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Stöber A, Marijic P, Kurz C, Schwarzkopf L, Kirsch F, Schramm A, Leidl R. Does uptake of specialty care affect HRQoL development in COPD patients beneficially? A difference-in-difference analysis linking claims and survey data. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:1561-1573. [PMID: 36637677 PMCID: PMC10550862 DOI: 10.1007/s10198-022-01562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND There is an evidence gap on whether the choice of specialty care beneficially affects health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). This study analyzes how newly initiated pulmonologist care affects the generic and disease-specific HRQoL in COPD patients over a period of 1 year. METHODS We linked claims data with data from two survey waves to investigate the longitudinal effect of specialty care on HRQoL using linear Difference-in-Difference models based on 1:3 propensity score matched data. Generic HRQoL was operationalized by EQ-5D-5L visual analog scale (VAS), and disease-specific HRQoL by COPD assessment test (CAT). Subgroup analyses examined COPD patients with low (GOLD AB) and high (GOLD CD) exacerbation risk. RESULTS In contrast to routine care patients, pulmonologists' patients (n = 442) experienced no significant deterioration in HRQoL (VAS - 0.0, p = 0.9870; CAT + 0.5, p = 0.0804). Models unveiled a small comparative advantage of specialty care on HRQoL (mean change: CAT - 0.8, VAS + 2.9), which was especially pronounced for GOLD AB (CAT - 0.7; VAS + 3.1). CONCLUSION The uptake of pulmonologist care had a statistically significant, but not clinically relevant, beneficial impact on the development of HRQoL by slowing down overall HRQoL deterioration within 1 year. Including specialty care more appropriately in COPD management, especially at lower disease stages (GOLD AB), could thus improve patients' health outcome.
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Affiliation(s)
- Alisa Stöber
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Munich, Germany.
- Pettenkoffer School of Public Health, Munich, Germany.
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Ludwig-Maximilians-University Munich (LMU), Munich, Germany.
| | - Pavo Marijic
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Munich, Germany
- Pettenkoffer School of Public Health, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology (IBE), Ludwig-Maximilians-University Munich (LMU), Munich, Germany
| | - Christoph Kurz
- Munich Center of Health Sciences (MC-Health), Institute for Health Economics and Management, Ludwig-Maximilians-University Munich (LMU), Munich, Germany
| | - Larissa Schwarzkopf
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Munich, Germany
- Pettenkoffer School of Public Health, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
- Institut Fuer Therapieforschung (IFT), Working Group Therapy and Health Services Research, Munich, Germany
| | - Florian Kirsch
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Munich, Germany
- Service Center of Health Care Management, AOK Bayern, Regensburg, Germany
| | - Anja Schramm
- Service Center of Health Care Management, AOK Bayern, Regensburg, Germany
| | - Reiner Leidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Munich, Germany
- Munich Center of Health Sciences (MC-Health), Institute for Health Economics and Management, Ludwig-Maximilians-University Munich (LMU), Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
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Valipour A, Aisanov Z, Avdeev S, Koblizek V, Kocan I, Kopitovic I, Lupkovics G, Man M, Bukovskis M, Tudoric N, Vukoja M, Naumnik W, Yanev N. Recommendations for COPD management in Central and Eastern Europe. Expert Rev Respir Med 2022; 16:221-234. [PMID: 35001780 DOI: 10.1080/17476348.2021.2023498] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries. AREAS COVERED Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE. EXPERT OPINION Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna Health Care Group, Vienna, Austria
| | - Zaurbek Aisanov
- Department of Pulmonology, Pirogov Russian State National Research Medical University, Moscow, Russia
| | - Sergey Avdeev
- Pulmonology Department, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vladimir Koblizek
- Department of Pneumology, Faculty of Medicine in Hradec Kralove, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Ivan Kocan
- University Hospital Martin, Jessenius Faculty of Medicine, Commenius University, Martin, Slovakia
| | - Ivan Kopitovic
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Gergely Lupkovics
- Adult Pulmonary Department, Institute for Pulmonary Diseases, Törökbálint, Hungary
| | - Milena Man
- Pulmonology Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maris Bukovskis
- Department of Internal Diseases, Faculty Medicine, University of Latvia, Riga, Latvia
| | - Neven Tudoric
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marija Vukoja
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Wojciech Naumnik
- First Department of Lung Diseases and Chemotherapy of Respiratory Neoplasms, Medical University of Bialystok, Bialystok, Poland
| | - Nikolay Yanev
- Department of Pulmonary Diseases, Medical University of Sofia, Sofia, Bulgaria
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Elsa LP, Justo G, Blanca L. Patient's awareness on COPD is the strongest predictor of persistence and adherence in treatment-naïve patients in real life: a prospective cohort study. BMC Pulm Med 2021; 21:388. [PMID: 34837978 PMCID: PMC8627039 DOI: 10.1186/s12890-021-01754-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is little evidence about the factors that predict persistence/adherence in treatment-naïve patients with COPD in clinical practice. The aim of this study was to evaluate persistence and adherence levels among treatment-naïve patients diagnosed with COPD who had a prescribed inhaled medication, using data from real-world clinical practice. METHODS Multicentric study with a 6 month-followed-up period. Patients were considered persistent if they collected all their inhaler refills. In a random sample of patients, we evaluated adherence using the Test of Adherence to Inhalers (TAI). We assessed Health Related Quality of Life (HRQL) with St George's Respiratory Questionnaire (SGRQ). RESULTS Of the 114 patients included, 46 (40.4%) were defined as persistent. Patients who had awareness about COPD (adjusted RR 2.672, 95% CI 1.125-6.349) were more likely to be persistent; patients with multidose DPI were less likely to be persistent that those with single dose DPI (adjusted RR 0.341, 95% CI 0.133-0.877). Higher levels of SGRQ total were associated with a lower probability of persistence (adjusted RR 0.945, 95%CI 0.894-0.998). Patients who had had an appointment with their GP in the previous six months were more likely to be persistent (adjusted RR 3.107, 95% CI 1.022-9.466). Patients who had awareness about COPD and those with lower symptom SGQR score were more likely to be adherent (24/25, 96.0% vs 16/22, 72.7%, p = 0.025, and mean 29.1, sd 19.4 vs mean 41.4, sd 15.9, respectively, p = 0.026, respectively). CONCLUSIONS Less than 50% of patients were defined as persistent. Patients' awareness of their disease and levels of HRQL were associated with high rate of persistence and adherence. In addition, frequent visits to general practitioner, increases the rate of persistence to treatment.
