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Domingo C, Fernandez M, Garin N, Milara J, Moran I, Muerza I, Pacheco A, Teruel C, Bentley R, Subiran R, Gil A. Determining What Represents Value in the Treatment of Refractory or Unexplained Chronic Cough from the Perspective of Key Stakeholders in Spain Using Multi-Criteria Decision Analysis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:119-130. [PMID: 36319945 PMCID: PMC9628572 DOI: 10.1007/s40258-022-00770-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Chronic cough is defined as cough lasting for more than 8 weeks. It can be described as refractory when persisting despite thorough clinical assessment and treatment of any cough-related underlying condition, or unexplained when no underlying cough-related condition can be identified. Refractory or unexplained chronic cough (RCC|UCC) greatly affects patient health-related quality of life (HRQoL). Although around 10% of the population suffer from chronic cough (with 40-60% of these patients suffering from RCC|UCC), there is limited information available in the literature about the condition and the assessment of treatment success. This study aimed to determine what represents value in the treatment of RCC|UCC from the perspective of key stakeholders in Spain using Multi-Criteria Decision Analysis (MCDA) methodology. METHODS A literature review was conducted to adapt the MCDA framework to the specific context of RCC|UCC. A total of 24 participants were involved, representing three key stakeholder groups (7 patients, 9 physicians and 8 hospital pharmacists). The study was structured in two phases. In Phase 1, participants validated the adapted MCDA framework and assigned relative weights (100-point allocation) to the framework's value criteria/sub-criteria during three individual stakeholder meetings, one per each stakeholder group. In Phase 2, participants were brought together in a multi-stakeholder meeting to review findings of each stakeholder group, after which stakeholders repeated the weighting exercise as a collective group. All meetings included reflective discussion by participants of each value criteria/sub-criteria included within the adapted MCDA framework, where stakeholders shared their perspectives and opinions on what represents value in RCC|UCC. RESULTS Refractory or unexplained chronic cough is regarded as a chronic medical condition, with variable severity across patients and the potential to heavily impact their HRQoL (including physical, psychological and social/work productivity domains). Current treatments used by healthcare professionals, which have not been specifically developed and are not approved for RCC|UCC, show limited clinical effectiveness and associated safety and tolerability issues, which result in frequent treatment discontinuations. The reduction of the average cough frequency over a 24-h period is regarded as the primary goal of treatment by stakeholders, with the aim of improving HRQoL. Improvement of other cough symptoms, such as intensity, is also considered important. Minor adverse events and a slower onset of treatment effect would be acceptable to stakeholders if accompanied by strong efficacy and improvement in HRQoL. Given the inability to measure cough frequency in clinical practice, Patient-Reported Outcomes (PROs) could be considered a proxy of treatment effectiveness. A multidisciplinary approach to the condition is regarded as key for treatment success. CONCLUSIONS Refractory or unexplained chronic cough is a medical condition that seriously impacts patients' HRQoL. The primary goal of treatment is to improve patients' HRQoL by reducing the frequency and intensity of cough.
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Affiliation(s)
- Christian Domingo
- Pulmonology Department, Hospital Parc Tauli, Sabadell, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mario Fernandez
- Otolaryngology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Noe Garin
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Javier Milara
- Pharmacy Department, Hospital General de Valencia, Valencia, Spain
| | - Ignacio Moran
- Spanish Federation of Patient Organisations with Allergic and Respiratory Diseases (FENAER), Madrid, Spain
| | - Irantzu Muerza
- Spanish Federation of Patient Organisations with Allergic and Respiratory Diseases (FENAER), Madrid, Spain
| | | | - Carlos Teruel
- Gastroenterology Department, Hospital Ramon y Cajal, Madrid, Spain
| | - Roy Bentley
- Global Market Access, Shionogi Inc., New Jersey, USA
| | | | - Alicia Gil
- Omakase Consulting S.L., Barcelona, Spain.
