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Lindh A, Giezeman M, Theander K, Zakrisson AB, Westerdahl E, Stridsman C. Factors Associated with Patient Education in Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Primary Health Care Register-Based Study. Int J Chron Obstruct Pulmon Dis 2024; 19:1069-1077. [PMID: 38765768 PMCID: PMC11102747 DOI: 10.2147/copd.s455080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose Patient education in chronic obstructive pulmonary disease (COPD) is recommended in treatment strategy documents, since it can improve the ability to cope with the disease. Our aim was to identify the extent of and factors associated with patient education in patients with COPD in a primary health care setting. Patients and Methods In this nationwide study, we identified 29,692 COPD patients with a registration in the Swedish National Airway Register (SNAR) in 2019. Data on patient education and other clinical variables of interest were collected from SNAR. The database was linked to additional national registers to obtain data about pharmacological treatment, exacerbations and educational level. Results Patient education had been received by 44% of COPD patients, 72% of whom had received education on pharmacological treatment including inhalation technique. A higher proportion of patients who had received education were offered smoking cessation support, had performed spirometry and answered the COPD Assessment Test (CAT), compared with patients without patient education. In the adjusted analysis, GOLD grade 2 (OR 1.29, 95% CI 1.18-1.42), grade 3 (OR 1.41, 95% CI 1.27-1.57) and grade 4 (OR 1.79, 95% CI 1.48-2.15), as well as GOLD group E (OR 1.17, 95% CI 1.06-1.29), ex-smoking (OR 1.70, 95% CI 1.56-1.84) and current smoking (OR 1.45, 95% CI 1.33-1.58) were positively associated with having received patient education, while cardiovascular disease (OR 0.92, 95% CI 0.87-0.98) and diabetes (OR 0.93, 95% CI 0.87-1.00) were negatively associated with receipt of patient education. Conclusion Fewer than half of the patients had received patient education, and the education had mostly been given to those with more severe COPD, ex- and current smokers and patients with fewer comorbidities. Our study highlights the need to enhance patient education at an earlier stage of the disease.
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Affiliation(s)
- Annika Lindh
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden
| | - Maaike Giezeman
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kersti Theander
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden
| | - Ann-Britt Zakrisson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Elisabeth Westerdahl
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Caroline Stridsman
- Department of Public Health and Clinical Medicine, The OLIN Unit, Umeå University, Umeå, Sweden
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Sandelowsky H, Krakau I, Modin S, Ställberg B, Nager A. Primary care patients with mild or stable chronic obstructive pulmonary disease need more support in disease management: a secondary analysis of a cluster randomized controlled trial. Scand J Prim Health Care 2023; 41:495-504. [PMID: 37975839 PMCID: PMC11001336 DOI: 10.1080/02813432.2023.2280039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE Patient education based on the patient's individual needs and circumstances is known to be associated with positive changes in clinical outcomes in chronic obstructive pulmonary disease (COPD). We aimed to assess the levels of patients' subjective needs for information about COPD before and after their general practitioners had taken part in a COPD education. DESIGN A secondary analysis of a cluster randomized controlled trial. SETTING 22 PHCCs in Stockholm, Sweden. SUBJECTS Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 293). OUTCOME MEASURES Scores in the Lung Information Needs Questionnaire (LINQ) at baseline and 18 months, spirometry results, and self-reported, descriptive patient data. RESULTS GPs' improved skills in COPD did not affect patients' self-management skills over time. In general, patients' information needs remained great in issues concerning diet, exercise and self-management. However, 43% of the patients reported reduced and 57% increased or unchanged information needs, over time. Reduced information needs were mainly associated with a high level of information needs at baseline (OR = 3.17 [95% CI 1.93-5.23], p < .01) and establishing contact with a physiotherapist (OR = 2.26 [95% CI 1.05-4.86], p = .038). Patients in a mild or stable phase of COPD with no recent exacerbations reported greater needs than those with unstable, deteriorated COPD. CONCLUSION Patients' information needs are substantial in most areas of self-management of COPD, and seem to covary with the patient's current clinical status. Care providers should thus continuously be vigilant about offering all patients with COPD support and education. TRIAL REGISTRATION Clinicaltrials.gov, 10 August 2014, Identifier NCT02213809.
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Affiliation(s)
- Hanna Sandelowsky
- Department of Medicine, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden
- Division of Family Medicine and Primary Care, Karolinska Institutet, NVS, Huddinge, Stockholm, Sweden
| | - Ingvar Krakau
- Department of Medicine, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Sonja Modin
- Division of Family Medicine and Primary Care, Karolinska Institutet, NVS, Huddinge, Stockholm, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- Division of Family Medicine and Primary Care, Karolinska Institutet, NVS, Huddinge, Stockholm, Sweden
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3
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Athlin Å, Lisspers K, Hasselgren M, Ställberg B, Janson C, Montgomery S, Giezeman M, Kisiel M, Nager A, Sandelowsky H, Arne M, Sundh J. Diagnostic spirometry in COPD is increasing, a comparison of two Swedish cohorts. NPJ Prim Care Respir Med 2023; 33:23. [PMID: 37264017 DOI: 10.1038/s41533-023-00345-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 05/15/2023] [Indexed: 06/03/2023] Open
Abstract
Spirometry should be used to confirm a diagnosis of chronic obstructive pulmonary disease (COPD). This test is not always performed, leading to possible misdiagnosis. We investigated whether the proportion of patients with diagnostic spirometry has increased over time as well as factors associated with omitted or incorrectly interpreted spirometry. Data from medical reviews and a questionnaire from primary and secondary care patients with a doctors' diagnosis of COPD between 2004 and 2010 were collected. Data were compared with a COPD cohort diagnosed between 2000 and 2003. Among 703 patients with a first diagnosis of COPD between 2004 and 2010, 88% had a diagnostic spirometry, compared with 59% (p < 0.001) in the previous cohort. Factors associated with not having diagnostic spirometry were current smoking (OR 2.21; 95% CI 1.36-3.60), low educational level (OR 1.81; 1.09-3.02) and management in primary care (OR 2.28; 1.02-5.14). The correct interpretation of spirometry results increased (75% vs 82%; p = 0.010). Among patients with a repeated spirometry, 94% had a persistent FEV1/FVC or FEV1/VC ratio <0.70.
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Affiliation(s)
- Åsa Athlin
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Mikael Hasselgren
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Maaike Giezeman
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden
| | - Marta Kisiel
- Department of Medical Sciences, Occupational and Environment Medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- Division of Family Medicine and Primary Care, Inst NVS, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Sandelowsky
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Family Medicine and Primary Care, Inst NVS, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
| | - Mats Arne
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Josefin Sundh
- Department of Respiratory Medicine, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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4
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Janson C, Wiklund F, Telg G, Stratelis G, Sandelowsky H. High use of short-acting β 2-agonists in COPD is associated with an increased risk of exacerbations and mortality. ERJ Open Res 2023; 9:00722-2022. [PMID: 37342089 PMCID: PMC10277875 DOI: 10.1183/23120541.00722-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/23/2023] [Indexed: 06/22/2023] Open
Abstract
Background Short-acting β2-agonist (SABA) overuse has been associated with an increased risk of exacerbations in asthma; however, less is known about SABA use in COPD. Our aim was to describe SABA use and investigate potential associations between high SABA use and the risk of future exacerbations and mortality in COPD. Methods This observational study identified COPD patients in primary care medical records in Sweden. Data were linked to the National Patient Registry, the Prescribed Drug Registry and the Cause of Death Registry. The index date was 12 months after the date of COPD diagnosis. During a 12-month prior to index baseline period, information on SABA use was collected. Patients were followed with respect to exacerbations and mortality for 12 months post index. Results Of the 19 794 COPD patients included (mean age 69.1 years, 53.3% females), 15.5% and 7.0% had collected ≥3 or ≥6 SABA canisters during the baseline period, respectively. A higher level of SABA use (≥6 canisters) was independently associated with a higher risk of both moderate and severe exacerbations (hazard ratio (HR) 1.28 (95% CI 1.17‒1.40) and 1.76 (95% CI 1.50‒2.06), respectively) during follow-up. In total, 673 (3.4%) patients died during the 12-month follow-up period. An independent association was found between high SABA use and overall mortality (HR 1.60, 95% CI 1.07‒2.39). This association, however, was not found in patients using inhaled corticosteroids as maintenance treatment. Conclusion In COPD patients in Sweden, high SABA use is relatively common and associated with a higher risk of exacerbations and all-cause mortality.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | | | - Georgios Stratelis
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
- AstraZeneca Nordic, Stockholm, Sweden
| | - Hanna Sandelowsky
- Department of Medicine, Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, , Stockholm, Sweden
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5
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Smith C, Hasselgren M, Janson C, Kisiel MA, Lisspers K, Nager A, Sandelowsky H, Ställberg B, Sundh J, Montgomery S. Does multimorbidity result in de-prioritisation of COPD in primary care? NPJ Prim Care Respir Med 2023; 33:2. [PMID: 36641480 PMCID: PMC9840635 DOI: 10.1038/s41533-023-00326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023] Open
Abstract
The aim of this study was to describe factors associated with having COPD regularly reviewed in primary care by a nurse or physician and assess whether there was de-prioritisation for COPD in multimorbid patients. We defined de-prioritisation as not having at least one check-up by a physician during a two-year period. Among 713 COPD patients in the Swedish PRAXIS study, 473 (66%) had at least one check-up during the study period (ending in 2014). Patients with check-ups were more likely to have three or more comorbid conditions (31.9% vs. 24.6%) and exacerbations (35.1% vs. 21.7%) than those without. Compared with those without comorbidity, those with three or more diagnoses had increased relative risk ratios (and 95% CI) for consultations discussing COPD with only a physician (5.63 (2.68-11.79)), COPD-nurse only (1.67 (0.83-3.37)) or both (2.11 (1.09-4.06)). COPD patients received more frequent check-ups considering COPD if they had comorbidity or a history of exacerbations. We found no evidence of de-prioritisation for COPD in multimorbid patients.