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Affiliation(s)
- López-Pintor Elsa
- Department of Engineering, Area of Pharmacy and Pharmaceutical Technologies, Miguel Hernández University, Crtra Alicante-Valencia km 81, Sant Joan d'Alacant, 03550, Alicante, Spain.,CIBER en Epidemiología y Salud Pública, Madrid, Spain
| | - Grau Justo
- Pneumology Department, General Hospital of Elche, Alicante, Spain
| | - Lumbreras Blanca
- CIBER en Epidemiología y Salud Pública, Madrid, Spain. .,Department of Public Health History of Science and Gynaecology, Miguel Hernández University, Crtra Alicante-Valencia km 81, Sant Joan d'Alacant, 03550, Alicante, Spain.
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Savran O, Godtfredsen N, Sørensen T, Jensen C, Ulrik CS. Characteristics of COPD Patients Prescribed ICS Managed in General Practice vs. Secondary Care. COPD 2021; 18:493-500. [PMID: 34470537 DOI: 10.1080/15412555.2021.1970737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Inhaled corticosteroids (ICS) for COPD have been much debated. Our aim was to investigate characteristics of ICS prescribed COPD patients managed only in general practice compared to those also managed in secondary care. Participating general practitioners recruited patients with COPD (ICPC 2nd ed. code R95) currently prescribed ICS (ACT code R03AK and R03BA). Data on demographics, comorbidities, smoking habits, spirometry, dyspnea score and exacerbation history were retrieved from medical records. Logistic regression analysis was applied to detect predictors associated with management in secondary care. 2,279 COPD patients (45% males and mean age 71 years) were recruited in primary care. Compared to patients managed in primary care only (n = 1,179), patients also managed in secondary care (n = 560) were younger (p = 0.013), had lower BMI, more life-time tobacco exposure (p = 0.03), more exacerbations (p < 0.001) and hospitalizations (p < 0.001) and lower FEV1/FVC-ratio (0.59 versus 0.52, respectively). Compared to patients managed in only primary care, logistic regression analysis revealed that management also in secondary care was associated to MRC-score ≥3 (OR 2.70; 95% CI 1.50-4.86; p = 0.001), FEV1%pred (OR 0.98; 95% CI 0.95 to 0.99; p = 0.036), and systemic corticosteroids for COPD exacerbation (OR 1.44; 95% CI 1.10-1.89; p = 0.008). In COPD patients prescribed ICS recruited in primary care, patients also managed in secondary care had more respiratory symptoms, lower lung function and exacerbations treated with systemic corticosteroids indicating that the most severe COPD patients, in general, are referred for specialist care.
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Affiliation(s)
- Osman Savran
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
| | - Nina Godtfredsen
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Hvidovre, Denmark
| | | | | | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Hvidovre, Denmark
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5
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Oslislo S, Heintze C, Möckel M, Schenk L, Holzinger F. What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany. BMC FAMILY PRACTICE 2020; 21:154. [PMID: 32731862 PMCID: PMC7393893 DOI: 10.1186/s12875-020-01222-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit. METHODS Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research). RESULTS Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED. CONCLUSIONS With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.
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Affiliation(s)
- Sarah Oslislo
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - Christoph Heintze
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Möckel
- Division of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.,Medical and Veterinary Sciences, James Cook University, The College of Public Health, 1 James Cook Dr, Townsville, Douglas, QLD, 4814, Australia
| | - Liane Schenk
- Institute of Medical Sociology and Rehabilitation Science, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Holzinger
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
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Utilization and determinants of use of non-pharmacological interventions in COPD: Results of the COSYCONET cohort. Respir Med 2020; 171:106087. [PMID: 32917358 DOI: 10.1016/j.rmed.2020.106087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Guidelines for chronic obstructive pulmonary disease (COPD) recommend supplementing pharmacotherapy with non-pharmacological interventions. Little is known about the use of such interventions by patients. We analyzed the utilization of a number of non-pharmacological interventions and identified potential determinants of use. METHODS Based on self-reports, use of interventions (smoking cessation, influenza vaccination, physiotherapy, sports program, patient education, pulmonary rehabilitation) and recommendation to use were assessed in 1410 patients with COPD. The utilization was analyzed according to sex and severity of disease. Potential determinants of utilization included demographic variables and disease characteristics and were analyzed using logistic regression models. RESULTS Influenza vaccination in the previous autumn/winter was reported by 73% of patients. About 19% were currently participating in a reimbursed sports program, 10% received physiotherapy, 38% were ever enrolled in an educational program, and 34% had ever participated in an outpatient or inpatient pulmonary rehabilitation program. Out of 553 current or former smokers, 24% had participated in a smoking cessation program. While reports of having received a recommendation to use mainly did not differ according to sex, women showed significantly (p < 0.05) higher utilization rates than men for all interventions except influenza vaccination. Smoking was a predictor for not having received a recommendation for utilization and also significantly associated with a reduced odds of utilization. We found a correlation between recommendation to use and utilization. CONCLUSIONS Utilization of non-pharmacological interventions was lower in men and smokers. A recommendation or offer to use by the physician could help to increase uptake.
