic health record (EHR) to target patients diagnosed with COPD without confirmatory spirometry impacted the incidence rates of spirometry referrals and completions. This retrospective before and after study assessed the impact of provider-facing clinical decision support that identified patients who had a diagnosis of COPD but had not received spirometry. Spirometry referrals, completions, and results were ascertained 1.5 years prior to and 1.5 years after the interventions were initiated. Inhaler prescriptions by class were also tallied. There were 10,949 unique patients with a diagnosis of COPD who were eligible for inclusion. 4,895 patients (44.7%) were excluded because they had completed spirometry prior to the cohort start dates. The pre-intervention cohort consisted of 2,622 patients, while the post-intervention cohort had 3,392. Spirometry referral rates pre-intervention were 20.2% compared to 31.6% post-intervention (p < 0.001). Spirometry completion rates rose from 13.2% pre-intervention to 19.3% afterwards (p < 0.001). 61.7% (585 of 948) had no evidence of airflow obstruction. After excluding patients with a diagnosis of asthma, 25.8% (126 of 488) patients who had no evidence of airflow obstruction had prescriptions for long-acting bronchodilators or inhaled steroids. A concerted EHR intervention modestly increased spirometry referral and completion rates in patients with a diagnosis of COPD without prior spirometry and decreased misclassification of disease.
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Affiliation(s)
- Christine Wang
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jonathan Siff
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
| | - Peter J. Greco
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
| | - Edward Warren
- Division of Pulmonary, Critical Care, and Sleep Medicine, The MetroHealth System, Cleveland, OH, USA
| | - J. Daryl Thornton
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, The MetroHealth System, Cleveland, OH, USA
- Center for Reducing Health Disparities, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, USA
| | - Yasir Tarabichi
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, The MetroHealth System, Cleveland, OH, USA
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Glassberg MK, Csete I, Simonet E, Elliot SJ. Stem Cell Therapy for COPD: Hope and Exploitation. Chest 2021; 160:1271-1281. [PMID: 33894254 DOI: 10.1016/j.chest.2021.04.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/05/2021] [Accepted: 04/11/2021] [Indexed: 12/21/2022] Open
Abstract
COPD is a chronic inflammatory and destructive disease characterized by progressive decline in lung function that can accelerate with aging. Preclinical studies suggest that mesenchymal stem cells (MSCs) may provide a therapeutic option for this incurable disease because of their antiinflammatory, reparative, and immunomodulatory properties. To date, clinical trials using MSCs demonstrate safety in patients with COPD. However, because of the notable absence of large, multicenter randomized trials, no efficacy or evidence exists to support the possibility that MSCs can restore lung function in patients with COPD. Unfortunately, the investigational status of cell-based interventions for lung diseases has not hindered the propagation of commercial businesses, exploitation of the public, and explosion of medical tourism to promote unproven and potentially harmful cell-based interventions for COPD in the United States and worldwide. Patients with COPD constitute the largest group of patients with lung disease flocking to these unregulated clinics. This review highlights the numerous questions and concerns that remain before the establishment of cell-based interventions as safe and efficacious treatments for patients with COPD.
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Affiliation(s)
- Marilyn K Glassberg
- Division of Pulmonary, Critical Care, and Sleep, Department of Medicine, University of Arizona College of Medicine, Phoenix, AZ.