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Affiliation(s)
- Carolina Smith
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden.
| | - Mikael Hasselgren
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Marta A Kisiel
- Department of Medical Sciences, Occupational and Environment Medicine, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- NVS, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Sandelowsky
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Scott Montgomery
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Epidemiology and Public Health, University College London, London, UK
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6
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Sandelowsky H, Janson C, Wiklund F, Telg G, de Fine Licht S, Ställberg B. Lack of COPD-Related Follow-Up Visits and Pharmacological Treatment in Swedish Primary and Secondary Care. Int J Chron Obstruct Pulmon Dis 2022; 17:1769-1780. [PMID: 35971390 PMCID: PMC9375582 DOI: 10.2147/copd.s372266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/18/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The Swedish guidelines recommend that patients with chronic obstructive pulmonary disease (COPD) on maintenance treatment are monitored annually, and within six weeks after an exacerbation. We describe the patterns of COPD-related visits in Sweden, both regular follow-up and post-exacerbation visits. Methods Patients (>40 years) with a first-time COPD diagnosis between 2006 and 2017 were identified in primary care medical records and linked to hospital contacts and administered drug data. The index date was defined as the first collection of inhaled COPD maintenance treatment after the diagnosis. Regular COPD visits within 15-months after the index, and post-exacerbation visits for COPD within six weeks and 15-months after an exacerbation were estimated using the cumulative incidence function adjusted for competing risk. Visits without a ICD code for COPD were not included in the analyses. Results A total of 19,857 patients (mean age 69 years, 57% females) were included. The overall probability of having a regular follow-up visit for COPD within 15 months post-index was 39.1%. In total, 15,095 (76%) patients experienced at least one COPD exacerbation during the observation period. Among them, the probability of having a post-exacerbation visit was 7.0% within six weeks and 29.7% within 15-months. Patients without a regular COPD follow-up visit claimed significantly more oral corticosteroids (25.6% vs 15.6%), more respiratory antibiotics (39.1% vs 23.1%), and less maintenance treatment (10.9% vs 16.5%). Conclusion Only 39% of COPD patients attended a regular follow-up visit within 15-months from the COPD diagnosis and one-third had a post-exacerbation visit. The adherence to guideline recommendations need to be improved.
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Affiliation(s)
- Hanna Sandelowsky
- Department of Medicine, Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Solna, Sweden.,Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | | | | | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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7
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Lundh L, Larsson K, Lindén A, Montgomery S, Palmberg L, Sandelowsky H. Biomarkers, Clinical Course, and Individual Needs in COPD Patients in Primary Care: The Study Protocol of the Stockholm COPD Inflammation Cohort (SCOPIC). Int J Chron Obstruct Pulmon Dis 2022; 17:993-1004. [PMID: 35528148 PMCID: PMC9075012 DOI: 10.2147/copd.s358056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/11/2022] [Indexed: 01/09/2023] Open
Abstract
Background To facilitate effective personalized medicine, primary health care needs better methods of assessing and monitoring chronic obstructive pulmonary disease (COPD). Aim This cohort study aims to investigate how biomarkers relate to clinical characteristics and COPD patients' subjective needs over time. Methods Patients (n=750) in different COPD severity according to the GOLD criteria and age- and sex-matched controls (n=750) will be recruited over a period of 5 years from 15 primary health care centers in Region Stockholm, Sweden, and followed for 10 years in the first instance. Data on patients' subjective needs will be collected via telephone/email, data on clinical/physiological variables (eg, symptoms, exacerbations, comorbidities, medications, smoking habits, lung function) from existing databases that are based on medical records, and data on biomarkers via repeated blood sampling. Quantitative and qualitative methods will be used. Initial results are expected after 2 years (feasibility test), and a larger body of evidence after 5 years. Discussion The study is expected to provide definitive and clinically useful scientific evidence about how biomarkers relate to clinical variables and patients' subjective needs. This new evidence will facilitate accurate, and personalized COPD management by the use of valid biomarkers. It will provide useful tools for primary care professionals and may facilitate optimal self-management.
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Affiliation(s)
- Lena Lundh
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden,Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Kjell Larsson
- Division of Integrative Toxicology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Lindén
- Division for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden,Karolinska Severe COPD Center, Department of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden,Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden,Department of Epidemiology and Public Health, University College London, London, UK
| | - Lena Palmberg
- Division of Integrative Toxicology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Sandelowsky
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden,Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden,Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden,Correspondence: Hanna Sandelowsky, Karolinska Institutet, Department of Medicine, Division of Clinical Epidemiology, Stockholm, SE-171 76, Sweden, Tel +46738902565, Email
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8
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Sandelowsky H, Weinreich UM, Aarli BB, Sundh J, Høines K, Stratelis G, Løkke A, Janson C, Jensen C, Larsson K. COPD - do the right thing. BMC FAMILY PRACTICE 2021; 22:244. [PMID: 34895164 PMCID: PMC8666021 DOI: 10.1186/s12875-021-01583-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/09/2021] [Indexed: 12/28/2022]
Abstract
A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.
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Affiliation(s)
- Hanna Sandelowsky
- Department of Medicine, Clinical Epidemiology Division T2, Karolinska University Hospital, Karolinska Institutet, Solna, SE-171 76, Stockholm, Sweden.
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
- Academic Primary Healthcare Centre, Stockholm County, Stockholm, Sweden.
| | - Ulla Møller Weinreich
- Department of Respiratory Diseases, Aalborg University Hospital, Aalborg, Denmark
- The Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Bernt B Aarli
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Georgios Stratelis
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
- AstraZeneca Nordic, Södertälje, Sweden
| | - Anders Løkke
- Department of Medicine, Little Belt Hospital, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | - Kjell Larsson
- Integrative Toxicology, National Institute of Environmental Medicine, IMM, Karolinska Institutet, Stockholm, Sweden
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9
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Sundh J, Tanash H, Arian R, Neves-Guimaraes A, Broberg K, Lindved G, Kern T, Zych K, Nielsen HB, Halling A, Ohlsson B, Jönsson D. Advanced Dental Cleaning is Associated with Reduced Risk of COPD Exacerbations - A Randomized Controlled Trial. Int J Chron Obstruct Pulmon Dis 2021; 16:3203-3215. [PMID: 34858021 PMCID: PMC8629912 DOI: 10.2147/copd.s327036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/13/2021] [Indexed: 01/02/2023] Open
Abstract
Purpose Infections from the oral microbiome may lead to exacerbations of chronic obstructive pulmonary disease (COPD). We investigated whether advanced dental cleaning could reduce exacerbation frequency. Secondary outcomes were disease-specific health status, lung function, and whether the bacterial load and composition of plaque microbiome at baseline were associated with a difference in outcomes. Patients and Methods One-hundred-one primary and secondary care patients with COPD were randomized to intervention with advanced dental cleaning or to dental examination only, repeated after six months. At baseline and at 12 months, data of exacerbations, lung function, COPD Assessment Test (CAT) score, and periodontal status were collected from questionnaires, record review, and periodontal examination. Student’s t-test and Mann–Whitney-U (MWU) test compared changes in outcomes. The primary outcome variable was also assessed using multivariable linear regression with adjustment for potential confounders. Microbiome analyses of plaque samples taken at baseline were performed using Wilcoxon signed ranks tests for calculation of alpha diversity, per mutational multivariate analysis of variance for beta diversity, and receiver operating characteristic curves for prediction of outcomes based on machine learning models. Results In the MWU test, the annual exacerbation frequency was significantly reduced in patients previously experiencing frequent exacerbations (p = 0.020) and in those with repeated advanced dental cleaning (p = 0.039) compared with the non-treated control group, but not in the total population including both patients with a single and repeated visits (p = 0.207). The result was confirmed in multivariable linear regression, where the risk of new exacerbations was significantly lower in patients both in the intention to treat analysis (regression coefficient 0.36 (95% CI 0.25–0.52), p < 0.0001) and in the population with repeated dental cleaning (0.16 (0.10–0.27), p < 0.0001). The composition of microbiome at baseline was moderately predictive of an increased risk of worsened health status at 12 months (AUC = 0.723). Conclusion Advanced dental cleaning is associated with a reduced frequency of COPD exacerbations. Regular periodontal examination and dental cleaning may be of clinical importance to prevent COPD exacerbations.
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Affiliation(s)
- Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Hanan Tanash
- Department of Respiratory Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Rahi Arian
- Department of Periodontology and Implantology, Public Dental Service, Örebro, Sweden
| | | | | | | | - Timo Kern
- Clinical Microbiomics, Copenhagen, Denmark
| | | | | | - Anders Halling
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Bodil Ohlsson
- Department of Internal Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Daniel Jönsson
- Public Dental Service of Skåne, Lund, Sweden.,Hypertension and Cardiovascular Disease, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden.,Faculty of Odontology, Malmö University, Malmö, Sweden
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10
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Hussey AJ, Wing K, Ferrone M, Licskai CJ. Integrated Disease Management for Chronic Obstructive Pulmonary Disease in Primary Care, from the Controlled Trial to Clinical Program: A Cohort Study. Int J Chron Obstruct Pulmon Dis 2021; 16:3449-3464. [PMID: 35221683 PMCID: PMC8866979 DOI: 10.2147/copd.s338851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Anna J Hussey
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
| | - Kevin Wing
- London School of Hygiene and Tropical Medicine, London, UK
| | - Madonna Ferrone
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
- Hotel-Dieu Grace Healthcare, Windsor, ON, Canada
| | - Christopher J Licskai
- Asthma Research Group Windsor-Essex County Inc., Windsor, ON, Canada
- London Health Sciences Centre, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Correspondence: Christopher J Licskai Schulich School of Medicine and Dentistry, Western University, London, ON, Canada Email
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Racial Disparities in Health Risk Indicators Reported by Alabamians Diagnosed with COPD. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189662. [PMID: 34574587 PMCID: PMC8470414 DOI: 10.3390/ijerph18189662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/01/2021] [Accepted: 09/09/2021] [Indexed: 12/27/2022]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a growing public health problem in the southern United States, particularly in Alabama. However, very little is known about specific health risk factors disproportionately impacting Alabamians with COPD. We conducted a latent class analysis of 2015–2019 Behavioral Risk Factor Surveillance System data from 4057 Alabamians with COPD (White = 2947, Black = 873, Other = 237). Eighteen risk indicators were examined across three health-related domains: (1) comorbidities, (2) limited healthcare access, and (3) substance use/abuse. Racial disparities between Black and white Alabamians with COPD were assessed using configural similarity analysis. Findings showed that almost one-third (31%) of Alabamians with COPD were in the high-risk class for eight comorbidities, and nearly one-half (48.88%) belonged to the high-risk class for limited healthcare access. Black Alabamians with COPD who did not have health insurance were much more likely to be at high risk for limited healthcare access (94.44%) when compared to their counterparts with insurance (5.56%), χ2(df = 2) = 1389.94, p < 0.0001. Furthermore, the proportion of high-risk, uninsured Black Alabamians with COPD (94.44%) substantially exceeded the percentage of high-risk, uninsured white Alabamians with COPD (59.70%). Most Alabamians with COPD (82.97%) were at low risk for substance use/abuse. Future research should explore new mechanisms for facilitating better healthcare access among high-risk Alabamians living with COPD and other prevalent comorbidities. Greater attention should be focused on Black Alabamians with COPD who cannot afford adequate health insurance.