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Cho EE, Mecredy GC, Wong HH, Stanbrook MB, Gershon AS. Which Physicians Are Taking Care of People With COPD? Chest 2019; 155:771-777. [PMID: 30664858 DOI: 10.1016/j.chest.2018.12.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/20/2018] [Accepted: 12/24/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is limited knowledge on what proportions of patients with COPD receive ambulatory care from primary care physicians, pulmonologists, or other specialists. We evaluated the types and combinations of physicians who provide ambulatory care to patients with COPD. METHODS We conducted a population-based cross-sectional study using health administrative datasets from Ontario, Canada between April 1, 2014 and March 31, 2015. Individuals age 35 years and older with physician-diagnosed COPD were identified, using a previously validated COPD case definition. The primary outcomes were ambulatory visits to primary care physicians, pulmonologists, and all other specialists within a 1-year period. RESULTS There were 895,155 individuals identified as having physician-diagnosed COPD. Of those, 56,533 individuals (6.3%) had no ambulatory care visits, 802,327 (89.6%) saw primary care physicians, and 95,782 (10.7%) consulted pulmonologists. By comparison, 736,496 (82.3%) saw other specialists, and 218,997 (24.5%) saw cardiologists. There were 32,473 individuals (3.6%) who underwent COPD-related hospitalizations. Of those in the subcohort with one hospitalization, about 30.0% saw pulmonologists; 43.7% of those who underwent two or more hospitalizations saw pulmonologists, and 9.9% with no hospitalization consulted pulmonologists. CONCLUSIONS Primary care physicians play a substantial role in caring for patients with COPD. But only one-half as many patients with COPD saw pulmonologists than cardiologists, suggesting that COPD may receive less specialty care compared with other chronic medical conditions. This information can help inform COPD care strategies to improve COPD care and minimize exacerbations and associated health-care costs. It also suggests a need for more research to provide guidance on when patients with COPD should be referred to pulmonologists.
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Affiliation(s)
- Eunice E Cho
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Harvey H Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Matthew B Stanbrook
- Department of Medicine, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Andrea S Gershon
- Department of Medicine, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Gershon AS, Macdonald EM, Luo J, Austin PC, Gupta S, Sivjee K, Upshur R, Aaron SD. Concomitant pulmonologist and primary care for chronic obstructive pulmonary disease: a population study. Fam Pract 2017; 34:708-716. [PMID: 28985364 DOI: 10.1093/fampra/cmx058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pulmonologists provide quality care, however, their number is not adequate to take care of all the chronic obstructive pulmonary disease (COPD) needs of the population and their services come with a cost. Their optimal role should be defined, ideally based on evidence, to ensure that their abilities are applied most efficiently where needed. OBJECTIVE To determine if concomitant pulmonologist and primary care physician care after COPD hospital or emergency department discharge was associated with better health outcomes than primary care services alone. METHODS A population cohort study was conducted in Ontario, Canada from 2004 to 2011. All individuals with a COPD hospital or emergency department discharge were included. Patients who visited both a pulmonologist and a primary care physician within 30 days of the index discharge were matched to patients who had visited a primary care physician alone using propensity scores. The composite outcome of death, COPD hospitalization or COPD emergency department visit was compared using proportional hazards regression. RESULTS In the propensity score matched sample, 39.7% of patients who received concomitant care and 38.9% who received primary care only died or visited the emergency department visit or hospital for COPD within 1 year (adjusted hazard ratio 1.08, 95% confidence interval 1.00-1.17). The former, however, were more likely to receive diagnostic testing and medications. CONCLUSION Patients who received concomitant care after COPD emergency department or hospital discharge did not have better outcomes than those who received primary care alone, however, they did receive more testing and medical management.
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Affiliation(s)
- Andrea S Gershon
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Erin M Macdonald
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jin Luo
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michaels Hospital, Toronto, Ontario, Canada
| | - Khalil Sivjee
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ross Upshur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Croft JB, Lu H, Zhang X, Holt JB. Geographic Accessibility of Pulmonologists for Adults With COPD: United States, 2013. Chest 2016; 150:544-53. [PMID: 27221645 PMCID: PMC5304918 DOI: 10.1016/j.chest.2016.05.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 04/28/2016] [Accepted: 05/11/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Geographic clusters in prevalence and hospitalizations for COPD have been identified at national, state, and county levels. The study objective is to identify county-level geographic accessibility to pulmonologists for adults with COPD. METHODS Service locations of 12,392 practicing pulmonologists and 248,160 primary care physicians were identified from the 2013 National Provider Identifier Registry and weighted by census block-level populations within a series of circular distance buffer zones. Model-based county-level population counts of US adults ≥ 18 years of age with COPD were estimated from the 2013 Behavioral Risk Factor Surveillance System. The percentages of all estimated adults with potential access to at least one provider type and the county-level ratio of adults with COPD per pulmonologist were estimated for selected distances. RESULTS Most US adults (100% in urbanized areas, 99.5% in urban clusters, and 91.7% in rural areas) had geographic access to a primary care physician within a 10-mile buffer distance; almost all (≥ 99.9%) had access to a primary care physician within 50 miles. At least one pulmonologist within 10 miles was available for 97.5% of US adults living in urbanized areas, but only for 38.3% in urban clusters and 34.5% in rural areas. When distance increased to 50 miles, at least one pulmonologist was available for 100% in urbanized areas, 93.2% in urban clusters, and 95.2% in rural areas. County-level ratios of adults with COPD per pulmonologist varied greatly across the United States, with residents in many counties in the Midwest having no pulmonologist within 50 miles. CONCLUSIONS County-level geographic variations in pulmonologist access for adults with COPD suggest that those adults with limited access will have to depend on care from primary care physicians.