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Slovarp LJ, Bozarth E. Altering cough reflex sensitivity with aerosolized capsaicin paired with behavioral cough suppression: a proof-of-concept study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:7. [PMID: 30788354 DOI: 10.21037/atm.2018.12.26] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The purpose of this prospective, quasi-experimental, single cohort proof-of-concept study was to determine feasibility and proof-of-concept of programmatically decreasing cough sensitivity through use of cough suppression strategies following inhalation of aerosolized capsaicin, in gradually increasing doses, across repeated treatment sessions. Methods Five healthy adults, ages 20-32 years of age, enrolled and completed the study. The study commenced in three phases. Phase I consisted of baseline cough sensitivity testing using pharmaceutical-grade aerosolized capsaicin, delivered via a Koko DigiDoser with nebulizer. The single-inhale, dose-response method was used. Doses that elicited two coughs (C2) and five coughs (C5) were recorded. Testing ceased when participants met the C5 threshold or when they had been given the maximum dose of 1,000 µmol/L. Phase II consisted of 5-6 treatment sessions, during which participants were exposed to increasing doses of aerosolized capsaicin while implementing behavioral cough suppression strategies. In phase III, cough sensitivity was re-tested at 1 and 3 weeks post-treatment. Participants were given explicit instructions to not try to suppress their cough. Participants who did not reach the C2 or C5 threshold at 1,000 µmol/L were assigned a score of 1,250 µmol/L. Results Each participant demonstrated a gradual increase in maximum capsaicin dose suppressed during each treatment session, with each successfully suppressing at 1,000 µmol/L by the final treatment session. C2 was greater than baseline in 4 of the 5 participants at 1 week post-treatment, and in 3 of the 5, at 3 weeks post-treatment. C5 was greater in all 5 participants at both post-treatment time points. In fact, 4 of the 5 participants did not reach the C5 threshold during either post-treatment testing sessions. Wilcoxon's Signed Rank Test, using the logC2 and logC5 values, revealed a significant difference relative to baseline in logC5 at 1 week (z=-2.02, P=0.04) and 3 weeks (z=-2.03, P=0.04) post-treatment. The difference in logC2 neared significance at 1 week post-treatment (z=-1.77, P=0.077), but was insignificant at 3 weeks post-treatment (z=-1.46, P=0.144). Conclusions This study demonstrates the potential of treating patients with refractory chronic cough (RCC), due to cough hypersensitivity, with a progressive desensitization approach paired with behavioral cough suppression. Additional research is needed using a randomized, placebo-controlled trial with patients with RCC.
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Affiliation(s)
- Laurie J Slovarp
- Department of Communicative Sciences and Disorders, The University of Montana, Missoula, MT, USA
| | - Emma Bozarth
- Department of Communicative Sciences and Disorders, The University of Montana, Missoula, MT, USA
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Taylor RJ, Lowe SR, Ellis N, Abdullah E, Patel S, Halstead LA. Laryngeal manifestations of cranial nerve IX/X compression at the brainstem. Laryngoscope 2018; 129:2105-2111. [PMID: 30582168 DOI: 10.1002/lary.27678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 09/09/2018] [Accepted: 10/22/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We report an association between lower cranial nerve (CN IX/X) vascular compression at the brainstem with laryngeal symptoms utilizing a stepwise algorithm that systematically evaluates and eliminates all other common etiologies. Our experiences with retromastoid craniectomy with lower cranial nerve (LCN) decompression versus non-neurosurgical treatments are detailed. STUDY DESIGN Retrospective chart review at a tertiary care academic medical center with follow-up telephone survey. METHODS Baseline demographics, clinical characteristics, quality-of-life surveys, and treatment outcomes were recorded for patients with laryngeal symptoms associated with LCN compression at the brainstem. RESULTS Forty-nine patients demonstrated LCN compression at the brainstem on imaging and presented with chief complaints of dysphonia (25 of 49, 51%), chronic cough (19 of 49, 39%), dysphoric breathing (3 of 49, 6%), and dysphagia (2 of 49, 4%). Poor initial scores were noted for Voice-Related Quality of Life (V-RQOL), Reflux Symptom Index, and Glottal Closure Index. Twenty-four patients underwent LCN decompression, of which 21 of 24 (88%) reported partial, near-complete, or complete improvement. Major perioperative complications occurred in four of 24 patients (17%). Patients who had undergone decompression were more likely to obtain complete/near-complete symptom resolution (10 of 24 patients, 42%) compared to those undergoing conservative treatments (2 of 25 patients, 8%) (P = 0.02). V-RQOL scores improved more in surgical patients [mean change score, 33.0 (standard deviation [SD], 31.2) than nonsurgical patients (mean change score 9.6, SD 20.9) (P = 0.03) (mean follow-up 3.0 years, SD 2.0). CONCLUSION Lower cranial nerve compression at the brainstem should be considered when all other etiologies are excluded. Retromastoid craniectomy with LCN decompression demonstrates an acceptable safety profile. LEVEL OF EVIDENCE 4 Laryngoscope, 129:2105-2111, 2019.