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Amado CA, Pérez-García C, Tamayo Fernández B, Agüero-Calvo J, Muñoz-Cacho P, Golpe R. Information Needs in COPD After an Educational Programme: Influence in Exacerbations and Admissions. Int J Chron Obstruct Pulmon Dis 2021; 15:2663-2671. [PMID: 33149564 PMCID: PMC7603652 DOI: 10.2147/copd.s275002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/25/2020] [Indexed: 01/12/2023] Open
Abstract
Introduction Improving patients’ information needs (IN) may contribute to better control in COPD. This study analyses IN using Lung Information Needs Questionnaire (LINQ) following an educational intervention, evaluates how clinical characteristics modify IN, and studies high IN as a prognostic factor for COPD exacerbations and hospital admissions. Methods Cohort of 143 patients with initial diagnosis of COPD included in a structured educational program. Two months after completing the program, IN was assessed using LINQ. Correlations between IN and clinical variables of COPD and distribution of IN in different clinical groups were analyzed. Univariate and multivariate analysis was performed to determine influence of IN on exacerbations and COPD admissions over the following year. Results LINQ scored 6.3±2.9. There were no differences in LINQ scoring between different clinical groups, but LINQ score positively correlated with age (r=0.184, p=0.029). High IN was a predictor of COPD hospitalizations (HR 2.3 [95% CI 1.1–5.1] (p=0.029)) but not of less severe exacerbations (p=0.334). Conclusion IN was not associated with any clinical variables, but it correlated with age. High IN proved to be an independent predictor of admissions.
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Affiliation(s)
- Carlos Antonio Amado
- Hospital Universitario Marqués de Valdecilla, Servicio de Neumología, Universidad de Cantabria, Santander, Spain
| | | | | | - Juan Agüero-Calvo
- Hospital Universitario Marqués de Valdecilla, Servicio de Neumología, Santander, Spain
| | | | - Rafael Golpe
- Hospital Universitario Lucus Augusti, Servicio de Neumología, Grupo C039 Biodiscovery HULA-USC, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santander, Spain
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13
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Barnes NC, Singh D, Lipson DA. Reply to: "Intraclass Difference in Pneumonia Risk with Fluticasone and Budesonide in COPD: A Systematic Review of Evidence from Direct-Comparison Studies" [Letter]. Int J Chron Obstruct Pulmon Dis 2021; 16:1299-1301. [PMID: 34007169 PMCID: PMC8121158 DOI: 10.2147/copd.s304368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/21/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Neil C Barnes
- Respiratory Therapy Area, GlaxoSmithKline, Middlesex, UK.,William Harvey Institute, Bart's and the London School of Medicine and Dentistry, London, UK
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - David A Lipson
- Clinical Sciences, GlaxoSmithKline, Collegeville, PA, USA.,Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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14
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Larsson K, Janson C, Lisspers K, Ställberg B, Johansson G, Gutzwiller FS, Mezzi K, Bjerregaard BK, Jorgensen L. The Impact of Exacerbation Frequency on Clinical and Economic Outcomes in Swedish COPD Patients: The ARCTIC Study. Int J Chron Obstruct Pulmon Dis 2021; 16:701-713. [PMID: 33776429 PMCID: PMC7987259 DOI: 10.2147/copd.s297943] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/04/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The aim of this study was to assess the association between exacerbation frequency and clinical and economic outcomes in patients with COPD. PATIENTS AND METHODS Electronic medical record data linked to National Health Registries were collected from COPD patients at 52 Swedish primary care centers (2000-2014). The outcomes analyzed were exacerbation rate, mortality, COPD treatments, lung function and healthcare costs during the follow-up period. Based on the exacerbation rate two years before index date, the patients were initially classified into three groups, either 0, 1 or ≥2 exacerbations per year. After the index date, the classification into exacerbation groups was updated each year based on the exacerbation rate during the last year of follow-up. A sensitivity analysis was conducted excluding patients with asthma diagnosis from the analysis. RESULTS In total 18,586 COPD patients were analyzed. A majority of the patients (60-70%) who either have had no exacerbation or frequent exacerbations (≥2/year) during the pre-index period remained in their group (ie, with 0 or ≥2 annual exacerbations) during up to 11 years of follow-up. Compared with having no exacerbation, mortality was higher in patients having 1 (HR; 2.06 [1.93-2.20]) and ≥2 (4.58 [4.33-4.84]) exacerbations at any time during the follow-up. Lung function decline was more rapid in patients with frequent exacerbations and there was an almost linear relationship between exacerbations frequency and mortality. Total healthcare costs were higher in the frequent exacerbation group (≥2/year) than in patients with no or one exacerbation annually (p<0.0001 for both). The results did not differ from the main analysis after exclusion of patients with a concurrent asthma diagnosis. CONCLUSION In addition to faster lung function decline and increased mortality, frequent exacerbations in COPD patients imply a significant economic burden.
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Affiliation(s)
- Kjell Larsson
- Integrative Toxicology, The National Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Gunnar Johansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Karen Mezzi
- Novartis Pharma AG, Global Patient Access, Basel, Switzerland
| | | | - Leif Jorgensen
- IQVIA Solutions, Real World Evidence Solutions, Copenhagen, Denmark
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Sajith M, Bargaje MD, Gharat S, Mathew J, Varghese A. Assessment of the effectiveness of a pharmacist approach for improving disease-specific knowledge and treatment in patients with chronic obstructive pulmonary disease. Eur J Hosp Pharm 2020; 28:e97-e101. [PMID: 33051196 DOI: 10.1136/ejhpharm-2020-002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Adequate knowledge is essential for the appropriate management of chronic conditions such as chronic obstructive pulmonary disease (COPD). However, some patients may not be able either to comprehend or obtain adequate information. This study aims to assess the effectiveness of the clinical pharmacist approach to refining disease-specific knowledge in patients with COPD treated in a tertiary care hospital. METHODS A prospective observational longitudinal study was carried out in adult COPD patients for 9 months in the tertiary care hospital of Pune. At the time of enrolment, disease-specific knowledge of patients with COPD was assessed using the Bristol COPD Knowledge Questionnaire (BCKQ). After the assessment, patients were educated, counselled verbally and provided with a validated COPD information leaflet. The patients' knowledge was reassessed 1 month and 3 months after enrolment. Pre and post scores of BCKQ were compared by ANOVA followed by Tukey's post hoc test. The difference in the proportions was calculated using the χ2 test. RESULTS Of 75 patients, the majority were men (53.33%), aged >60 years (72%), employed (62.67%) and had obtained secondary education (37.33%). The mean baseline BCKQ overall score of the patients was 25.87, which increased after education to 42.43 on the first visit (1 month) and to 45.62 on the second visit (3 months) (p<0.0001). At baseline, the topics 'vaccination', 'inhaled steroids' and 'antibiotics' returned the lowest mean scores of 0.37, 0.38 and 0.60, which were increased to 2.30, 2.70 and 2.72, respectively, after follow-up. CONCLUSION The knowledge of patients with COPD about the disease and its treatment was poor at the time of enrolment. Proper counselling and education provided by the clinical pharmacist helped to improve the patients' knowledge about COPD and its treatment.
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Affiliation(s)
- Manjusha Sajith
- Clinical Pharmacy, Bharati Vidyapeeth Deemed University Poona College of Pharmacy, Pune, India
| | | | - Smruti Gharat
- Clinical Pharmacy, Bharati Vidyapeeth University, Pune, Maharashtra, India
| | - Joelin Mathew
- Clinical Pharmacy, Bharati Vidyapeeth University, Pune, Maharashtra, India
| | - Amruta Varghese
- Clinical Pharmacy, Bharati Vidyapeeth University, Pune, Maharashtra, India
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Abstract
In chronic obstructive pulmonary disease (COPD), treatment with inhaled corticosteroids (ICSs) in combination with long acting beta-2-agonists (LABA) or LABA/long-acting muscarinic antagonists (LAMA) is used in order to reduce exacerbations. Treatment with ICS is, however, associated with side effects such as oropharyngeal candidiasis, skin thinning or easy bruising and pneumonia. The aim of this review was to investigate when to use ICS in COPD and to compare the effectiveness and safety of different ICSs. Studies comparing the effect of ICS/LABA and LABA/LAMA on exacerbations have shown divergent results, whereas most studies comparing ICS/LABA/LAMA (triple therapy) with LABA/LAMA have reported fewer exacerbations with triple therapy. Several investigations have shown that the number of eosinophils in blood predicts whether a patient will benefit from treatment with ICS. There is also data indicating that ICS has a small but significant positive effect on lung function decline and decrease mortality. There are four observational studies showing a better effect on exacerbations with budesonide/formoterol than fluticasone propionate/salmeterol and three observational studies showing less risk of pneumonia with budesonide than fluticasone propionate. Studies comparing the effect and safety of other ICSs such as fluticasone furoate and beclomethasone are too few to draw firm conclusions from. In conclusion, ICS together with LABA or LABA/LAMA reduces the risk of exacerbations in COPD. The indication of using ICS in COPD is stronger if the patient has increased blood eosinophils levels. There are data indicating that the choice of ICS matters, with studies showing a better effect-safety profile with budesonide compared to fluticasone propionate whereas it is not possible to make benefit-risk comparisons between the other licensed ICSs.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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Siltanen H, Aine T, Huhtala H, Kaunonen M, Vasankari T, Paavilainen E. Psychosocial issues need more attention in COPD self-management education. Scand J Prim Health Care 2020; 38:47-55. [PMID: 32024406 PMCID: PMC7054946 DOI: 10.1080/02813432.2020.1717087] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: To find out how regularly the contents of patient education regarded as essential for COPD patients' self-management are provided by healthcare professionals in specialised healthcare (SHC) and primary healthcare (PHC) in Finland.Design: A cross-sectional study based on an e-questionnaire with 42 items on the content of self-management education of COPD patients.Setting: The study sample included all public SHC units with pulmonary outpatient clinics (n = 29) and nine out of 160 health centres in Finland.Subjects: 83 doctors and 162 nurses.Main outcome measures: The respondents' answers on how regularly they included the contents regarded as essential for COPD patients' self-management in their education of COPD patients.Results: COPD patients were educated regularly on medical issues regarding COPD treatment, such as smoking cessation, exercise and pharmacological treatment. However, issues vital for coping with the disease, such as psychological well-being, stress management or fatigue, were often ignored. Patient education in SHC seemed to be more systematic than education in PHC. The education provided by the asthma/COPD nurses (n = 70) was more systematic than the education provided by the other nurses (n = 84).Conclusion: Healthcare professionals' continuous education should cover not only the medical but also the psychosocial aspects of coping with COPD. The role of doctors and nurses should be considered to ensure that there is no gap in COPD patients' education. Training asthma/COPD nurses and promoting specialised nurse-led asthma/COPD clinics in primary care could be beneficial while improving practices of patient education that enhance patients' ability to cope with the disease.KEY POINTSIssues vital for coping with chronic obstructive pulmonary disease (COPD), such as psychological well-being, stress and fatigue, are irregularly included in self-management education both in primary and specialised healthcare.Patient education provided by asthma/COPD nurses is more regular than patient education provided by other nurses.The distribution of work between doctors and nurses should be considered to ensure that there is no gap in COPD patients' education.
