Diagnostic accuracy of primary care asthma/COPD working hypotheses, a real life study

The Impact of an Electronic Health Record Intervention on Spirometry Completion in Patients with Chronic Obstructive Pulmonary Disease

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.

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 use of a direct bronchial challenge test in primary care to diagnose asthma

Many asthmatics in primary care have mild symptoms and lack airflow obstruction. If variable expiratory airflow limitation cannot be determined by spirometry or peak expiratory flow, despite a history of respiratory symptoms, a positive bronchial challenge test (BCT) can confirm the diagnosis of asthma. However, BCT is traditionally performed in secondary care. In this observational real-life study, we retrospectively analyze 5-year data of a primary care diagnostic center carrying out BCT by histamine provocation. In total, 998 primary care patients aged ≥16 years underwent BCT, without any adverse events reported. To explore diagnostic accuracy, we examine 584 patients with a high pretest probability of asthma. Fifty-seven percent of these patients have a positive BCT result and can be accurately diagnosed with asthma. Our real-life data show BCT is safe and feasible in a suitably equipped primary care diagnostic center. Furthermore, it could potentially reduce diagnostic referrals to secondary care.

Personalised exhaled nitric oxygen fraction (F ENO)-driven asthma management in primary care: a F ENO subgroup analysis of the ACCURATE trial

Background

The aim of this study was to identify patients who benefit most from exhaled nitric oxide fraction (F_ENO)-driven asthma management in primary care, based on prespecified subgroups with different levels of F_ENO.

Methods

We used data from 179 adults with asthma from a 12-month primary care randomised controlled trial with 3-monthly assessments of F_ENO, asthma control, medication usage, costs of medication, severe asthma exacerbations and quality of life. In the original study, patients were randomised to either a symptom-driven treatment strategy (controlled asthma (Ca) strategy) or a F_ENO+symptom-driven strategy (FCa). In both groups, patients were categorised by their baseline level of F_ENO as low (<25 ppb), intermediate (25–50 ppb) and high (>50 ppb). At 12 months, we compared, for each prespecified F_ENO subgroup, asthma control, asthma-related quality of life, medication usage, and costs of medication between the Ca and FCa strategy.

Results

We found a difference between the Ca and FCa strategy for the mean dosage of beclomethasone strategy of 223 µg (95% CI 6–439), p=0.04) and for the total costs of asthma medication a mean reduction of US$159 (95% CI US$33–285), p=0.03) in patients with a low baseline F_ENO level. No differences were found for asthma control, severe asthma exacerbations and asthma-related quality of life in patients with a low baseline F_ENO level. Furthermore, in patients with intermediate or high level of F_ENO, no differences were found.

Conclusions

In primary care, F_ENO-driven asthma management is effective in patients with a low F_ENO level, for whom it is possible to down-titrate medication, while preserving asthma control and quality of life.

In primary care, F_ENO-driven asthma management is effective in patients with a low F_ENO, for whom it is possible to down-titrate medication while preserving asthma control and quality of lifehttps://bit.ly/2wC25N7d

Overdiagnosis of COPD in Subjects With Unobstructed Spirometry: A BOLD Analysis

BACKGROUND

There are several reports on underdiagnosis of COPD, while little is known about COPD overdiagnosis and overtreatment. We describe the overdiagnosis and the prevalence of spirometrically defined false positive COPD, as well as their relationship with overtreatment across 23 population samples in 20 countries participating in the BOLD Study between 2003 and 2012.

METHODS

A false positive diagnosis of COPD was considered when participants reported a doctor's diagnosis of COPD, but postbronchodilator spirometry was unobstructed (FEV1/FVC > LLN). Additional analyses were performed using the fixed ratio criterion (FEV1/FVC < 0.7).

RESULTS

Among 16,177 participants, 919 (5.7%) reported a previous medical diagnosis of COPD. Postbronchodilator spirometry was unobstructed in 569 subjects (61.9%): false positive COPD. A similar rate of overdiagnosis was seen when using the fixed ratio criterion (55.3%). In a subgroup analysis excluding participants who reported a diagnosis of "chronic bronchitis" or "emphysema" (n = 220), 37.7% had no airflow limitation. The site-specific prevalence of false positive COPD varied greatly, from 1.9% in low- to middle-income countries to 4.9% in high-income countries. In multivariate analysis, overdiagnosis was more common among women, and was associated with higher education; former and current smoking; the presence of wheeze, cough, and phlegm; and concomitant medical diagnosis of asthma or heart disease. Among the subjects with false positive COPD, 45.7% reported current use of respiratory medication. Excluding patients with reported asthma, 34.4% of those with normal spirometry still used a respiratory medication.