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Affiliation(s)
- Robert J Taylor
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Stephen R Lowe
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Nic Ellis
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Evan Abdullah
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Sunil Patel
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Lucinda A Halstead
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Slovarp L, Loomis BK, Glaspey A. Assessing referral and practice patterns of patients with chronic cough referred for behavioral cough suppression therapy. Chron Respir Dis 2018; 15:296-305. [PMID: 29430939 PMCID: PMC6100168 DOI: 10.1177/1479972318755722] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 11/17/2017] [Accepted: 12/15/2017] [Indexed: 12/19/2022] Open
Abstract
The purpose of this exploratory research was to describe current referral and practice patterns for behavioral cough suppression therapy (BCST) throughout the United States, and to assess the need for improving the efficiency of BCST referral patterns. In study I, 126 speech-language pathologists, who treat patients with refractory chronic cough (RCC) in the United States, completed a survey about referral patterns, cough duration, and patient frustration level. In study II, 36 adults with RCC referred for BCST completed a four-part survey about cough symptoms and treatment. The survey included the Leicester Cough Questionnaire (LCQ) before and after BCST. Study I revealed significant patient frustration about the treatment process and the wait-time for BCST. Participants in study II reported average cough duration of over 2 years before BCST. Twenty-seven of 31 participants in study II improved by at least 1.3 on the LCQ, indicating a clinically significant improvement in 87% of patients. This study suggests that the current management model for CC may be unduly time-consuming, and expensive for patients with CC who are successfully treated with BCST. Practitioners are encouraged to consider BCST earlier in the treatment process.
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Affiliation(s)
- Laurie Slovarp
- Department of Communicative Sciences and Disorders, University of Montana, Missoula, Montana, USA
| | | | - Amy Glaspey
- Department of Communicative Sciences and Disorders, University of Montana, Missoula, Montana, USA
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Perotin JM, Launois C, Dewolf M, Dumazet A, Dury S, Lebargy F, Dormoy V, Deslee G. Managing patients with chronic cough: challenges and solutions. Ther Clin Risk Manag 2018; 14:1041-1051. [PMID: 29922064 PMCID: PMC5995432 DOI: 10.2147/tcrm.s136036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Chronic cough is a common complaint and a frequent cause of medical consultation. Its management can be difficult. We present here an overview of the current guidelines for the management of chronic cough. Different steps are detailed, including the initial research of an obvious etiology and alert signs that should lead to further investigation of underlying condition. The diagnosis of the most frequent causes: asthma, non-asthmatic eosinophilic bronchitis, gastroesophageal reflux disease and upper airway cough syndrome should be considered, assessed and treated accordingly. Recent advances have been made in the comprehension of refractory chronic cough pathophysiology as well as its pharmacologic and non-pharmacologic treatment, especially speech pathology therapy.
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Affiliation(s)
- Jeanne-Marie Perotin
- Department of Respiratory Diseases, University Hospital of Reims, Reims, France.,INSERM UMRS 1250, University Hospital of Reims, Reims, France
| | - Claire Launois
- Department of Respiratory Diseases, University Hospital of Reims, Reims, France
| | - Maxime Dewolf
- Department of Respiratory Diseases, University Hospital of Reims, Reims, France
| | - Antoine Dumazet
- Department of Respiratory Diseases, University Hospital of Reims, Reims, France
| | - Sandra Dury
- Department of Respiratory Diseases, University Hospital of Reims, Reims, France
| | - François Lebargy
- Department of Respiratory Diseases, University Hospital of Reims, Reims, France
| | - Valérian Dormoy
- INSERM UMRS 1250, University Hospital of Reims, Reims, France
| | - Gaëtan Deslee
- Department of Respiratory Diseases, University Hospital of Reims, Reims, France.,INSERM UMRS 1250, University Hospital of Reims, Reims, France