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Affiliation(s)
- Hannele Siltanen
- Department of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland;
- Nursing Research Foundation, Helsinki, Finland;
- The Finnish Centre for Evidence-Based Health Care: A Joanna Briggs Institute Affiliated Group, Helsinki, Finland;
- CONTACT Hannele Siltanen Department of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Tiina Aine
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland;
| | - Heini Huhtala
- Department of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland;
| | - Marja Kaunonen
- Department of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland;
- Pirkanmaa Hospital District, Tampere, Finland;
| | - Tuula Vasankari
- Division of Medicine, Department of Pulmonary Disease and Clinical Allergology, University of Turku, Turku, Finland;
- Finnish Lung Health Association (FILHA), Helsinki, Finland;
| | - Eija Paavilainen
- Department of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland;
- Etelä-Pohjanmaa Hospital District, Seinäjoki, Finland
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Ellingsen J, Johansson G, Larsson K, Lisspers K, Malinovschi A, Ställberg B, Thuresson M, Janson C. Impact of Comorbidities and Commonly Used Drugs on Mortality in COPD - Real-World Data from a Primary Care Setting. Int J Chron Obstruct Pulmon Dis 2020; 15:235-245. [PMID: 32099348 PMCID: PMC7006848 DOI: 10.2147/copd.s231296] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/09/2020] [Indexed: 01/21/2023] Open
Abstract
Background Life expectancy is significantly shorter for patients with chronic obstructive pulmonary disease (COPD) than the general population. Concurrent diseases are known to infer an increased mortality risk in those with COPD, but the effects of pharmacological treatments on survival are less established. This study aimed to examine any associations between commonly used drugs, comorbidities and mortality in Swedish real-world primary care COPD patients. Methods Patients with physician-diagnosed COPD from a large primary care population were observed retrospectively, utilizing primary care records and mandatory Swedish national registers. The time to all-cause death was assessed in a stepwise multiple Cox proportional hazards regression model including demography, socioeconomic factors, exacerbations, comorbidities and medication. Results During the observation period (1999-2009) 5776 (32.5%) of 17,745 included COPD patients died. Heart failure (hazard ratio [HR]: 1.88, 95% confidence interval [CI]: 1.74-2.04), stroke (HR: 1.52, 95% CI: 1.40-1.64) and myocardial infarction (HR: 1.40, 95% CI: 1.24-1.58) were associated with an increased risk of death. Use of inhaled corticosteroids (ICS; HR: 0.79, 95% CI: 0.66-0.94), beta-blockers (HR: 0.86, 95% CI: 0.76-0.97) and acetylsalicylic acid (ASA; HR: 0.87, 95% CI: 0.77-0.98) was dose-dependently associated with a decreased risk of death, whereas use of long-acting muscarinic antagonists (LAMA; HR: 1.33, 95% CI: 1.14-1.55) and N-acetylcysteine (NAC; HR: 1.26, 95% CI: 1.08-1.48) were dose-dependently associated with an increased risk of death in COPD patients. Conclusion This large, retrospective, observational study of Swedish real-world primary care COPD patients indicates that coexisting heart failure, stroke and myocardial infarction were the strongest predictors of death, underscoring the importance of timely recognition and treatment of comorbidities. A decreased risk of death associated with the use of ICS, beta-blockers and ASA, and an increased risk associated with the use of LAMA and NAC, was also found.
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Affiliation(s)
- Jens Ellingsen
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Gunnar Johansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Kjell Larsson
- Integrative Toxicology, National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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Sandelowsky H, Krakau I, Modin S, Ställberg B, Nager A. COPD patients need more information about self-management: a cross-sectional study in Swedish primary care. Scand J Prim Health Care 2019; 37:459-467. [PMID: 31694439 PMCID: PMC6883432 DOI: 10.1080/02813432.2019.1684015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective: In Sweden, patients with chronic conditions, such as chronic obstructive pulmonary disease (COPD), often receive education at specialized nurse-led clinics at primary health care centers (PHCCs). Identifying patients' needs for information about COPD is the key to individualized care. This study aimed to assess self-reported needs for information about COPD in primary care patients with either moderate (GOLD 2) or severe (GOLD 3) COPD and identify patient characteristics and exacerbation patterns associated with the findings.Design: A cross-sectional study.Setting: Twenty-four PHCCs in Stockholm, Sweden.Subjects: Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 542).Main outcome measures: The Lung Information Needs Questionnaire (LINQ) was used to assess perceived information needs. Spirometry results and descriptive, self-reported data on patient factors such as exacerbation history, treatment, smoking, weight/height, comorbidities, health care contacts, education and symptoms were collected.Results: Overall, the greatest reported needs were for information about self-management and diet. GOLD 2 patients (68%) expressed greater needs for information than GOLD 3 patients (32%). We found significant associations between high information needs and patient-related factors such as 'No assigned GP' (OR = 4.32 [95% CI 2.65-7.05]) and 'No contact with COPD nurse in the past 12 months' (OR = 1.83 [95% CI 1.19-2.81]).Conclusion: COPD patients felt they knew too little about self-management of their disease. Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. These associations were strongest in patients with moderate COPD.Key points: As patients with COPD often have multimorbidity, identifying patients' needs for information about COPD is essential to providing individualized patient education and care. In this study of 542 patients from 24 Swedish primary care centers, we found that:Patients with COPD, particularly those with moderate airflow limitation (i.e. GOLD 2) felt they needed more information about COPD than currently provided by health care professionals in primary care.Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. GPs' part in COPD patient education should not be overlooked, as individualized COPD care relies on GPs' expertise in managing patients with multimorbidity.
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Affiliation(s)
- Hanna Sandelowsky
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden;
- Section for Family Medicine and Primary Care, NVS, Karolinska Institutet, Stockholm, Sweden;
- CONTACT Hanna Sandelowsky Academic Primary Health Care Centre, Box 45436, 104 31 Stockholm, Sweden
| | - Ingvar Krakau
- Section for Family Medicine and Primary Care, NVS, Karolinska Institutet, Stockholm, Sweden;
- Department of Medicine, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden;
| | - Sonja Modin
- Section for Family Medicine and Primary Care, NVS, Karolinska Institutet, Stockholm, Sweden;
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- Section for Family Medicine and Primary Care, NVS, Karolinska Institutet, Stockholm, Sweden;
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Chehl N, Maheshwari A, Yoo H, Cook C, Zhang T, Brown S, Thuluvath PJ. HCV compliance and treatment success rates are higher with DAAs in structured HCV clinics compared to general hepatology clinics. Medicine (Baltimore) 2019; 98:e16242. [PMID: 31305402 PMCID: PMC6641794 DOI: 10.1097/md.0000000000016242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The real-world cure rates for hepatitis C (HCV) with direct-acting antivirals (DAAs) based on intention-to-treat (ITT) analysis may be lower than reported in the literature because of non-compliance.To determine whether patients treated in a structured outpatient HCV clinic (SHC) had higher compliance and treatment success rates compared to those treated in general hepatology clinics (GHC).In this study, we compared the treatment and compliance success rates of 488 and 840 patients treated in the SHC and GHC, respectively. The SHC required a pre-treatment clinic visit when patients picked up their initial medication, and received detailed education of the treatment plan and follow-up. In the GHC, the medications were delivered to patients' homes, and there was less formal education. Compliance success was defined as a combination of treatment completion and obtaining at least 1 post-treatment viral load at week 4 or 12. Treatment success was defined as either SVR4 or SVR12.Fifty of 488 (10.3%) patients from the SHC and 163 of 840 (19.4%) patients from the GHC were lost to follow-up (P < .0001). sustained virological response (SVR) rates were similar in compliant patients in both the SHC (419/438, 95.6%) and GHC (642/677, 94.8%), but treatment success rates by intention to treat (ITT) (overall 79.9%) were higher in SHC compared to GHC (85.9% vs 76.4%, P < .0001). Multivariate analysis showed that female patients (P = .01), older age (P = .0005), treatment in SHC (OR 1.7, 95% CI 1.2, 2.3, P = .0008), and sofosbuvir/simeprevir compared to sofosbuvir/ledipasvir had higher odds of compliance success; elbasvir/grazoprevir or dasabuvir/ombitasvir/paritaprevir/ritonavir had lower odds of compliance success compared to sofosbuvir/ledipasvir. Female patients (P = .02), older age (P < .0001), previous treatment (P = .03), treatment in SHC (OR 1.7, 95% CI 1.2, 2.3, P = .0008), and sofosbuvir/ledipasvir compared to sofosbuvir/velpatasvir, sofosbuvir, or elbasvir/grazoprevir had higher odds of treatment success. With 1:1 matching, the SHC group still had significantly higher odds than the GHC group of achieving treatment and compliance success.Our study shows that the effectiveness of HCV treatment could be improved by coordinating treatment in a structured HCV clinic.