CONCLUSIONS

False positive COPD is frequent. This might expose nonobstructed subjects to possible adverse effects of respiratory medication.

Asthma patients' perception on their care pathway: a qualitative study

Because of insufficient asthma control in many patients, the collaboration between stakeholders is regarded as a promising strategy to improve asthma outcomes. This study explored the perceptions of French adult asthma patients on their care pathway. We conducted a qualitative study based on the interviews of 30 asthma patients aged 18–40 years, recruited in French primary care. We performed a thematic analysis of the data collected, using the NVivo software. According to the patients, the stakeholders involved in asthma management included those visible to healthcare professionals (patient, general practitioner, specialist(s), pharmacist, physiotherapist, family and friends) and those concealed by the patients (complementary and alternative practitioners); other stakeholders, such as nurses and occupational physicians, were not involved. Asthma management at diagnosis and follow-up phases proved to be unstructured, and were associated with poor patient education. This was supported by patients’ ambivalence (in relation to illness and treatments), poor communication between patients and healthcare professionals (lack of listening and use of inappropriate vocabulary by physicians, underreporting of alternative medicine use by patients) and weak cooperation between professionals (limited to interaction between the general practitioner and the specialist, either pulmonologist or allergist). Asthma management would probably benefit from a more coordinated care pathway at each phase of the disease that is consistent with the expectations and goals of the patients. It should be based on improved organization (involvement of other healthcare professionals and the patient as partners) and processes (regular follow-up, specific tools such as peak flow meter or action plan).

Inaccurate diagnosis of COPD: the Welsh National COPD Audit

BACKGROUND

The diagnosis of chronic obstructive pulmonary disease (COPD) is confirmed with spirometry demonstrating persistent airflow obstruction.

AIM

To evaluate the clinical characteristics and management of patients in primary care on COPD registers with spirometry incompatible with COPD.

DESIGN AND SETTING

A primary care audit of Welsh COPD Read-Coded patient data from the Quality and Outcomes Framework (QOF) COPD register in Wales.

METHOD

Patients on the QOF COPD register with incompatible spirometry (post-bronchodilator forced expiratory lung volume in 1 second/forced vital capacity [FEV1/FVC] ratio ≥0.70) were compared with those with compatible spirometry (FEV1/FVC <0.70).

RESULTS

This audit included 63% of Welsh practices contributing 48 105 patients. Only 19% (n = 8957) of patients were post-bronchodilator FEV1/FVC Read-Coded and were included in this study. Of these, 75% (n = 6702) had compatible spirometry and 25% (n = 2255) did not. Patients with incompatible spirometry were more likely female (P = 0.009), never-smokers (P<0.001), had higher body mass index (P<0.001), and better mean FEV1 (P<0.001). Medical Research Council (MRC) breathlessness scores, exacerbation frequency, and asthma co-diagnosis were similar between groups. Patients in both groups were just as likely to receive inhaled corticosteroid (ICS) and long-acting beta-agonists (LABAs), but patients with incompatible spirometry were less likely to receive long-acting muscarinic antagonists (LAMAs) (P<0.001) or LABA/ICS (P = 0.002) combinations.

CONCLUSION

Patients on the COPD QOF register with spirometry incompatible with COPD are symptomatic and managed using significant resources. If quality of care and effective resource use are to be improved, focus must be given to correct diagnosis in this group.

Concomitant diagnosis of asthma and COPD: a quantitative study in UK primary care

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) share many characteristics and symptoms, and the differential diagnosis between the two diseases can be difficult in primary care. This study explored potential overlap between both diseases in a primary care environment.

AIM

To quantify how commonly patients with COPD have a concomitant diagnosis of asthma, and how commonly patients with asthma have a concomitant diagnosis of COPD in UK primary care. Additionally, the study aimed to determine the extent of possible misdiagnosis and missed opportunities for diagnosis.

DESIGN AND SETTING

Patients with validated asthma and patients with validated COPD in primary care were identified from the UK Clinical Practice Research Datalink (CPRD) in separate validation studies, and the diseases were confirmed by review of GP questionnaires.