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Luize AP, Menezes AMB, Perez-Padilla R, Muiño A, López MV, Valdivia G, Lisboa C, Montes de Oca M, Tálamo C, Celli B, Nascimento OA, Gazzotti MR, Jardim JR. Assessment of five different guideline indication criteria for spirometry, including modified GOLD criteria, in order to detect COPD: data from 5,315 subjects in the PLATINO study. NPJ Prim Care Respir Med 2014; 24:14075. [PMID: 25358021 PMCID: PMC4373468 DOI: 10.1038/npjpcrm.2014.75] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/04/2014] [Accepted: 08/05/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Spirometry is the gold standard for diagnosing chronic obstructive pulmonary disease (COPD). Although there are a number of different guideline criteria for deciding who should be selected for spirometric screening, to date it is not known which criteria are the best based on sensitivity and specificity. AIMS Firstly, to evaluate the proportion of subjects in the PLATINO Study that would be recommended for spirometry testing according to Global initiative for Obstructive Lung Disease (GOLD)-modified, American College of Chest Physicians (ACCP), National Lung Health Education Program (NLHEP), GOLD and American Thoracic Society/European Respiratory Society (ATS/ERS) criteria. Secondly, we aimed to compare the sensitivity, specificity, and positive predictive and negative predictive values, of these five different criteria. METHODS Data from the PLATINO study included information on respiratory symptoms, smoking and previous spirometry testing. The GOLD-modified spirometry indication criteria are based on three positive answers out of five questions: the presence of cough, phlegm in the morning, dyspnoea, age over 40 years and smoking status. RESULTS Data from 5,315 subjects were reviewed. Fewer people had an indication for spirometry (41.3%) according to the GOLD-modified criteria, and more people had an indication for spirometry (80.4%) by the GOLD and ATS/ERS criteria. A low percentage had previously had spirometry performed: GOLD-modified (14.5%); ACCP (13.2%); NLHEP (12.6%); and GOLD and ATS/ERS (12.3%). The GOLD-modified criteria showed the least sensitivity (54.9) and the highest specificity (61.0) for detecting COPD, whereas GOLD and ATS/ERS criteria showed the highest sensitivity (87.9) and the least specificity (20.8). CONCLUSION There is a considerable difference in the indication for spirometry according to the five different guideline criteria. The GOLD-modified criteria recruit less people with the greatest sum of sensitivity and specificity.
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Affiliation(s)
- Ana P Luize
- Respiratory Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Rogelio Perez-Padilla
- Respiratory Division, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Adriana Muiño
- Respiratory Division, Universidad de la República, Montevideo, Uruguay
| | | | - Gonzalo Valdivia
- Respiratory Division, Pontifícia Universidad Católica de Chile, Santiago, Chile
| | - Carmem Lisboa
- Respiratory Division, Pontifícia Universidad Católica de Chile, Santiago, Chile
| | | | - Carlos Tálamo
- Respiratory Division, Universidad Central de Venezuela, Caracas, Venezuela
| | - Bartolomé Celli
- Brighans Women´s Hospital, Harvard University, Boston, MA, USA
| | | | - Mariana R Gazzotti
- Respiratory Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José R Jardim
- Respiratory Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW Cough lasting more than 8 weeks is a common presenting complaint to the otolaryngologist. Historically, chronic cough has been attributed to post-nasal drip, laryngopharyngeal reflux and cough-variant asthma. This study reviews chronic cough from the viewpoint of an otolaryngologist. RECENT FINDINGS More recent studies suggest the influence of laryngeal neuropathy and its interplay with laryngopharyngeal reflux. There is limited evidence for post-nasal drip or cough-variant asthma causing chronic cough. SUMMARY In this study, we review the evidence for cause of chronic cough, as well as up to date techniques for the otolaryngologist, including transnasal esophagoscopy, to assess the patient in clinic allowing accurate diagnosis. Treatment options for the otolaryngologist are discussed and the role of multidisciplinary input emphasized.
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Chronic cough, reflux, postnasal drip syndrome, and the otolaryngologist. Int J Otolaryngol 2012; 2012:564852. [PMID: 22577385 PMCID: PMC3332192 DOI: 10.1155/2012/564852] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 02/07/2012] [Indexed: 01/02/2023] Open
Abstract
Objectives. Chronic cough is a multifactorial symptom that requires multidisciplinary approach. Over the last years, general practitioners refer increasingly more chronic cough patients directly to the otolaryngologist. The aim of this paper is to highlight the issues in diagnosis and management of chronic cough patients from the otolaryngologist perspective. Design. Literature review. Results. Gastroesophageal reflux and postnasal drip syndrome remain one of the most common causes of chronic cough. Better diagnostic modalities, noninvasive tests, and high technology radiological and endoscopic innovations have made diagnosis of these difficult-to-treat patients relatively easier. Multidisciplinary assessment has also meant that at least some of these cases can be dealt with confidently in one stop clinics. Conclusions. As the number of referrals of chronic cough patients to an Ear Nose Throat Clinic increases, the otolaryngologist plays a pivotal role in managing these difficult cases.
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