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Larsson K, Janson C, Ställberg B, Lisspers K, Olsson P, Kostikas K, Gruenberger JB, Gutzwiller FS, Uhde M, Jorgensen L, Johansson G. Impact of COPD diagnosis timing on clinical and economic outcomes: the ARCTIC observational cohort study. Int J Chron Obstruct Pulmon Dis 2019; 14:995-1008. [PMID: 31190785 PMCID: PMC6526023 DOI: 10.2147/copd.s195382] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/11/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose: Assess the clinical and economic consequences associated with an early versus late diagnosis in patients with COPD. Patients and methods: In a retrospective, observational cohort study, electronic medical record data (2000-2014) were collected from Swedish primary care patients with COPD. COPD indicators (pneumonia, other respiratory diseases, oral corticosteroids, antibiotics for respiratory infections, prescribed drugs for respiratory symptoms, lung function measurement) registered prior to diagnosis were applied to categorize patients into those receiving early (2 or less indicators) or late diagnosis (3 or more indicators registered >90 days preceding a COPD diagnosis). Outcome measures included annual rate of and time to first exacerbation, mortality risk, prevalence of comorbidities and health care utilization. Results: More patients with late diagnosis (n=8827) than with early diagnosis (n=3870) had a recent comorbid diagnosis of asthma (22.0% vs 3.9%; P<0.0001). Compared with early diagnosis, patients with late diagnosis had a higher exacerbation rate (hazard ratio [HR] 1.89, 95% confidence interval [CI]: 1.83-1.96; P<0.0001) and shorter time to first exacerbation (HR 1.61, 95% CI: 1.54-1.69; P<0.0001). Mortality was not different between groups overall but higher for late versus early diagnosis, after excluding patients with past asthma diagnosis (HR 1.10, 95% CI: 1.02-1.18; P=0.0095). Late diagnosis was also associated with higher direct costs than early diagnosis. Conclusion: Late COPD diagnosis is associated with higher exacerbation rate and increased comorbidities and costs compared with early diagnosis. The study highlights the need for accurate diagnosis of COPD in primary care in order to reduce exacerbations and the economic burden of COPD.
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Affiliation(s)
- Kjell Larsson
- Work Environment Toxicology, Karolinska Institutet, Stockholm, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | | | | | | | | | | | - Gunnar Johansson
- Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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22
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de Miguel-Díez J, Jiménez-García R, López de Andrés A, Zaragoza Arnáez F. Effectiveness of an Intervention to Improve Management of COPD using the AUDIT Methodology: Results of the Neumo-Advance Study. Clin Drug Investig 2019; 39:653-664. [PMID: 31037610 DOI: 10.1007/s40261-019-00787-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE The implementation of chronic obstructive pulmonary disease (COPD) guidelines in the real-world setting remains low. Pulmonologists should participate in the new paradigms of chronicity of COPD, by providing their knowledge, expertise, innovation and research. The objective of this study was to survey pulmonologists on the adherence to COPD guidelines and to measure the change of attitude after holding meetings presenting the latest research on the subject. METHODS Fifty questions on COPD management were sent to 150 pulmonologists. Using the AUDIT methodology, the responses were discussed at several face-to-face meetings, held in different autonomous communities of Spain. The same questionnaire was subsequently sent to the participants and changes in their responses were analysed. RESULTS In total, 148 physicians (60.1% female) completed study. The main responses were: (1) 16.2% diagnose following clinical criteria; (2) 78.4% performed diagnostic tests other than spirometry; (3) 73.6% always determined alpha-1 antitrypsin levels (81.8% in the second questionnaire, p < 0.05); (4) 73% determined the patient's phenotype; (5) 42% always asked about passive exposure to cigarette smoke (55% after the meetings, p < 0.05); (6) 58.1% always asked about exposure to other pollutants or biomass; (7) 29.1% always assessed inhalational technique; (8) dual bronchodilators were the most common treatment (49.3%) used for patients with frequent exacerbator phenotype, glycopyrronium + indacaterol being the preferred option (44.1%); (9) 41.2% discontinued inhaled corticosteroids treatment (54.7% in the second questionnaire, p < 0.05); (10) for exacerbation admissions, 52% replaced maintenance bronchodilators with short-acting agents and introduced early background treatment (58.8% in the second round, p < 0.05). Few variations occurred in the participants' answers after the meetings. CONCLUSIONS The adherence of pulmonologists to clinical practice recommendations for COPD management is suboptimal. As well as face-to-face meetings, more intensive interventions are required to raise awareness on the importance of improving compliance with clinical guidelines.
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Affiliation(s)
- Javier de Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), C/Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - Rodrigo Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas S/n, 28922, Alcorcón, Madrid, Spain
| | - Ana López de Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas S/n, 28922, Alcorcón, Madrid, Spain
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Stellefson M, Paige SR, Barry AE, Wang MQ, Apperson A. Risk factors associated with physical and mental distress in people who report a COPD diagnosis: latent class analysis of 2016 behavioral risk factor surveillance system data. Int J Chron Obstruct Pulmon Dis 2019; 14:809-822. [PMID: 31040659 PMCID: PMC6462160 DOI: 10.2147/copd.s194018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Challenges associated with COPD increase patients’ risk of physical immobility and emotional distress, perpetuating a cycle of symptomatic living that hinders patients’ self-management and adherence to a treatment regimen. There is limited evidence available on how discrete behavioral and health risk factors contribute to the physical and mental distress experienced by people living with COPD. Purpose This secondary data analysis of 2016 Behavioral Risk Factor Surveillance System (BRFSS) sought to identify subgroups of people with COPD who were at the highest risk for physical and mental distress. Methods We selected 16 relevant risk indicators in four health-related domains – 1) health risk behaviors, 2) lack of preventive vaccinations, 3) limited health care access, and 4) comorbidities – as predictors of physical and mental health-related quality of life (HRQoL) in the COPD population. Latent class modeling (LCM) was applied to understand how various health-related indicators in these four health domains influenced reports of physical and/or mental distress. Results The majority of BRFSS respondents who reported a COPD diagnosis experienced physical (53.76%) and/or mental (58.23%) distress in the past 14 days. Frequent physical and mental distress were more common in females with COPD in the 45–64 years age group, who were also identified as white and in the lower socioeconomic group. Respondents with intermediate- to high-risk behaviors, intermediate to multiple comorbidities, limited access to health care, and intermediate to low use of preventive vaccinations were more likely to report frequent physical distress compared to the low-risk respondents. Similarly, respondents with high-risk behaviors, intermediate to multiple comorbidities, and low use of preventive vaccinations were more likely to report frequent mental distress than the low-risk group. Discussion This analysis of updated 2016 BRFSS data identified high-risk Americans with COPD who could benefit from disease management and secondary/tertiary health promotion interventions that may improve HRQoL. Future research should address noted disparities in risk factors, particularly among low socioeconomic populations living with COPD.
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Affiliation(s)
- Michael Stellefson
- Department of Health Education & Promotion, East Carolina University, Greenville, NC, USA,
| | - Samantha R Paige
- STEM Translational Communication Center, University of Florida, Gainesville, FL, USA
| | - Adam E Barry
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
| | - Min Qi Wang
- Department of Behavioral and Community Health, University of Maryland, College Park, MD, USA
| | - Avery Apperson
- Department of Health Education & Promotion, East Carolina University, Greenville, NC, USA,
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24
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Nyberg A, Tistad M, Wadell K. Can the COPD web be used to promote self-management in patients with COPD in swedish primary care: a controlled pragmatic pilot trial with 3 month- and 12 month follow-up. Scand J Prim Health Care 2019; 37:69-82. [PMID: 30700230 PMCID: PMC6452803 DOI: 10.1080/02813432.2019.1569415] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Evaluate the feasibility of the COPD Web and its study design and study procedures and to increase the understanding of the potential effect of the tool in order to provide guidance for a future large scale trial. DESIGN Parallel-group controlled pragmatic pilot trial. SUBJECTS There was a total of 83 patients with COPD (mean age 70 ± 8 years with a forced expiratory volume in first second percent predicted of 60 ± 17%). The intervention group (n = 43) was introduced to and had access to the COPD Web in addition to usual care, while the control group (n = 40) received usual care alone. MAIN OUTCOME MEASURES The feasibility of the COPD Web (i.e., if and how the COPD Web was used) was automatically collected through the website, while outcomes on health, conceptual knowledge, and physical activity (PA) were collected through questionnaires at baseline, 3 months and 12 months. RESULTS At 3 months, 77% of the intervention group was considered users, and the majority of time spent on the site was related to PA and exercises and was spent during the first month (>80%). In addition, the intervention group reported increased PA (odds ratio [OR] = 4.4, P < .001), increased conceptual knowledge in five domains (OR = 2.6-4.2, all P < .05), and altered disease management strategies (e.g., increased PA) (OR ≥ 2.7 P < .05) in comparison to the control group. The latter was also different between groups at 12 months (OR = 3.7, P = .044). Knowledge of PA was correlated with level of PA (ρ = .425-.512, P < .05) as well as to the use of PA as a strategy to manage their disease (χ2 = 11.2-32.9, P < .05). CONCLUSION Giving patients with COPD access to the COPD Web in addition to their ordinary primary care might be an effective shorter term (3 month) strategy to promote self-management. However, these results needs to be confirmed in a definitive large-scale trial. Key points Even though self-management strategies are an important part of chronic obstructive pulmonary disease (COPD) management, access to support for such strategies are limited for a large part of the COPD-population. Promoting self-management through the COPD Web might increase short-term levels of physical activity, promote conceptual knowledge and alter disease management strategies. The primary care COPD population in this study experienced limited impact of the disease in daily life, limited exertional dyspnea, and high generic quality-of-life, but vastly reduced levels of physical activity. A future large scale study should include strategies to encourage greater exposures to the COPD Web, including an extended analysis of factors associated with using or not using the tool over time and its impact on outcome measures, objective measures of conceptual knowledge, and physical activity, and it should include a large enough sample size to enable sub-group analyses and strategies to enhance recruitment.