METHOD

The prevalence of concurrent asthma and COPD in validated cases of either disease was examined based on CPRD coding, GP questionnaires, and requested additional information.

RESULTS

In total, 400 patients with COPD and 351 patients with asthma in primary care were identified. Of the patients with validated asthma, 15% (n = 52) had previously received a diagnostic COPD Read code, although COPD was only likely in 14.8% (95% confidence interval [CI] = 11.3 to 19.0) of patients with validated asthma. More than half (52.5%, n = 210) of patients with validated COPD had previously received a diagnostic asthma Read code. However, when considering additional evidence to support a diagnosis of asthma, concurrent asthma was only likely in 14.5% (95% CI = 11.2 to 18.3) of patients with validated COPD.

CONCLUSION

A concurrent asthma and COPD diagnosis appears to affect a relative minority of patients with COPD (14.5%) or asthma (14.8%). Asthma diagnosis may be over-recorded in people with COPD.

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.

Missed diagnosis and overtreatment of COPD among smoking primary care population in Central Greece: old problems persist

Background

The diagnosis of COPD is not always consistent with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy in daily clinical practice, especially in primary care. This study aimed to estimate the overall COPD prevalence and severity, to identify differences between newly and previously diagnosed patients, and to evaluate the potential COPD overtreatment in a smoking population attending a primary care spirometry surveillance program.

Methods

A study was conducted in 10 primary health care centers of Central Greece during a 7-month period. Eligible participants were aged ≥40 years and were either current smokers or exsmokers.

Results

A total of 186 subjects were included (68% males, mean age 62.3±12.6 years, mean life-time tobacco exposure 50 pack-years). COPD prevalence was 17.8%, identified to be higher in elderly males. Forty-two percent of the COPD group were newly diagnosed patients, who were of younger age, current smokers, presented with less dyspnea and better health status, and mainly appeared with mild-to-moderate disease. Interestingly, 61.4% of non-COPD and 85.7% of newly diagnosed COPD individuals had been using inhaled medication under primary care provider's prescription without ever undergoing spirometry or further evaluation by a pulmonologist; thus, the phenomena of COPD overdiagnosis and missed diagnosis came into the spotlight. Moreover, only 26.3% of known COPD patients were properly medicated according to GOLD guidelines, while half of them were inappropriately treated with triple inhaled therapy.

Conclusion

We reported a significant prevalence of COPD in smoking population attending this spirometry program. A remarkable proportion of COPD patients were undiagnosed and made case finding worthwhile. Underutilization of spirometry in the diagnosis and management of COPD as well as general practitioners' nonadherence to the GOLD treatment guidelines was confirmed by our data. These findings highlight the need for a major overhaul and culture change in primary care settings of Central Greece.

Effect of the asthma-chronic obstructive pulmonary disease syndrome on the stroke, Parkinson's disease, and dementia: a national cohort study

Background

To evaluate the association of asthma–chronic obstructive pulmonary disease syndrome (ACOS) with neurodegenerative diseases (stroke, Parkinson's disease and dementia) and the role of the steroids in the neurodegenerative diseases among the ACOS cohort.

Materials and Methods

Comparison of the ACOS cohort (N = 10,260) with the non-ACOS cohort (n = 20,513) based on the patients aged ≧40 years in the National Health Insurance Research Database from January 1, 2000 to December 31, 2010. These patients follow up to diagnosis of neurodegenerative diseases or the December 31, 2011; using multivariable Cox proportional hazards models.

Results

After adjustment for potential confounders, the [adjusted hazard ratio (aHR), 95% confidence interval (CI)] in the ACOS cohort were [1.39, 1.28–1.50] [1.56, 1.34–1.81] and [1.43, 1.29–1.59] for stroke, Parkinson's disease, dementia; respectively. The [aHR, 95% CI] for ACOS cohort with (inhaler corticosteroids ≧0.13 gram/ oral steroids ≧0.08gram) were with less risk (all aHR<1, p values <0.05) for these 3 neurodegenerative diseases except Parkinson's disease with inhaler corticosteroids >0.43 gram. The risk of stroke and dementia were the lower in patients with < 250 μg/d of a fluticasone equivalent inhaler corticosteroids (aHR = 0.53, 95% CI = 0.35–0.79; aHR = 0.53, 95% CI = 0.31–0.90, respectively).