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Affiliation(s)
- Janet B Croft
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Hua Lu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xingyou Zhang
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - James B Holt
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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Escarrabill J, Torrente E, Esquinas C, Hernández C, Monsó E, Freixas M, Almagro P, Tresserras R. Auditoría clínica de los pacientes que ingresan en el hospital por agudización de EPOC. Estudio MAG-1. Arch Bronconeumol 2015; 51:483-9. [DOI: 10.1016/j.arbres.2014.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 06/18/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
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11
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Schmidt M, Demoule A, Deslandes-Boutmy E, Chaize M, de Miranda S, Bèle N, Roche N, Azoulay E, Similowski T. Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process. Crit Care 2014; 18:R115. [PMID: 24898342 PMCID: PMC4229873 DOI: 10.1186/cc13906] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 05/20/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. METHODS COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation. RESULTS Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation. CONCLUSIONS The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient's personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 ‘Neurophysiologie Respiratoire Expérimentale et Clinique’, 47-83 boulevard de l'Hôpital, 75013 Paris, France
- INSERM, UMR_S 1158 ‘Neurophysiologie Respiratoire Expérimentale et Clinique’, 47-83 boulevard de l'Hôpital, 75013 Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘R3S’), 47 boulevard de l'Hôpital, F-75013 Paris, France
| | - Alexandre Demoule
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘R3S’), 47 boulevard de l'Hôpital, F-75013 Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 974, 47-83 boulevard de l'Hôpital, 75013 Paris, France
- INSERM, UMR_S 974, F-75005 Paris, France
| | - Emmanuelle Deslandes-Boutmy
- Hôpitaux de Paris, Hôpital Saint Louis, Service de Biostatistique, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Marine Chaize
- Hôpitaux de Paris, Hôpital Saint Louis, Service de Réanimation Médicale, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Sandra de Miranda
- Hôpitaux de Paris, Hôpital Saint Louis, Service de Réanimation Médicale, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Nicolas Bèle
- Hôpitaux de Paris, Hôpital Saint Louis, Service de Réanimation Médicale, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Nicolas Roche
- Hôpitaux de Paris, Hôpital Cochin – Site Val de Grâce, Service de Pneumologie et Soins Intensifs Respiratoires, Université Paris Descartes, 27 Rue du Faubourg Saint-Jacques, F-75014 Paris, France
| | - Elie Azoulay
- Hôpitaux de Paris, Hôpital Saint Louis, Service de Réanimation Médicale, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Thomas Similowski
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 ‘Neurophysiologie Respiratoire Expérimentale et Clinique’, 47-83 boulevard de l'Hôpital, 75013 Paris, France
- INSERM, UMR_S 1158 ‘Neurophysiologie Respiratoire Expérimentale et Clinique’, 47-83 boulevard de l'Hôpital, 75013 Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘R3S’), 47 boulevard de l'Hôpital, F-75013 Paris, France
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12
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Llauger MA, Rosas A, Burgos F, Torrente E, Tresserras R, Escarrabill J. [Accesibility and use of spirometry in primary care centers in Catalonia]. Aten Primaria 2014; 46:298-306. [PMID: 24768654 PMCID: PMC6983645 DOI: 10.1016/j.aprim.2013.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 12/01/2013] [Accepted: 12/05/2013] [Indexed: 11/05/2022] Open
Abstract
Objetivo Conocer la accesibilidad y la utilización de la espirometría forzada (EF) en los dispositivos públicos de atención primaria en Cataluña. Diseño Estudio transversal mediante encuesta. Participantes Trescientos sesenta y seis equipos de atención primaria (EAP) de Cataluña. Tercer trimestre de 2010. Mediciones Encuesta con información relativa a los espirómetros, la formación, la interpretación y el control de calidad, y el grado de prioridad que la calidad de la espirometría tenía para el equipo. Se analizaron: media de EF/100 habitantes/año; índice de EF/mes/EAP; índice de EF/mes/10.000 habitantes. Resultados principales Porcentaje de respuesta: 75%. El 97,5% de los EAP dispone de espirómetro y realiza una media de 2,01 espirometrías/100 habitantes (34,68 espirometrías/EAP/mes). El 83% dispone de profesionales formados y más del 50% de los centros realizan formación reglada, pero no se dispone de información sobre la calidad de la misma. En el 70% se hace algún tipo de calibración. La interpretación la realiza el médico de familia en el 87,3% de los casos. En el 68% de los casos no se lleva a cabo ningún tipo de control de calidad de la exploración. En dos tercios de los casos se introducen manualmente los datos en la historia clínica informatiza. Más del 50% se atribuye una prioridad alta para las estrategias de mejora de la calidad de la EF. Conclusiones A pesar de la accesibilidad a la EF deben realizarse esfuerzos para estandarizar la formación, incrementar el número de exploraciones y promover el control de calidad sistemático.
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Affiliation(s)
- M Antònia Llauger
- EAP Encants, SAP Muntanya-Dreta de Barcelona, ICS, Barcelona, España; Pla Director de les Malalties de l'Aparell Respiratori (PDMAR), Departament de Salut de Catalunya, Barcelona, España.
| | - Alba Rosas
- Pla Director de les Malalties de l'Aparell Respiratori (PDMAR), Departament de Salut de Catalunya, Barcelona, España; Subdirecció de Planificació Sanitària, Direcció General de Planificació i Recerca en Salut, Departament de Salut, Generalitat de Catalunya, Barcelona, España
| | - Felip Burgos
- Centre Diagnòstic Respiratori, Institut del Tòrax, Hospital Clínic, IDIBAPS, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Palma de Mallorca, España
| | - Elena Torrente
- Pla Director de les Malalties de l'Aparell Respiratori (PDMAR), Departament de Salut de Catalunya, Barcelona, España; Red de servicios de Salud Orientados a Enfermedades Crónicas (REDISECC), Madrid, España; Agència d'Informació, Avaluació i Qualitat en Salut (AIAQS), Barcelona, España
| | - Ricard Tresserras
- Pla Director de les Malalties de l'Aparell Respiratori (PDMAR), Departament de Salut de Catalunya, Barcelona, España; Subdirecció de Planificació Sanitària, Direcció General de Planificació i Recerca en Salut, Departament de Salut, Generalitat de Catalunya, Barcelona, España; Observatori de Teràpies Respiratòries (OBsTRD), FORES, Vic (Barcelona), España
| | - Joan Escarrabill
- Pla Director de les Malalties de l'Aparell Respiratori (PDMAR), Departament de Salut de Catalunya, Barcelona, España; Red de servicios de Salud Orientados a Enfermedades Crónicas (REDISECC), Madrid, España; Observatori de Teràpies Respiratòries (OBsTRD), FORES, Vic (Barcelona), España; Programa d'Atenció a la Cronicitat, Hospital Clínic i Barcelona Esquerra, Barcelona, España
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13
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Scherr A, Graf R, Bain M, Christ-Crain M, Müller B, Tamm M, Stolz D. Pancreatic stone protein predicts positive sputum bacteriology in exacerbations of COPD. Chest 2013; 143:379-387. [PMID: 22922487 DOI: 10.1378/chest.12-0730] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Pancreatic stone protein/regenerating protein (PSP/reg) serum levels are supposed to be increased in bacterial inflammation. PSP/reg levels also might be useful, therefore, as a predictor of bacterial infection in COPD. METHODS Two hundred consecutive patients presenting to the ED due to acute exacerbation of COPD were prospectively assessed. Patients were evaluated based on clinical, laboratory, and lung functional parameters at admission (exacerbation) and after short-term follow-up (14-21 days). PSP/reg serum values were measured by a newly developed enzyme-linked immunosorbent assay. RESULTS PSP/reg levels were elevated in subjects with COPD exacerbation (23.8 ng/mL; 95% CI, 17.1-32.7) when compared with those with stable disease (19.1 ng/mL; 95% CI, 14.1-30.4; P 5 .03) and healthy control subjects (14.0 ng/mL; 95% CI , 12.0-19.0; P , .01). Higher PSP/reg values were observed in exacerbations with positive sputum bacteriology compared with those with negative sputum bacteriology (26.1 ng/mL [95% CI, 19.2-38.1] vs 20.8 ng/mL [95% CI , 15.6-27.2]; P , .01). Multivariate regression analysis revealed PSP/reg level as an independent predictor of positive sputum bacteriology. A combination of a PSP/reg cutoff value of . 33.9 ng/mL and presence of discolored sputum had a specificity of 97% to identify patients with pathogenic bacteria on sputum culture. In contrast, PSP/reg levels , 18.4 ng/mL and nonpurulent sputum ruled out positive bacterial sputum culture (sensitivity, 92%). In survival analysis, high PSP/reg levels at hospital admission were associated with increased 2-year mortality. CONCLUSIONS Serum PSP/reg level might represent a promising new biomarker to identify bacterial etiology of COPD exacerbation.