| | | | | | - Sharon J Elliot
- Division of Pulmonary, Critical Care, and Sleep, Department of Medicine, University of Arizona College of Medicine, Phoenix, AZ; University of Miami Miller School of Medicine, Miami, FL
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Gelb AF, Yamamoto A, Verbeken EK, Hogg JC, Tashkin DP, Tran DNT, Moridzadeh RM, Fraser C, Schein MJ, Decramer M, Glassy EF, Nadel JA. Normal Routine Spirometry Can Mask COPD/Emphysema in Symptomatic Smokers. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2021; 8:124-134. [PMID: 33513660 PMCID: PMC8047618 DOI: 10.15326/jcopdf.2020.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recent studies have emphasized the difficulty of early detection of chronic obstructive pulmonary disease (COPD) in symptomatic smokers with normal routine spirometry. This includes post-bronchodilator normal forced expiratory volume in 1 second (FEV1)(L)≥80% predicted, forced vital capacity (FVC)(L)≥80% predicted, and FEV1/FVC ≥70% or greater than age corrected lower limit of normal (LLN). However, in COPD the pathologic site of small airway obstruction and emphysema begins in the small peripheral airways ≤2 mm id which normally contribute <20% of total airway resistance. METHODS Expiratory airflow at high and low lung volumes post-bronchodilator were measured and correlated with lung computed tomography (CT) and lung pathology (6 patients) in 16 symptomatic, treated smokers, and all with normal routine spirometry. RESULTS Despite normal routine spirometry, all16 patients had isolated, abnormal forced expiratory flow at 75% of FVC (FEF75) using data from Knudson et al, Hankinson et al NHAMES III, and Quanjer et al and the Global Lung Function Initiative. This reflects isolated detection of small airways obstruction and/or emphysema. Measuring airflow at FEF50 detected only 8 of 16 patients, maximal expiratory flow at 25%-75% of FVC (MEF25-75) only 4 of 16, residual volume (RV) 4 of 16, and RV to total lung capacity ratio only 2 of 16. There was excellent correlation between limited lung pathology and lung CT for absence of emphysema. CONCLUSION This study confirms our earlier observations that detection of small airways obstruction and/or emphysema, in symptomatic smokers with normal routine spirometry, requires analysis of expiratory airflow at low lung volumes, including FEF75. Dependence upon normal routine spirometry may result in clinical and physiologic delay in the diagnosis and treatment in symptomatic smokers with emphysema and small airways obstruction.
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Affiliation(s)
- Arthur F. Gelb
- Pulmonary Division, Department of Medicine, Lakewood Regional Medical Center, Lakewood, California, United States and David Geffen School of Medicine at University of California-Los Angeles Health Sciences, Los Angeles, California, United States
| | - Alfred Yamamoto
- Department of Pathology, Lakewood Regional Medical Center, Lakewood, California, United States
| | - Eric K. Verbeken
- Department of Pathology, Katholieke Univeritair Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - James C. Hogg
- University of British Columbia James Hogg Research Centre, St. Paul`s Hospital Vancouver, British Columbia, Canada
| | - Donald P. Tashkin
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at University of California-Los Angeles Health Sciences, Los Angeles, California, United States
| | - Diem N. T. Tran
- Independent pulmonary function investigator, Lakewood, California, United States
| | | | - Christine Fraser
- Independent pulmonary function investigator, Lakewood, California, United States
| | - Mark J. Schein
- Department of Radiology, Lakewood Regional Medical Center, Lakewood, California, United States
| | - Marc Decramer
- Department of Clinical and Experimental Medicine, Katholieke Univeritair Leuven-University of Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Eric F. Glassy
- Affiliated Pathologists Medical Group, Rancho Dominguez, California, United States
| | - Jay A. Nadel
- Cardiovascular Research Institute and Departments of Medicine, Physiology, and Radiology, School of Medicine, University of California San Francisco, San Francisco, California, United States
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Affiliation(s)
- Alberto Papi
- Respiratory Medicine Unit, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Studnicka M, Horner A, Sator L, Buist AS, Lamprecht B. COPD: Should Diagnosis Match Physiology? Chest 2020; 157:473-475. [PMID: 32033652 DOI: 10.1016/j.chest.2019.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 09/30/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Michael Studnicka
- Department of Pulmonary Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Andreas Horner
- Department of Pulmonology, Kepler University Hospital, Linz, Austria; Faculty of Medicine, Johannes-Kepler-University, Salzburg, Austria; Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Portland, OR.
| | - Lea Sator
- Department of Pulmonary Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Bernd Lamprecht
- Department of Pulmonology, Kepler University Hospital, Linz, Austria; Faculty of Medicine, Johannes-Kepler-University, Salzburg, Austria
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Vanfleteren LEW, Fabbri LM. Response. Chest 2020; 157:475-476. [DOI: 10.1016/j.chest.2019.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 10/19/2019] [Indexed: 11/28/2022] Open
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