Conclusions

The ACOS cohort had a higher risk of the neurodegenerative diseases. The lower dose of the inhaler corticosteroids with cumulative dose ≧0.13 gram have the less risk of stroke and dementia.

Pulmonary function, exhaled nitric oxide and symptoms in asthma patients with obesity: a cross-sectional study

Background

Obesity is a risk factor for the development of asthma. In patients with obesity the diagnosis of asthma is often based on symptoms, but without objective measurements. Nevertheless, obesity-associated asthma is recognized as a distinct asthma phenotype. Therefore, this study explores lung function and symptoms in asthma patients with and without obesity.

Methods

The Netherlands Epidemiology of Obesity (NEO) study is a population-based cohort study with 6671 participants (aged 45–65 years) of whom 472 had asthma. Of this latter group, linear regression analysis was used to examine differences in lung function and symptoms between asthma patients with (n = 248) and without obesity (n = 224), and between asthma patients with and without increased Fe_NO. Analyses were adjusted for confounders.

Results

Asthma patients with obesity had lower predicted FEV₁ and FVC values than patients without obesity [adjusted mean difference (MD) -3.3% predicted, 95% CI -6.5, −0.2; adjusted MD −5.0% predicted, 95% CI -7.8, −2.1]. The prevalence of symptoms was higher in patients with obesity. Asthma patients with obesity and with increased Fe_NO had lower FEV₁ and FEV₁/FVC values compared with those with low Fe_NO (adjusted MD −6.9% predicted, 95% CI -11.7, −2.0; −2.4%, 95% CI -4.6, −0.2).

Conclusion

Asthma patients with obesity had lower FEV₁ and FVC values than patients without obesity. This suggests that patients with obesity have restrictive lung function changes, rather than obstructive changes. Asthma patients with obesity and increased Fe_NO showed more obstructive changes. Fe_NO might help to identify patients with eosinophilic inflammation-driven asthma, whereas patients with low Fe_NO might have an obesity-associated asthma phenotype in which symptoms are partly caused by the obesity.

Electronic supplementary material

The online version of this article (10.1186/s12931-017-0684-9) contains supplementary material, which is available to authorized users.

The contribution of an asthma diagnostic consultation service in obtaining an accurate asthma diagnosis for primary care patients: results of a real-life study

Previous studies showed that general practitioners have problems in diagnosing asthma accurately, resulting in both under and overdiagnosis. To support general practitioners in their diagnostic process, an asthma diagnostic consultation service was set up. We evaluated the performance of this asthma diagnostic consultation service by analysing the (dis)concordance between the general practitioners working hypotheses and the asthma diagnostic consultation service diagnoses and possible consequences this had on the patients' pharmacotherapy. In total 659 patients were included in this study. At this service the patients' medical history was taken and a physical examination and a histamine challenge test were carried out. We compared the general practitioners working hypotheses with the asthma diagnostic consultation service diagnoses and the change in medication that was incurred. In 52% (n = 340) an asthma diagnosis was excluded. The diagnosis was confirmed in 42% (n = 275). Furthermore, chronic rhinitis was diagnosed in 40% (n = 261) of the patients whereas this was noted in 25% (n = 163) by their general practitioner. The adjusted diagnosis resulted in a change of medication for more than half of all patients. In 10% (n = 63) medication was started because of a new asthma diagnosis. The 'one-stop-shop' principle was met with 53% of patients and 91% (n = 599) were referred back to their general practitioner, mostly within 6 months. Only 6% (n = 41) remained under control of the asthma diagnostic consultation service because of severe unstable asthma. In conclusion, the asthma diagnostic consultation service helped general practitioners significantly in setting accurate diagnoses for their patients with an asthma hypothesis. This may contribute to diminish the problem of over and underdiagnosis and may result in more appropriate treatment regimens.

ASTHMA

SERVICE HELPS GENERAL PRACTITIONERS MAKE ACCURATE DIAGNOSES: A consultation service can help general practitioners more accurately diagnose asthma and select the appropriate treatments for their patients. Researchers in The Netherlands, led by Frank Smeenk from Catharina Hospital in Eindhoven, describe an asthma diagnostic consultation service they created to support GPs in their diagnostic process for patients suspected of having asthma. Over a four-year period, the service received a total of 659 referrals and only confirmed the diagnosis of asthma in 275 cases. Another 20 patients had asthma overlapping with chronic obstructive pulmonary syndrome. The service also picked up other diseases, such as rhinitis, that general practitioners had missed. Overall, because of the consultation service and its revised diagnoses, more than half of all patients adjusted their medications. Most patients required only a single consultation and could then be referred back to their physicians.