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Affiliation(s)
- Andreas Scherr
- Clinic of Pulmonary Medicine and Respiratory Cell Research, Diabetes and Clinical Nutrition, University Hospital, Basel
| | - Rolf Graf
- Pancreatitis Research Laboratory, University Hospital Zurich, Zurich
| | - Martha Bain
- Pancreatitis Research Laboratory, University Hospital Zurich, Zurich
| | - Mirjam Christ-Crain
- Clinic of Endocrinology, Diabetes and Clinical Nutrition, University Hospital, Basel
| | - Beat Müller
- Medical University Clinic, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Michael Tamm
- Clinic of Pulmonary Medicine and Respiratory Cell Research, Diabetes and Clinical Nutrition, University Hospital, Basel
| | - Daiana Stolz
- Clinic of Pulmonary Medicine and Respiratory Cell Research, Diabetes and Clinical Nutrition, University Hospital, Basel.
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14
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Garcia-Gutierrez S, Quintana JM, Barrio I, Bare M, Fernandez N, Vidal S, Gonzalez N, Lafuente I, Arteta E, Esteban C, Pulido E. Application of appropriateness criteria for hospitalization in COPD exacerbation. Intern Emerg Med 2013; 8:349-57. [PMID: 23508735 DOI: 10.1007/s11739-013-0927-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 03/02/2013] [Indexed: 10/27/2022]
Abstract
The IRYSS-COPD appropriateness study was developed in 16 hospitals belonging to the Spanish National Health Service from June 2008 to September 2010 (n = 2,877). The objectives were to apply a set of explicit criteria for the appropriateness of hospital admission created by the RAND/UCLA methodology to patients evaluated in the emergency department (ED) for exacerbations of COPD. This is a prospective cohort study. We explored the relationship between appropriateness of admission as defined by the explicit criteria and the final decision to admit or discharge. A total of 2,877 patients were included for analysis; of these, 1,747 (60.7 %) were admitted and 1,130 (39.3 %) were discharged from the ED to home. Among patients classified by the explicit criteria as appropriate for hospital admission, 81.3 % were admitted, compared with 64.81 % of those classified as uncertain and 48.65 % of those classified as inappropriate for admission. Severity of exacerbation was the most influencing variable in the decision. Application of our explicit criteria for appropriate hospital admission among a large sample of patients experiencing an exacerbation of COPD in the ED setting suggests that these criteria could be used as the basis for clinical decision-making and health-care assessment.
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Affiliation(s)
- Susana Garcia-Gutierrez
- Unidad de Investigación, Hospital Galdakao-Usansolo, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barrio Labeaga s/n, 48960, Galdakao, Vizcaya, Spain.
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15
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Roger N, Burgos F, Giner J, Rosas A, Tresserras R, Escarrabill J. Survey about the use of lung function testing in public hospitals in Catalonia in 2009. Arch Bronconeumol 2013; 49:371-7. [PMID: 23414603 DOI: 10.1016/j.arbres.2012.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 12/12/2012] [Accepted: 12/19/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Underdiagnosis is one of the problems with the greatest impact on respiratory disease management and requires specific interventions. Access to quality spirometry is especially important and is an objective of the Master Plan for Respiratory Diseases of the Department of Health of the Generalitat de Catalunya. OBJECTIVE To determine the current use of spirometry at public hospitals in Catalonia, possible deficiencies and options for improvement. METHODS A cross-sectional survey of 65 public hospitals in Catalonia in 2009. Descriptive analyses were developed for each public health-care region. RESULTS A lack of uniformity was observed in the use of spirometry at the regional level (between 0,98 and 1.50 spirometries per 100 inhabitants). We identified two factors associated with a higher rate of spirometry: i) the existence of a Respiratory Medicine Department at the hospital, and ii) the existence of a set location to carry out spirometries. Several areas for improvement also were identified: quality control of the test itself, the inclusion of spirometry in electronic health-care records and continuing education programs. CONCLUSIONS The results of this study have identified areas for improvement in spirometry programs.
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Affiliation(s)
- Nuria Roger
- Direcció d'Especialitats Mèdiques, Consorci Hospitalari de Vic, Vic, Barcelona, España.
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Laforest L, Licaj I, Devouassoux G, Hartwig S, Marvalin S, Van Ganse E. Factors associated with early adherence to tiotropium in chronic obstructive pulmonary disease. Chron Respir Dis 2012; 10:11-8. [DOI: 10.1177/1479972312464245] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Tiotropium is an innovative intervention in chronic obstructive pulmonary disease (COPD). Early adherence to tiotropium remains inadequately explored, notably time from initiation to discontinuation (persistence). In patients with COPD, the factors associated with the risk of discontinuing the treatment with tiotropium within 12 months following initiation were identified (12-month persistence). Claim databases from the French Social Security were used. A random sample of patients (aged 50–80 years) who initiated tiotropium soon after launch was selected. Factors associated with the persistence were investigated (Log-rank test and multivariate Cox model). Of the 1147 newly treated patients (mean age 68 years, 33% women), 64% remained in the treatment of tiotropium for over a period of 12 months following initiation. More than 10% of the patients interrupted therapy after a single dispensing, most often those with mild COPD. Lower risks of discontinuing tiotropium within 12 months following initiation were observed when it was initiated by a private sector specialist (hazard ratio (HR) = 0.65, 95% confidence interval (CI) = (0.52–0.82)), by hospital-based physician (HR = 0.58, 95% CI = (0.42–0.78)), when ≥ 2 other respiratory drugs were associated (HR = 0.74, 95% CI = (0.58–0.95)) and in case of long-term disease status (HR = 0.78, 95% CI = (0.63–0.97)). Conversely, no clear effect appeared according to age or gender. In this population of patients with COPD, fewer early discontinuations of tiotropium were observed in patients having a severe condition.