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Affiliation(s)
- Andre Nyberg
- Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Umeå, Sweden
- CONTACT Andre Nyberg Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, 90187Umeå, Sweden
| | - Malin Tistad
- Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Umeå, Sweden
- School of Education Health and Social studies, Dalarna University, Falun, Sweden
| | - Karin Wadell
- Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Umeå, Sweden
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25
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Molina París J, Mascarós Balaguer E, Ocaña Rodríguez D, Simonet Aineto P, Campo Sien C. [Healthcare resources for asthma management at primary care level: Asthmabarometer Project]. Aten Primaria 2018; 52:258-266. [PMID: 30591208 PMCID: PMC7118562 DOI: 10.1016/j.aprim.2018.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/10/2018] [Accepted: 09/13/2018] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVE The objective of this study was to describe the current provision of basic resources for asthma management in Primary Health Care (PHC). DESIGN Cross-sectional study, with an ad hoc quantitative survey. LOCATION AND PARTICIPANTS A total of 380 primary healthcare physicians in Spain. INTERVENTIONS AND MAIN MEASUREMENTS Analysis of perceptions of management and use of basic human, organisational and material resources to ensure appropriate care provision to asthma patients. RESULTS Survey respondents stated that their centre did not have a consultant doctor (64%) or nurse (62%) in respiratory disease. Almost all (92%) of the centres have spirometers, of which 70% have peak flow meters, and 93% have placebo inhalers. In the last year, respondents have received specific theoretical/practical training from the centre (46%), and by third parties (83%). More than three-quarters (78%) of the centres has educational material available for patients. There is no specific healthcare protocol in 36% of the centres, and 43% had no referral protocol. A clinical interview is conducted to monitor the patient (90%), but there are no validated questionnaires to measure therapeutic adherence (85%), or a checklist to check inhalation technique (83%). Differences are observed in the relevant variables in the analysis of each Spanish Autonomous Community. CONCLUSIONS Access to certain resources in the care of patients with asthma is limited in aspects of coordination between levels, varied according to Spanish Autonomous Community, and improved in most health resources in Asthma.
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Affiliation(s)
- Jesús Molina París
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Francia I, Fuenlabrada, Madrid, España.
| | - Enrique Mascarós Balaguer
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Fuente de San Luis, Valencia, España
| | - Daniel Ocaña Rodríguez
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Algeciras-Norte, Cádiz, España
| | - Pere Simonet Aineto
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Viladecans-2, Atención Primaria Costa de Ponent-Institut Català de la Salut, Barcelona, España
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26
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Sandelowsky H, Krakau I, Modin S, Ställberg B, Johansson SE, Nager A. Effectiveness of traditional lectures and case methods in Swedish general practitioners' continuing medical education about COPD: a cluster randomised controlled trial. BMJ Open 2018; 8:e021982. [PMID: 30099398 PMCID: PMC6089265 DOI: 10.1136/bmjopen-2018-021982] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To study the effects of continuing medical education (CME) about chronic obstructive pulmonary disease (COPD) for general practitioners (GPs) by comparing two commonly used CME methods with each other and no CME (reference group). DESIGN A pragmatic cluster randomised controlled trial with primary healthcare centres (PHCCs) as units of randomisation. SETTING, PARTICIPANTS AND INTERVENTIONS 24 PHCCs in Stockholm County, Sweden, were randomised into two CME intervention arms: case method learning (CM) (n=12) and traditional lectures (TL) (n=12). A reference group without CME (n=11) was recruited separately. GPs (n=255) participated in the study arm to which their PHCC was allocated: CM, n=87; TL, n=93; and reference, n=75. Two 2-hour CME seminars were given in a period of 3 months. PRIMARY OUTCOME MEASURES Changes in scores between baseline and 12 months on a 13-item questionnaire about evidence-based COPD management (0-2 points/question, maximum total score 26 points). RESULTS 133 (52%) GPs completed the questionnaire both at baseline and 12 months. Both CM and TL resulted in small yet significantly higher total scores at 12 months than at baseline (CM, 10.34 vs 11.44; TL, 10.21 vs 10.91; p<0.05); there were few significant differences between these CME methods. At both baseline and 12 months, all three groups' scores were generally high on questions about smoking cessation support and low on those that measured spirometry interpretation skills, interprofessional care and management of multimorbidity. CONCLUSIONS Neither short CM nor short TL CME sessions substantially improve GPs' skills in managing COPD. It is justified to challenge the use of these common CME methods as a strategy for improving GPs' level of knowledge about management of COPD and other complex chronic diseases characterised by multimorbidity. TRIAL REGISTRATION NUMBER NCT02213809; Results.
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Affiliation(s)
- Hanna Sandelowsky
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
| | - Ingvar Krakau
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sonja Modin
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Sven-Erik Johansson
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
| | - Anna Nager
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
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27
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Gustafsson T, Nordeman L. The nurse's challenge of caring for patients with chronic obstructive pulmonary disease in primary health care. Nurs Open 2018; 5:292-299. [PMID: 30062022 PMCID: PMC6056438 DOI: 10.1002/nop2.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/30/2018] [Indexed: 12/14/2022] Open
Abstract
AIM The aim was to describe asthma and chronic obstructive pulmonary disease nurses' experiences of caring for patients with chronic obstructive pulmonary disease in primary health care. DESIGN Descriptive qualitative research. METHODS Ten asthma and chronic obstructive pulmonary disease specialized nurses were interviewed. Systematic Text Condensation by Malterud was used to analyse the data. RESULTS Two main categories were found: the patient-nurse relationship and available resources. Several challenges emerged when connecting with patients and the nurses found it difficult to individualize care. They struggled with a lack of time and support from other professionals. Being responsible for asthma and chronic obstructive pulmonary disease practice was experienced as positive, but could become overwhelming. The asthma and chronic obstructive pulmonary disease nurses described several challenges and the need for support and resources to provide the best possible care for patients with chronic obstructive pulmonary disease.
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Affiliation(s)
- Tanja Gustafsson
- Research and Development Center Södra ÄlvsborgNärhälsan, Research and Development Primary Health Care Region Västra GötalandBoråsSweden
- Närhälsan Fristad Primary Health Care CenterBoråsSweden
- Faculty of Caring Science, Work Life and Social WelfareUniversity of BoråsBoråsSweden
| | - Lena Nordeman
- Research and Development Center Södra ÄlvsborgNärhälsan, Research and Development Primary Health Care Region Västra GötalandBoråsSweden
- Department of Health and RehabilitationUnit of PhysiotherapyInstitute of Neuroscience and PhysiologySahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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28
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Sandelin M, Mindus S, Thuresson M, Lisspers K, Ställberg B, Johansson G, Larsson K, Janson C. Factors associated with lung cancer in COPD patients. Int J Chron Obstruct Pulmon Dis 2018; 13:1833-1839. [PMID: 29922050 PMCID: PMC5995277 DOI: 10.2147/copd.s162484] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The risk of dying of lung cancer is up to eightfold higher in patients with COPD than in age- and gender-matched controls. The aim of this study was to investigate the factors associated with lung cancer in a large cohort of COPD patients from primary care centers. Methods To analyze whether age, gender, socioeconomic factors, comorbidity, and medication affect the risk of lung cancer in COPD, we used a COPD cohort of primary care patients. Data from primary care medical records and mandatory Swedish national registers were collected and linked in this population-based, retrospective observational registry study (NCT01146392). Results Of the total cohort, 19,894 patients were included in the study. Five hundred and ninety-four lung cancer cases were diagnosed, corresponding to 3.0% of the studied population. In a multivariate analysis, the risk of lung cancer was lower if the COPD patients had a concurrent asthma diagnosis (HR: 0.54, CI: 0.41–0.71), while the risk of lung cancer increased with increasing age. A decreased lung cancer risk was observed in an exposure-dependent manner in patients who were prescribed inhaled corticosteroids (HR: 0.52, CI: 0.37–0.73), while the opposite was found for the use of acetylsalicylic acid (HR: 1.58, CI: 1.15–2.16). Conclusion In this large population-based cohort, a concurrent asthma diagnosis and use of inhaled corticosteroids were independently related to decreased risk of lung cancer in COPD patients, while the use of acetylsalicylic acid was associated with an increased risk. The findings of the present study should be seen as hypothesis generating and need to be confirmed in prospective studies.
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Affiliation(s)
- Martin Sandelin
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Stéphanie Mindus
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | | | - Karin Lisspers
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Gunnar Johansson
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Kjell Larsson
- Lung and Allergy Research Unit, National Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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29
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Sandelowsky H, Natalishvili N, Krakau I, Modin S, Ställberg B, Nager A. COPD management by Swedish general practitioners - baseline results of the PRIMAIR study. Scand J Prim Health Care 2018; 36:5-13. [PMID: 29334861 PMCID: PMC5901441 DOI: 10.1080/02813432.2018.1426148] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/10/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common cause of suffering and death. Evidence-based management of COPD by general practitioners (GPs) is crucial for decreasing the impact of the disease. Efficient strategies include early diagnosis, smoking cessation and multimodal treatment. AIM To describe knowledge about and skills for managing COPD in GPs in Sweden. METHODS Prior to COPD education (the PRIMAIR Study), GPs at primary health care centers (PHCCs) in Stockholm replied to 13 written, patient-case based, multiple choice and free-text questions about COPD. Their knowledge and practical management skills were assessed by assigned points that were analyzed with non-parametric tests. RESULTS Overall, 250 GPs at 34 PHCCs replied (89% response rate). Total mean score was 9.9 (maximum 26). Scores were highest on 'management of smoking cessation', 'follow-up after exacerbation' and 'diagnostic procedures'. Spirometry was used frequently, although interpretation skills were suboptimal. 'Management of maintenance therapy', 'management of multimorbidity' and 'interprofessional cooperation' had mediocre scores. Scores were unrelated to whether there was a nurse-led asthma/COPD clinic at the PHCC. CONCLUSIONS Swedish GPs' knowledge of COPD and adherence to current guidelines seem insufficient. A nurse-led asthma/COPD clinic at the PHCC does not correlate with sufficient COPD skills in the GPs. The relevance of this study to participants' actual clinical practice and usefulness of easy-to-access clinical guides are interesting topics for future investigation. To identify problem areas, we suggest using questionnaires prior to educational interventions. Key Points General practitioners (GPs) play a crucial role in providing evidence-based care for patients with chronic obstructive pulmonary disease (COPD) who are treated in primary care. Swedish GPs' knowledge about COPD and adherence to current guidelines seem insufficient. Areas in greatest need of improvement are spirometry interpretation, management of maintenance therapy, management of multimorbidity in patients with COPD and interprofessional cooperation.