Mapping the Asthma Care Process: Implications for Research and Practice

BACKGROUND

Whether people with asthma gain and maintain control over their condition depends not only on the availability of effective drugs, but also on multiple patient and health care professional (HCP) behaviors. Research in asthma rarely considers how these behaviors interact with each other and drug effectiveness to determine health outcomes, which may limit real-life applicability of findings.

OBJECTIVE

The objective of this study was to develop a logic process model (Asthma Care Model; ACM) that explains how patient and HCP behaviors impact on the asthma care process.

METHODS

Within a European research project on asthma (ASTRO-LAB), we reviewed asthma care guidelines and empirical literature, and conducted qualitative interviews with patients and HCPs. Findings were discussed with the project team and respiratory care experts and integrated in a causal model.

RESULTS

The model outlines a causal sequence of treatment events, from diagnosis and assessment to treatment prescription, drug exposure, and health outcomes. The relationships between these components are moderated by patient behaviors (medication adherence, symptom monitoring, managing triggers, and exacerbations) and HCP behaviors (medical care and self-management support). Modifiable and nonmodifiable behavioral determinants influence the behaviors of patients and HCPs. The model is dynamic as it includes feedback loops of behavioral and clinical outcomes, which influence future patient and HCP decision making. Key evidence for each relationship is summarized to derive research priorities and clinical recommendations.

CONCLUSIONS

The ACM model is of interest to both researchers and practitioners, and intended as a first version (ACM-v1) of a common framework for generating and translating research evidence in asthma care.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

Diagnostic accuracy of respiratory diseases in primary health units

Respiratory diseases are responsible for about a fifth of all deaths worldwide and its prevalence reaches 15% of the world population. Primary health care (PHC) is the gateway to the health system, and is expected to resolve up to 85% of health problems in general. Moreover, little is known about the diagnostic ability of general practitioners (GPs) in relation to respiratory diseases in PHC. This review aims to evaluate the diagnostic ability of GPs working in PHC in relation to more prevalent respiratory diseases, such as acute respiratory infections (ARI), tuberculosis, asthma and chronic obstructive pulmonary disease (COPD). 3,913 articles were selected, totaling 30 after application of the inclusion and exclusion criteria. They demonstrated the lack of consistent evidence on the accuracy of diagnoses of respiratory diseases by general practitioners. In relation to asthma and COPD, studies have shown diagnostic errors leading to overdiagnosis or underdiagnosis depending on the methodology used. The lack of precision for the diagnosis of asthma varied from 54% underdiagnosis to 34% overdiagnosis, whereas for COPD this ranged from 81% for underdiagnosis to 86.1% for overdiagnosis. For ARI, it was found that the inclusion of a complementary test for diagnosis led to an improvement in diagnostic accuracy. Studies show a low level of knowledge about tuberculosis on the part of general practitioners. According to this review, PHC represented by the GP needs to improve its ability for the diagnosis and management of this group of patients constituting one of its main demands.

Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: A cluster-randomized trial in primary care

BACKGROUND

Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (Feno), allow further tailoring of treatment.

OBJECTIVE

We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or Feno-driven controlled asthma (FCa).

METHODS

In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire [ACQ] score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and Feno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate.

RESULTS

Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy (P < .02). There were no differences in quality of life (P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate.

CONCLUSION

A symptom- plus Feno-driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.

Prevalence of asthma and its association with rhinitis in the elderly

BACKGROUND

Asthma and rhinitis are frequent respiratory diseases in children and adults. Despite the increase in the aging population, there are few epidemiologic data on both diseases in the elderly. So far, no population-based study has analyzed the association between asthma and rhinitis symptoms and severity in this age group. This study aimed to estimate the prevalence of physician-diagnosed asthma in the population aged ≥65 years in mainland Portugal and to evaluate its association with the presence and classification of rhinitis according to ARIA recommendations, in this age group.

METHODS

A cross-sectional, nationwide, population-based survey of individuals aged ≥65 years, living in mainland Portugal was performed.