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Affiliation(s)
- Laurent Laforest
- Unité de Pharmacoépidémiologie, CHU-Lyon, d’Odontologie - UMR 5558 CNRS - Université Claude Bernard Lyon, France
| | - Idlir Licaj
- Unité de Pharmacoépidémiologie, CHU-Lyon, d’Odontologie - UMR 5558 CNRS - Université Claude Bernard Lyon, France
| | - Gilles Devouassoux
- Service de pneumologie, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Susanne Hartwig
- Unité de Pharmacoépidémiologie, CHU-Lyon, d’Odontologie - UMR 5558 CNRS - Université Claude Bernard Lyon, France
| | - Serge Marvalin
- Direction Régionale du Service Médical Rhône-Alpes, 26, rue d'Aubigny, Lyon, France
| | - Eric Van Ganse
- Unité de Pharmacoépidémiologie, CHU-Lyon, d’Odontologie - UMR 5558 CNRS - Université Claude Bernard Lyon, France
- Service de pneumologie, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
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Previous outpatient antibiotic use in patients admitted to hospital for COPD exacerbations: room for improvement. Infection 2012; 41:361-70. [PMID: 22907284 DOI: 10.1007/s15010-012-0316-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/04/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Several studies have analyzed factors associated to hospitalization in chronic obstructive pulmonary disease (COPD) patients. However, data are lacking on the quality of treatment received by patients prior to hospital admission. The present study analyzed how often patients requiring hospitalization for a COPD exacerbation had received previous treatment for the exacerbation, particularly antibiotics. METHODS This was a multicenter, cross-sectional, observational study conducted in 30 Spanish hospitals among COPD patients aged >40 years who were hospitalized for an acute exacerbation. Patients were grouped according to whether or not they had received treatment prior to admission and, subsequently, according to whether or not they had received antibiotics. Patient eligibility for antibiotic therapy was assessed using both national and European guidelines. RESULTS The study population consisted of 298 patients, of which 277 (93 %) were men, with a mean [standard deviation (SD)] age of 69.1 (9.5) years. One hundred and thirty-three patients (45 %) had received treatment prior to admission; among these, 76/133 (57 %) had received antibiotic therapy. However, 81-91 % of these patients fulfilled criteria for this therapy. Antibiotic use was significantly associated with yellow or green-yellow sputum prior to the exacerbation, a higher number of exacerbations in the previous year, more visits to emergency departments, and bronchiectasis. On the other hand, 10-20 % of patients who did receive antibiotics were not eligible for this therapy according to guidelines. CONCLUSIONS This study demonstrates a low rate of previous outpatient treatment and antibiotic use among patients with a COPD exacerbation requiring hospital admission.
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Glaab T, Vogelmeier C, Hellmann A, Buhl R. Guideline-based survey of outpatient COPD management by pulmonary specialists in Germany. Int J Chron Obstruct Pulmon Dis 2012; 7:101-8. [PMID: 22371651 PMCID: PMC3282602 DOI: 10.2147/copd.s27887] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Little is known about the role of guidelines for the practical management of chronic obstructive pulmonary disease (COPD) by office-based pulmonary specialists. The aim of this study was to assess their outpatient management in relation to current guideline recommendations for COPD. Methods A nationwide prospective cross-sectional COPD questionnaire survey in the form of a multiple-choice questionnaire was sent to 1000 office-based respiratory specialists in Germany. The product-neutral questions focused on routine COPD management and were based on current national and international COPD guideline recommendations being consistent in severity classification and treatment recommendations. Results A total of 590 pulmonary specialists (59%) participated in the survey. Body plethysmography was considered the standard for diagnosis (65.9%), followed by spirometry (32%). Most respondents were able to cite the correct spirometric criteria for classifying moderate (87%) to very severe COPD (77%). A quarter of the respondents equated the World Health Organization (WHO) definition of chronic bronchitis with COPD. Notably, most participants preferred the updated national COPD guidelines (51.4%) to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines (40.2%). Improvement of functional exercise capacity and quality of life were considered the two most relevant treatment goals; whereas impact on mortality was secondary. Treatment of COPD largely complied with the guidelines. However, a significant percentage of the pulmonary specialists differed in their assessment of the benefits of various therapeutic measures from evidence-based results. Referral for pulmonary rehabilitation was uncommon, regardless of the severity of COPD. Conclusion The findings of this large national survey suggest that most pulmonary specialists adhere to the current COPD guideline recommendations in daily practice. However, physicians’ knowledge of guidelines is not sufficient as the sole benchmark when assessing their implementation in day-to-day practice. Necessary changes in the health care system must include more effective ways to transfer knowledge to clinical practice and to give access to interventions of proven clinical benefit.