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Affiliation(s)
- Hanna Sandelowsky
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden
| | | | - Ingvar Krakau
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Sonja Modin
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Science, Family Medicine and Preventive medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- NVS, Section for Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
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30
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Lisspers K, Larsson K, Johansson G, Janson C, Costa-Scharplatz M, Gruenberger JB, Uhde M, Jorgensen L, Gutzwiller FS, Ställberg B. Economic burden of COPD in a Swedish cohort: the ARCTIC study. Int J Chron Obstruct Pulmon Dis 2018; 13:275-285. [PMID: 29391785 PMCID: PMC5769573 DOI: 10.2147/copd.s149633] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background We assessed direct and indirect costs associated with COPD in Sweden and examined how these costs vary across time, age, and disease stage in a cohort of patients with COPD and matched controls in a real-world, primary care (PC) setting. Patients and methods Data from electronic medical records linked to the mandatory national health registers were collected for COPD patients and a matched reference population in 52 PC centers from 2000 to 2014. Direct health care costs (drug, outpatient or inpatient, PC, both COPD related and not COPD related) and indirect health care costs (loss of income, absenteeism, loss of productivity) were assessed. Results A total of 17,479 patients with COPD and 84,514 reference controls were analyzed. During 2013, direct costs were considerably higher among the COPD patient population (€13,179) versus the reference population (€2,716), largely due to hospital nights unrelated to COPD. Direct costs increased with increasing disease severity and increasing age and were driven by higher respiratory drug costs and non-COPD-related hospital nights. Indirect costs (~€28,000 per patient) were the largest economic burden in COPD patients of working age during 2013. Conclusion As non-COPD-related hospital nights represent the largest direct cost, management of comorbidities in COPD would offer clinical benefits and relieve the financial burden of disease.
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Affiliation(s)
- Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala
| | - Kjell Larsson
- Department of Work Environment Toxicology, The National Institute of Environmental Medicine, Karolinska Institute, Solna
| | - Gunnar Johansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala
| | | | | | | | | | | | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala
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31
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Högman M, Sulku J, Ställberg B, Janson C, Bröms K, Hedenström H, Lisspers K, Malinovschi A. 2017 Global Initiative for Chronic Obstructive Lung Disease reclassifies half of COPD subjects to lower risk group. Int J Chron Obstruct Pulmon Dis 2018; 13:165-173. [PMID: 29379281 PMCID: PMC5757198 DOI: 10.2147/copd.s151016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Unlike the 2014 guidelines, the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have removed lung function from the risk assessment algorithm of patients with COPD. The aim of this investigation was to analyze the proportion of subjects who would change to a lower risk group when applying GOLD2017 and determine if they exhibit different characteristics in terms of inflammation, symptoms and comorbidity compared to the subjects who would remain in a high-risk group. Subjects and methods A total of 571 subjects with physician-diagnosed and spirometry-verified COPD were included in the present study. The data consisted of measurements of lung function, inflammatory markers, together with questionnaires that covered comorbidities, COPD symptoms and medication. Results From group C, 53% of the subjects would be reclassified to the lower risk group A, and from group D, 47% of the subjects would be reclassified to the lower risk group B when using GOLD2017 instead of GOLD2014. Compared to the subjects who would remain in group D, those who would change to group B were more often men (56% vs 72%); of an older age, mean (SD), 71 (8) years vs 68 (7) years; had more primary care contact (54% vs 33%); had lower levels of blood neutrophils, geometrical mean (95% CI), 5.3 (5.0, 5.7) vs 4.6 (4.3, 4.9); reported less anxiety/depression (20% vs 34%); experienced less asthma (29% vs 46%) and had fewer symptoms according to the COPD assessment test, 16 (5) vs 21 (7). All p-values were <0.05. Conclusion The removal of spirometry from risk assessment in GOLD2017 would lead to the reclassification of approximately half of the subjects in the risk groups C and D to the lower risk groups A and B. There are differences in age, gender, health care contacts, inflammation, comorbidity and symptom burden among those changing from group D to group B. The effects of reclassification and changes in eventual treatment for disease control and symptom burden need further investigation.
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Affiliation(s)
- Marieann Högman
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research
| | - Johanna Sulku
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala.,Center for Research & Development, Uppsala University/Region Gävleborg, Gävle
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala.,Center for Clinical Research, Uppsala University, County Council Dalarna, Falun
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research
| | - Kristina Bröms
- Center for Research & Development, Uppsala University/Region Gävleborg, Gävle.,Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala
| | - Hans Hedenström
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala.,Center for Clinical Research, Uppsala University, County Council Dalarna, Falun
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
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Sandelowsky H, Krakau I, Modin S, Ställberg B, Nager A. Case Method in COPD education for primary care physicians: study protocol for a cluster randomised controlled trial. Trials 2017; 18:197. [PMID: 28449709 PMCID: PMC5408477 DOI: 10.1186/s13063-017-1889-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 03/09/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality worldwide. It is often undiagnosed and insufficiently managed. Effective forms of continuing medical education (CME) for primary care physicians (PCPs) are necessary to ensure the implementation of guidelines in clinical practice and, thus, improve patients' health. METHODS In this study, we will measure the effects of CME by Case Method and compare them against those of traditional lectures and no CME at all through an unblinded, cluster randomised controlled trial (CRCT). Thirty-three primary health care centres (PHCCs) in Stockholm, Sweden, with a total of 180 PCPs will be involved. Twenty-two primary PHCCs, will be cluster-randomised into: an intervention group who will receive CME by Case Method (n = 11) and a control group who will receive traditional lectures (n = 11). The remaining PHCCs (n = 11) will be a reference group and will receive no CME. From the intervention and control groups, 460 randomly selected patients with COPD in GOLD stages 2 and 3 will participate, while no patients will be recruited from the reference group. For the patients, smoking status, actual treatment and urgent visits to a health provider due to airway problems will be registered. For the PCPs, professional competence (i.e. knowledge and management skills) in COPD, will be measured using a questionnaire based on current guidelines and guideline implementation problems in clinical practice which has previously been described by the authors. Data will be collected at baseline and at follow-up, which will be after 1.5 years for the patients, and 1 year for the PCPs. Statistical methods for individual-level and cluster-level analyses will be used. DISCUSSION COPD is considered a particularly complex clinical challenge involving managing multimorbidity, symptom adaptation, and lifestyle problematisation. Case Method in CME for PCPs may contribute to a better understanding of the impact of COPD on patients' lives and, thus, improve their management of it. The present study is expected to contribute scientific knowledge about indicators for an effective CME in COPD that is tailor-made to primary care physicians. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02213809 . Registered on 10 August 2014. Protocol version: Issue date: May 2014.
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Affiliation(s)
- Hanna Sandelowsky
- Division of Family Medicine and Primary Care, NVS, Karolinska Institutet, Alfred Nobels Allé 23, D2, Huddinge, Stockholm 14183 Sweden
| | - Ingvar Krakau
- Division of Family Medicine and Primary Care, NVS, Karolinska Institutet, Alfred Nobels Allé 23, D2, Huddinge, Stockholm 14183 Sweden
| | - Sonja Modin
- Division of Family Medicine and Primary Care, NVS, Karolinska Institutet, Alfred Nobels Allé 23, D2, Huddinge, Stockholm 14183 Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- Division of Family Medicine and Primary Care, NVS, Karolinska Institutet, Alfred Nobels Allé 23, D2, Huddinge, Stockholm 14183 Sweden
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Sundh J, Janson C, Johansson G, Lindén A, Löfdahl CG, Sandström T, Larsson K. Characterization of secondary care for COPD in Sweden. Eur Clin Respir J 2017; 4:1270079. [PMID: 28326177 PMCID: PMC5328327 DOI: 10.1080/20018525.2016.1270079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/03/2016] [Accepted: 12/05/2016] [Indexed: 10/31/2022] Open
Abstract
Introduction: Only a selected proportion of chronic obstructive pulmonary disease (COPD) patients are managed in secondary care. The aim of this study was to characterize disease severity, treatment and structure of secondary care for COPD in Sweden. Methods: Information was collected from 29 of 33 existing secondary care units of respiratory medicine in Sweden, using both individual data from 373 consecutively enrolled COPD patients with Global initiative on Obstructive Lung Disease (GOLD) stage III-IV and a structural questionnaire about available resources at the units. Patient data included exacerbations, health status assessed by COPD Assessment Test (CAT), lung function, comorbid conditions, pharmacological treatment and vaccinations. Structural data included available smoking cessation support, multidisciplinary rehabilitation, physical training, patient education and routine follow-up after exacerbations at the respective unit. All patients were reclassified according to the GOLD 2014 group A-D classification. Multiple linear regression investigated associations of available resources with number of exacerbations and CAT score. Results: According to GOLD 2014, 87% of the population were GOLD D and 13% were GOLD C. Triple inhaled therapy were prescribed in 88% of the patients. Over 75% of the units had resources for smoking cessation, multidisciplinary rehabilitation, physical training and patient education. Routine follow-up after exacerbations was available in 35% of the units. Being managed at units with access to structured patient education was associated with statistically significantly fewer exacerbations (adjusted regression coefficient (95% confidence interval) -0.79 (-1.39 to -0.19), p = 0.010). Conclusion: Most stage III-IV COPD patients managed at secondary care respiratory units in Sweden have maximized inhaled therapy and high risk disease even when reclassified according to GOLD 2014. Most units have access to smoking cessation, rehabilitation and patient education. Patients managed at units with structured patient education have a lower exacerbation risk.