RESULTS

Data were obtained from 3678 respondents. The prevalence of physician-diagnosed asthma was 10.9% (95% confidence interval (95%CI) 9.9-11.9). The frequency of asthma diagnosis increased with the number of nasal symptoms (p < 0.001). A strong association between asthma and rhinitis was found (odds ratio (OR) 13.86 (95%CI 10.66-18.02)). The strength of this association increased with the persistence and severity of rhinitis, being particularly high in elderly subjects with moderate-severe persistent rhinitis (OR 39.9 (95%CI 27.5-58.0)).

CONCLUSIONS

Asthma is common in the elderly and strongly associated with rhinitis. The OR for asthma is especially high in persistent and severe ARIA classification rhinitis types. This study strengthens the need for an integrated assessment of asthma together with rhinitis in the elderly.

Changed terms for drug payment influenced GPs' diagnoses and prescribing practice for inhaled corticosteroids

BACKGROUND

Inhaled glucocorticosteroids (ICS) are first-line anti-inflammatory treatment in asthma, but not in chronic obstructive pulmonary disease (COPD). To restrict ICS use in COPD to cases of severe disease, new terms for reimbursement of drug costs were introduced in Norway in 2006, requiring a diagnosis of COPD to be verified by spirometry.

OBJECTIVES

To describe how GPs' diagnoses and treatment of patients who used ICS before 2006 changed after a reassessment of the patients that included spirometry.

METHODS

From the shared electronic patient record system in one group practice, patients ≥ 50 years prescribed ICS (including in combination with long-acting beta2-agonists) during the previous year were identified and invited to a tailored consultation including spirometry to assure the quality of diagnosis and treatment. GPs' diagnoses and ICS prescribing patterns after this reassessment were recorded, retrospectively.

RESULTS

Of 164 patients identified, 112 were included. Post-bronchodilator spirometry showed airflow limitation indicating COPD in 55 patients. Of the 57 remaining patients, five had a positive reversibility test. The number of patients diagnosed with asthma increased (from 25 to 62) after the reassessment. A diagnosis of COPD was also more frequently used, whereas fewer patients had other pulmonary diagnoses. ICS was discontinued in 31 patients; 20 with mild to moderate COPD and 11 with normal spirometry.

CONCLUSION

Altered reimbursement terms for ICS changed GPs' diagnostic practice in a way that made the diagnoses better fit with the treatment given, but over-diagnosis of asthma could not be excluded. Spirometry was useful for identifying ICS overuse.

Consultation performance of general practitioners when supported by an asthma/COPDC-service

Background

General practitioners (GPs) can refer patients to an asthma/COPD service (AC-service) for diagnostic assessment of spirometry and medical history and for asthma or COPD monitoring. The AC-service reports diagnostic results and additional information about disease burden (BORG-score for complaints, MRC-dyspnoea score, exacerbation rate), life style, medication and compliance, to the patient’s GP. This study explores how GPs use this additional information when discussing the patient’s disease burden and how this influences GPs’ information and education provision during consultations with asthma/COPD patients.

Method

Patients with (a suspicion of) asthma or COPD were referred to an AC-service and consulted their GPs after they had received a report from the AC-service. Retrospectively patients answered questions about their GPs’ performance during these consultations. Performances were compared with performances of the same GPs during consultations without support of the AC-service (usual care), earlier that year.

Results

Of consultations not initiated by an AC-service check-up, 91% focussed on complaints, the initial reason for the consultation. In AC-service supported follow-up consultations, GPs explored disease burden when the (BORG-)score for complaints was high - as reported by the AC-service - even when patients themselves thought it was irrelevant. GPs put significantly less effort in exploring disease burden when the Borg-score was low (BORG 3–4: 69%; BORG1-2: 51%, p = 0,01). GPs mostly ignored MRC-dyspnoea scores: attention to dyspnoea was 18% for MRC-score <3 and 25% for MRC-score ≥3 (p = 0,63). GPs encouraged physical fitness in 13% of patients. Smoking behaviour was discussed with 66% of the actual smokers but only 14% remembered a stop smoking advice. Furthermore, pharmacotherapeutic management education in AC-service supported consultations did not differ from performance in usual care according to patient evaluations.

Conclusion

Other than taking into account the severity of complaints, there was no difference between GPs’ performance in AC-service supported and in usual care consultations. AC-service reports are thus not effective by themselves. GPs should be encouraged to use the information better and systematically check all relevant aspects that characterize the disease burden of their patients.