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Affiliation(s)
- Thomas Glaab
- Department of Respiratory Diseases III, Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
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Paladini L, Hodder R, Bellia V, Marchionni N, Di Bari M, Cecchini I, Pistelli R, Antonelli-Incalzi R. Physician specialty as a source of heterogeneity in the care of patients with COPD. Chest 2012; 140:1666-1667. [PMID: 22147829 DOI: 10.1378/chest.11-1690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Luciana Paladini
- Department of Geriatrics, University Campus Bio-Medico, Rome, Italy.
| | - Rick Hodder
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Vincenzo Bellia
- Biomedical Department of Internal and Specialized Medicine DIBIMIS, University of Palermo, Palermo, Italy
| | - Niccolò Marchionni
- Department of Critical Care Medicine and Surgery, Unit of Gerontology and Geriatric Medicine, University of Florence, Florence, Italy
| | - Mauro Di Bari
- Department of Critical Care Medicine and Surgery, Unit of Gerontology and Geriatric Medicine, University of Florence, Florence, Italy
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Geitona M, Hatzikou M, Steiropoulos P, Alexopoulos EC, Bouros D. The cost of COPD exacerbations: a university hospital--based study in Greece. Respir Med 2011; 105:402-9. [PMID: 20970310 DOI: 10.1016/j.rmed.2010.09.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 09/24/2010] [Accepted: 09/28/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hospitalization attributed to severe exacerbations is the major cost driver of Chronic Obstructive Pulmonary Disease (COPD). Given that in Greece no previous studies have addressed the economic burden of COPD, the aim of the study was to examine the hospitalization cost of COPD patients with severe exacerbations in the region of Thrace. METHODS Sample consisted of 142 COPD patients with severe exacerbations who were admitted to the pneumonology department of the University Teaching Hospital of Alexandroupolis (UTHA) in 2006 and 2007. Data collection was performed retrospectively and resource utilization was derived from patients' files. General Linear Model univariate analysis was applied in order to test the influence of disease severity on costs. RESULTS Mean actual cost per severe exacerbation was €1711; the amount of €621 is reimbursed by social security funds. Price discrepancies are observed between the actual and the nominal cost per patient in all disease stage categories. Mean hospitalization cost per COPD patient increases slightly with the severity of the disease. However, in the very severe stage it greatly increases mainly due to Intensive Care Unit (ICU) admission. In multivariate analysis the length of stay and the stage of the disease were both related to significantly increased costs, while the existence of co-morbidities exhibited marginal significant relation to increased cost. CONCLUSIONS The cost estimation of severe exacerbations is important as it could trigger further research and also provide the opportunity of creating national epidemiological and economic data. Such data could contribute to the estimation of the total economic and societal burden of COPD in the country.
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Affiliation(s)
- Mary Geitona
- Department of Social Policy, University of Peloponnese, Korinthos, Greece
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Wesseling G, Vrijhoef HJ. Acute exacerbations of COPD: recommendations for integrated care. Expert Rev Respir Med 2010; 2:489-94. [PMID: 20477212 DOI: 10.1586/17476348.2.4.489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are significant events that come with high costs for patients and for society. Initial management of exacerbations consists of pharmacotherapy and a reassessment of pre-existing management and self-management strategies. Currently, care for AECOPDs is often suboptimal. Integrated care consisting of self-management support, delivery system design, decision support and clinical information systems will probably improve the quality of healthcare delivery for patients with AECOPDs. In this review, we summarize current knowledge related to the epidemiology and management of AECOPDs, identify shortcomings in current clinical practice and give recommendations for innovative, integrated and optimized care for these patients.
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Affiliation(s)
- Geertjan Wesseling
- Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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Lange P, Andersen KK, Munch E, Sørensen TB, Dollerup J, Kassø K, Larsen HB, Dahl R. Quality of COPD care in hospital outpatient clinics in Denmark: The KOLIBRI study. Respir Med 2009; 103:1657-62. [PMID: 19520562 DOI: 10.1016/j.rmed.2009.05.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 05/02/2009] [Accepted: 05/10/2009] [Indexed: 11/15/2022]
Abstract
BACKGROUND We studied the quality of care for COPD patients in 22 hospital-based outpatient clinics in Denmark and evaluated if participation by the staff in an educational programme could improve the quality of care and adherence to the COPD guidelines. METHODS We performed two audits of the hospital records one year apart before and after the educational programme for the participating doctors and nurses. A total of 941 patient records were included in the first audit and 927 in the second. The indicators of quality of care comprised amongst others referral to pulmonary rehabilitation, smoking cessation advice, nutritional advice, instruction in inhalation technique and assessment of BMI, smoking status, pack years, lung function parameters, dyspnoea oxygen saturation and co-morbidities. RESULTS In general, the quality of care for COPD patients in Denmark was suboptimal and not in accordance with the recently published guidelines both in the 1st and the 2nd audit. Yet, we observed a substantial improvement from the 1st to the 2nd audit. For example, referral to rehabilitation improved from 56.3 to 62.7% (p=0.006) Assessment of BMI improved from 7.8 to 56.1% and assessment of dyspnoea using MRC dyspnoea scale increased from 7.2 to 47.2% (both p<0.001). When analysing the results with focus on the performance of the individual outpatient clinics we also observed an improvement in the quality. CONCLUSION We conclude that it is possible to improve the quality of care for COPD by focusing on a more systematic approach to the patient assessment by education of the staff of the outpatient clinics. A repeated and continuous education and discussion with the clinical staff is probably essential to reach an acceptable level of the quality of care for outpatients with COPD.
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Affiliation(s)
- Peter Lange
- Department of Cardiology and Respiratory Medicine, Hvidovre Hospital, Denmark.
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Garcia-Aymerich J, Gómez FP, Antó JM. [Phenotypic characterization and course of chronic obstructive pulmonary disease in the PAC-COPD Study: design and methods]. Arch Bronconeumol 2009; 45:4-11. [PMID: 19186292 DOI: 10.1016/j.arbres.2008.03.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Accepted: 03/25/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The Phenotype and Course of Chronic Obstructive Pulmonary Disease (PAC-COPD) study aims to improve our understanding of the phenotypic heterogeneity of this disease and the extent to which this heterogeneity is related to clinical course. The main objectives are a) to characterize the phenotypic variability in first-time hospitalizations for exacerbation of COPD and to propose a classification into subtypes and b) to ascertain the association between the defined subtypes and the clinical and functional course of COPD. PATIENTS AND METHODS This is a cross-sectional and cohort study of 342 patients with COPD from 9 tertiary hospitals in 3 autonomous communities. The minimum follow-up period is 5 years. The main variables of interest are respiratory symptoms, smoking, alcohol use, physical activity, use of health care services, medical care, treatment received, activities of daily living, comorbid conditions, sleepiness, anxiety and depression, quality of life, forced spirometry and bronchodilation tests, lung volume and inspiratory capacity measured by body plethysmography, carbon monoxide diffusing capacity, baseline arterial blood gas values, respiratory and peripheral muscle function, electrocardiogram, body weight and composition measured by bioelectric impedance, chest radiograph, skin prick test, capacity for exercise measured in the 6-minute walk test and cardiopulmonary exercise test, induced sputum (for quantitative microbiological culture and determination of inflammatory markers), nighttime pulse oximetry, chest computed tomography scan, and echocardiography. Serum and plasma samples are also taken to measure levels of inflammatory markers and oxidative stress, for genetic analysis, and for other possible measurements that might be required in the future. The statistical analysis combines factor analysis and survival models such as Cox regression analysis. This project will enable us to reconsider the definition and classification of COPD and to better understand the factors associated with its natural history.