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Affiliation(s)
- Josefin Sundh
- Department of Respiratory Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory; Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Gunnar Johansson
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Anders Lindén
- Unit for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Claes-Göran Löfdahl
- Department of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Thomas Sandström
- Department of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | - Kjell Larsson
- Unit for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Arne M, Emtner M, Lisspers K, Wadell K, Ställberg B. Availability of pulmonary rehabilitation in primary care for patients with COPD: a cross-sectional study in Sweden. Eur Clin Respir J 2016; 3:31601. [PMID: 27900930 PMCID: PMC5129097 DOI: 10.3402/ecrj.v3.31601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 10/16/2016] [Indexed: 02/03/2023] Open
Abstract
Background Pulmonary rehabilitation (PR) is an important, evidence-based component for the management of individuals with chronic obstructive pulmonary disease (COPD). In daily practice, the majority of COPD patients are treated in primary care. However, information about the availability of PR in primary care in Sweden is lacking. The aim was to investigate the availability of rehabilitation resources in primary care settings for patients with COPD in Sweden. Methods A cross-sectional descriptive design was applied, using web-based questionnaires sent to all primary care centres in four regions, comprising more than half of the 9.6 million inhabitants of Sweden. The main questionnaire included questions about the content and availability of rehabilitation resources for COPD patients. PR was defined as exercise training and one or more of the following activities: education, nutritional intervention, energy conservation techniques or psychosocial support. Results A total of 381 (55.9%) of the 682 primary care centres answered the main questionnaire. In addition to physicians and nurses, availability of healthcare professionals for rehabilitation in primary care settings was physiotherapists 92.0%, occupational therapists 91.9%, dieticians 83.9% and social workers or psychologists 98.4%. At 23.7% of all centres, PR was not available to COPD patients – neither in primary care nor at hospitals. Conclusion Despite high availability of professionals for rehabilitation in primary care settings, about one-quarter of managers at primary care centres stated that their COPD patients had no access to PR. This indicates a need to structure resources for rehabilitation and to present and communicate the available resources within the healthcare system.
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Affiliation(s)
- Mats Arne
- Primary Care Research Unit, Karlstad, Sweden.,Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden;
| | - Margareta Emtner
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Karin Wadell
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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Pleasants RA, Riley IL, Mannino DM. Defining and targeting health disparities in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2016; 11:2475-2496. [PMID: 27785005 PMCID: PMC5065167 DOI: 10.2147/copd.s79077] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The global burden of chronic obstructive pulmonary disease (COPD) continues to grow in part due to better outcomes in other major diseases and in part because a substantial portion of the worldwide population continues to be exposed to inhalant toxins. However, a disproportionate burden of COPD occurs in people of low socioeconomic status (SES) due to differences in health behaviors, sociopolitical factors, and social and structural environmental exposures. Tobacco use, occupations with exposure to inhalant toxins, and indoor biomass fuel (BF) exposure are more common in low SES populations. Not only does SES affect the risk of developing COPD and etiologies, it is also associated with worsened COPD health outcomes. Effective interventions in these people are needed to decrease these disparities. Efforts that may help lessen these health inequities in low SES include 1) better surveillance targeting diagnosed and undiagnosed COPD in disadvantaged people, 2) educating the public and those involved in health care provision about the disease, 3) improving access to cost-effective and affordable health care, and 4) markedly increasing the efforts to prevent disease through smoking cessation, minimizing use and exposure to BF, and decreasing occupational exposures. COPD is considered to be one the most preventable major causes of death from a chronic disease in the world; therefore, effective interventions could have a major impact on reducing the global burden of the disease, especially in socioeconomically disadvantaged populations.
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Affiliation(s)
- Roy A Pleasants
- Duke Asthma, Allergy, and Airways Center
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine
- Durham VA Medical Center, Durham, NC
| | - Isaretta L Riley
- Duke Asthma, Allergy, and Airways Center
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine
- Durham VA Medical Center, Durham, NC
| | - David M Mannino
- Division of Pulmonary, Critical Care, and Sleep Medicine, Pulmonary Epidemiology Research Laboratory, University of Kentucky, Lexington, KY, USA
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Sandelowsky H, Hylander I, Krakau I, Modin S, Ställberg B, Nager A. Time pressured deprioritization of COPD in primary care: a qualitative study. Scand J Prim Health Care 2016; 34:55-65. [PMID: 26849465 PMCID: PMC4911027 DOI: 10.3109/02813432.2015.1132892] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To identify factors that hinder discussions regarding chronic obstructive pulmonary disease (COPD) between primary care physicians (PCPs) and their patients in Sweden. SETTING Primary health care centres (PHCCs) in Stockholm, Sweden. SUBJECTS A total of 59 PCPs. DESIGN Semi-structured individual and focus-group interviews between 2012 and 2014. Data were analysed inspired by grounded theory methods (GTM). RESULTS Time-pressured patient-doctor consultations lead to deprioritization of COPD. During unscheduled visits, deprioritization resulted from focusing only on acute health concerns, while during routine care visits, COPD was deprioritized in multi-morbid patients. The reasons PCPs gave for deprioritizing COPD are: "Not becoming aware of COPD", "Not becoming concerned due to clinical features", "Insufficient local routines for COPD care", "Negative personal attitudes and views about COPD", "Managing diagnoses one at a time", and "Perceiving a patient's motivation as low''. CONCLUSIONS De-prioritization of COPD was discovered during PCP consultations and several factors were identified associated with time constraints and multi-morbidity. A holistic consultation approach is suggested, plus extended consultation time for multi-morbid patients, and better documentation and local routines. KEY POINTS Under-diagnosis and insufficient management of chronic obstructive pulmonary disease (COPD) are common in primary health care. A patient-doctor consultation offers a key opportunity to identify and provide COPD care. Time pressure, due to either high number of patients or multi-morbidity, leads to omission or deprioritization of COPD during consultation. Deprioritization occurs due to lack of awareness, concern, and local routines, negative personal views, non-holistic consultation approach, and low patient motivation. Better local routines, extended consultation time, and a holistic approach are needed when managing multi-morbid patients with COPD.
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Affiliation(s)
- Hanna Sandelowsky
- NVS, Section for Family Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
- CONTACT Hanna Sandelowsky Karolinska Institutet, NVS, Section for Family Medicine, Alfred Nobels Allé 12, S-14183 Huddinge, Stockholm, Sweden
| | - Ingrid Hylander
- NVS, Section for Family Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - Ingvar Krakau
- NVS, Section for Family Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - Sonja Modin
- NVS, Section for Family Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Science, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Anna Nager
- NVS, Section for Family Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
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Løkke A, Ahlbeck L, Bjermer L, Mortensen J, Østrem A, Pasternack I, Safioti G, Torvinen S. Expert Nordic perspectives on the potential of novel inhalers to overcome unmet needs in the management of obstructive lung disease. Eur Clin Respir J 2015; 2:29445. [PMID: 26689215 PMCID: PMC4684578 DOI: 10.3402/ecrj.v2.29445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 11/17/2015] [Indexed: 11/14/2022] Open
Abstract
The effective self-management of obstructive lung disease is dependent upon the patient achieving good inhaler technique. However, many current inhalers are complicated to use, which may lead to handling difficulties. These difficulties can cause clinically relevant errors, whereby pharmacotherapy fails to achieve adequate lung deposition and therapeutic effect. In this report, the potential of novel inhaler devices to overcome unmet needs in the management of obstructive lung disease is considered by a panel of Nordic experts. The panel concludes that innovative inhalers can contribute to good disease management and better use of healthcare resources.
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Affiliation(s)
- Anders Løkke
- Department of Respiratory Medicine, Aarhus County Hospital, Aarhus, Denmark;
| | - Lars Ahlbeck
- Allergy Centre University Hospital, Linköping and Respiratory System Drug Committee at Region Östergötland, Linköping, Sweden
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Institute of Clinical Science, Lund University, Lund, Sweden
| | - Jann Mortensen
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Denmark
- Department of Medicine, National Hospital, Torshavn, Faroe Islands
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López Ramírez C, Calero Acuña C, Represas Represas C, Aballe Santos L, Casamor R, Fernández-Villar A, López-Campos JL. Evaluation of the visit frequency and the use of questionnaires and indices for COPD: a national survey from the On-Sint study. CLINICAL RESPIRATORY JOURNAL 2015; 11:367-373. [PMID: 26149089 DOI: 10.1111/crj.12349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/23/2015] [Accepted: 06/29/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Despite widespread recommendations to use standardized questionnaires and multidimensional indices for the assessment of patients with chronic obstructive pulmonary disease (COPD), few data are available on the application of these tools in clinical practice. This study evaluates the attitude of physicians participating in the On-Sint cohort toward the use of health status questionnaires and multidimensional indices, as well as toward the frequency of visits and spirometry in primary care and specialized care. METHODS During the constitution of the On-Sint cohort, the participating physicians were surveyed about their clinical practice. They were questioned on the frequency of spirometry and visits and on the use of various questionnaires and indices. The health status questionnaires assessed were St. George's respiratory questionnaire, chronic respiratory questionnaire, airways questionnaire 20 and COPD assessment test (CAT). Physicians were also asked about the use of the medical research council (MRC) dyspnea scale and multidimensional indices such as body mass index, airflow obstruction, dyspnea, exercise capacity (BODE). RESULTS Of the 356 physicians who participated in the study, 258 (72.5 %) completed the investigator's questionnaire (185 primary care, 73 specialized care). Nonscheduled visits were inversely proportional to the severity of COPD. Overall, 34.1% reported using health status questionnaires, mainly CAT (20.9%). We found differences between primary and specialized care in the use of multidimensional indices (84.9% vs 47.6%; P < 0.001). Of all the participants, 33.3% reported using the MRC scale and 28.7% the BODE index. CONCLUSIONS Multidimensional indices and questionnaires are not commonly used with some differences between primary care and specialized care physicians. There is a considerable variability in the frequency of follow-up visits and spirometry.
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Affiliation(s)
- Cecilia López Ramírez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Spain
| | - Carmen Calero Acuña
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Represas Represas
- Servicio de Neumología. Instituto de Investigación Biomédica de Vigo (IBIV), Complexo Hospitalario de Vigo, Spain
| | - Luz Aballe Santos
- Servicio de Neumología. Instituto de Investigación Biomédica de Vigo (IBIV), Complexo Hospitalario de Vigo, Spain
| | - Ricard Casamor
- Medical Department, Novartis Farmacéutica, Barcelona, Spain
| | - Alberto Fernández-Villar
- Servicio de Neumología. Instituto de Investigación Biomédica de Vigo (IBIV), Complexo Hospitalario de Vigo, Spain
| | - José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/Universidad de Sevilla, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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