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Affiliation(s)
- J Garcia-Aymerich
- Centre for Research in Environmental Epidemiology (CREAL), Institut Municipal d'Investigació Mèdica-Hospital del Mar, Universitat Pompeu Fabra, CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, España.
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Garcia-Aymerich J, Gómez FP, Antó JM. Phenotypic Characterization and Course of Chronic Obstructive Pulmonary Disease in the PAC-COPD Study: Design and Methods. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1579-2129(09)71781-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease. Can Respir J 2008; 14:485-9. [PMID: 18060094 DOI: 10.1155/2007/425248] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is associated with significant mortality. It is currently the fourth leading cause of death in Canada and the world. OBJECTIVES To describe the mortality of elderly patients in Ontario after hospital admission for COPD. METHODS A retrospective cohort study was conducted using the Discharge Abstract Database from the Canadian Institute for Health Information. Patients aged 65 years and older who were admitted to hospital between 2001 and 2004 with primary discharge diagnoses labelled with International Classification of Diseases, Ninth Revision codes 491, 492 and 496 were included in the study. RESULTS Mortality rates were 8.81, 12.10, 14.53 and 27.72 per 100 COPD hospital admissions at 30, 60, 90 and 365 days after hospital discharge, respectively. Mortality also increased with age, and men had higher rates than women. No significant differences in mortality rates were found between different socioeconomic groups (P>0.05). Patients with shared care of a family physician or general practitioner and a specialist had significantly lower mortality rates than the overall rate (P<0.05), and their rates were approximately one-half the rate of patients with only one physician. CONCLUSIONS Hospitalization with COPD is associated with significant mortality. Patients who were cared for by both a family physician or general practitioner and a specialist had significantly lower mortality rates than those cared for by only one physician, suggesting that continuous and coordinated care results in better survival.
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Yawn BP, Wollan PC. Knowledge and attitudes of family physicians coming to COPD continuing medical education. Int J Chron Obstruct Pulmon Dis 2008; 3:311-7. [PMID: 18686740 PMCID: PMC2629969 DOI: 10.2147/copd.s2486] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE COPD remains under-recognized and under-treated. Much of early COPD care is given by primary care physicians but only when COPD is recognized. This survey explores the attitudes, beliefs, and knowledge related to COPD recognition, diagnosis, and treatment from family physicians and nurse practitioners (NPs) and physician assistants (PAs) working in primary care. METHODS We completed a survey of family physicians, and NPs/PAs attending one of three CME programs on five common chronic conditions including COPD. RESULTS Return rate was 62% (n = 284) including 178 physicians and 100 NPs/PAs. Fewer than half of the respondents reported knowledge of or use of COPD guidelines. The barriers to recognition and diagnosis of COPD they reported included the multiple morbidities of most COPD patients, failure of patients to report COPD symptoms, as well as lack of knowledge and inadequate training in COPD diagnosis and management. Three quarters (74%) of respondents reported use of spirometry to diagnose COPD but only 32% said they included reversibility assessment. COPD was incorrectly assessed as a disease primarily of men (78% ofrespondents) that appeared after age 60 (61%). Few respondents reported that they believed COPD treatment was useful or very useful for improving symptoms (15%) or decreasing exacerbations (3%) or that pulmonary rehabilitation was helpful (3%), but 13% reported they thought COPD treatment could extend longevity. CONCLUSIONS Primary care physicians and NPs/PAs working in primary care continue to report lack of awareness and use of COPD guidelines, as well as correct information related to COPD epidemiology or potential benefits of available treatments including pulmonary rehabilitation. It is unlikely that diagnosis and management of COPD will improve in primary care until these knowledge gaps and discrepancies with published efficacy of therapy issues are addressed.
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Affiliation(s)
- Barbara P Yawn
- Olmsted Medical Center, Research Department, Rochester, MN 55904, USA.
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Lampela P, Säynäjäkangas O, Jokelainen J, Keistinen T. Does place of treatment affect prognosis for chronic obstructive pulmonary disease (COPD)? Eur J Gen Pract 2008; 14:123-8. [PMID: 22548298 DOI: 10.1080/13814780802444410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND It has been shown previously that mortality from acute chronic obstructive pulmonary disease (COPD) is higher at small hospitals than at large teaching hospitals. OBJECTIVE To examine mortality at this acute stage and referral for further treatment by specialities in Finland, and trends in these between the 1990s and 2000s. METHODS Data on all periods of treatment for patients over 44 years of age with a principal or subsidiary diagnosis of COPD beginning and ending in 1995-2004 were extracted from the Finnish hospital discharge register. Particular attention was paid to acute-stage treatment periods managed by a general practitioner, pulmonary specialist, or specialist in internal medicine that had begun as emergency admissions and had a principal diagnosis of COPD, and to any further treatment immediately following these. RESULTS General practitioners referred 5.1% of their acute-stage patients to a specialist in secondary care in 1995-2004. Of the total of 77,445 acute-stage treatment periods, 3% (2328) ended in the death of the patient, implying the loss of 8.3% of the patients involved. The age- and sex-adjusted risk of death attached to treatment periods managed by a general practitioner relative to those managed by a pulmonary specialist was 0.83 (95% CI 0.75-0.91). CONCLUSION It is quite possible to treat acute exacerbations of COPD efficiently and safely in a health centre hospital ward. New treatment modalities and health service structures seem to have led to a decrease in acute exacerbations of COPD since the year 2000, even though the number of patients with this disease has increased as a consequence of ageing of the population. Further research is required on the efficacy of treatment by a general practitioner, e.g., with data on re-hospitalization.
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Affiliation(s)
- Pekka Lampela
- Department of Public Health Science and General Practice, University of Oulu, Oulu, Finland.
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