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Miravitlles M, González-Torralba F, Represas-Represas C, Pomares X, Márquez-Martín E, González C, Amado C, Forné C, Alonso S, Alcázar B, Barrecheguren M, Jurado Mirete JM, Naval E. Pulmonologists' Opinion on the Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Patients in Spain: A Cross-Sectional Survey. Int J Chron Obstruct Pulmon Dis 2022; 17:1577-1587. [PMID: 35855745 PMCID: PMC9288191 DOI: 10.2147/copd.s369118] [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: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Identifying the variables that guide decision-making in relation to the use of inhaled corticosteroids (ICS) can contribute to the appropriate use of these drugs. The objective of this study was to identify the clinical variables that physicians consider most relevant for prescribing or withdrawing ICS in COPD. Methods A cross-sectional survey was conducted in Spain from November 2020 to May 2021. Therapeutic decisions on the use of ICS in 11 hypothetical COPD patient profiles were collected using an online survey answered by specialists with experience in the management of patients with COPD. Mixed-effects logistic regression was used to analyze the impact of patients' characteristics in the therapeutic decision for prescribing ICS or proceeding to its withdrawal. Results A total of 74 pulmonologists agreed to collaborate in the survey and answered the questionnaire. The results showed great variability, with only 2 profiles achieving consensus for starting or withdrawing the treatment. The frequency and severity of exacerbations influenced the decision to prescribe ICS in a dose-response fashion (1 exacerbation odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.02 to 3.43, two exacerbations OR = 11.6, 95% CI: 4.47 to 30.2 and three OR = 123, 95% CI: 25 to 601). Similarly, increasing blood eosinophils and history of asthma were associated with ICS use. On the other hand, pneumonia reduced the probability of initiating treatment with ICS (OR = 0.54 [0.29 to 0.98]). Lung function and dyspnea degree did not influence the clinician's therapeutic decision. The results for withdrawal of ICS were similar but in the opposite direction. Conclusion In accordance with guidelines, exacerbations, blood eosinophils and history of asthma or pneumonia are the factors considered by pulmonologist for the indication or withdrawal of ICS. However, the agreement in prescription or withdrawal of ICS when confronted with hypothetical cases is very low, suggesting a great variability in clinical practice.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain
| | | | | | - Xavier Pomares
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Pneumology Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Eduardo Márquez-Martín
- CIBER de Enfermedades Respiratorias (CIBERES), ISCIII, Madrid, Spain.,Medical-Surgical Unit for Respiratory Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Cruz González
- Pneumology Department, Hospital Clínico de Valencia, Valencia, Spain
| | - Carlos Amado
- Pneumology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carles Forné
- Heorfy Consulting, Lleida, Spain.,Basic Medical Sciences Department, University of Lleida, Lleida, Spain
| | - Soledad Alonso
- Pneumology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Bernardino Alcázar
- Pneumology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | - Elsa Naval
- Pneumology Department, Hospital Universitario de La Ribera, Alzira, Spain
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Izquierdo JL, Morena D, González Y, Paredero JM, Pérez B, Graziani D, Gutiérrez M, Rodríguez JM. Clinical Management of COPD in a Real-World Setting. A Big Data Analysis. Arch Bronconeumol 2020; 57:94-100. [PMID: 32098727 DOI: 10.1016/j.arbres.2019.12.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the quality of diagnosis and treatment of COPD using Big Data methodology on the Savana Manager 2.1 clinical platform. MATERIALS AND METHODS A total of 59,369 patients with a diagnosis of COPD were included from a population of 1,219,749 adults over 40 years of age. RESULTS In total, 78% were men. Spirometry data were available for only 26,453 (43.5%) subjects. Disease severity was classified in 18,172 patients: 4,396 mild, 7,100 moderate, and 6,676 severe, although only 27%, 34%, and 28%, respectively, presented obstructive spirometry. The clinical management of COPD is mainly the responsibility of the primary care and pulmonology departments, while internal medicine and, to a lesser extent, geriatrics also participate. Drug treatment was based on bronchodilators and inhaled corticosteroids (ICS). A marked decline in the use of long-acting beta-2 agonists (LABA) in monotherapy and a slight reduction in ICS/LABA combinations, associated with a LAMA in 74% of cases, was observed. All-cause in-hospital mortality among the overall population was 5.6% compared to 1% of the general population older than 40 years. In total, 35% were admitted to hospital, with an average stay of 6.6 days and a rate of hospital mortality in this group of 10.74%. DISCUSSION This study identifies the main features of an unselected COPD population and the major errors made in the management of the disease.
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Affiliation(s)
- José Luis Izquierdo
- Departamento de Medicina y Especialidades, Universidad de Alcalá, Madrid, España; Servicio de Neumología, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - Diego Morena
- Servicio de Neumología, Hospital Universitario de Guadalajara, Guadalajara, España
| | | | - José Manuel Paredero
- Servicio de Farmacia de Atención Primaria, GAI de Guadalajara, Guadalajara, España
| | - Bernardino Pérez
- Servicio de Informática, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Desirée Graziani
- Servicio de Neumología, Hospital Universitario de Guadalajara, Guadalajara, España
| | - Matilde Gutiérrez
- Servicio de Contratación Administrativa, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - José Miguel Rodríguez
- Departamento de Medicina y Especialidades, Universidad de Alcalá, Madrid, España; Servicio de Neumología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
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Izquierdo JL, Miravitlles M, Esquinas C, Pérez M, Calle M, López Campos JL, Rodríguez González-Moro JM, Casanova C, Esteban C, de Lucas P. Características de los pacientes con EPOC tratados en neumología en España según grupos GOLD y fenotipos clínicos GesEPOC. Arch Bronconeumol 2018; 54:559-567. [DOI: 10.1016/j.arbres.2018.03.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/15/2018] [Accepted: 03/18/2018] [Indexed: 10/14/2022]
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Calle Rubio M, Rodríguez Hermosa JL, Soler-Cataluña JJ, López-Campos JL, Alcazar Navarrete B, Soriano JB, Rodríguez Gónzalez-Moro JM, Fuentes Ferrer ME, Miravitlles M. Atención médica según el nivel de riesgo y su adecuación a las recomendaciones de la guía española de la enfermedad pulmonar obstructiva crónica (EPOC) (GesEPOC): Estudio EPOCONSUL. Arch Bronconeumol 2018; 54:270-279. [DOI: 10.1016/j.arbres.2017.11.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/09/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
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Calle Rubio M, Casamor R, Miravitlles M. Identification and distribution of COPD phenotypes in clinical practice according to Spanish COPD Guidelines: the FENEPOC study. Int J Chron Obstruct Pulmon Dis 2017; 12:2373-2383. [PMID: 28848338 PMCID: PMC5557116 DOI: 10.2147/copd.s137872] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background The Spanish Guidelines for COPD (GesEPOC) describe four clinical phenotypes: non-exacerbator (NE), asthma-COPD overlap syndrome (ACO), frequent exacerbator with emphysema (EE), and exacerbator with chronic bronchitis (ECB). The objective of this study was to determine the frequency of COPD phenotypes, their clinical characteristics, and the availability of diagnostic tools to classify COPD phenotypes in clinical practice. Materials and methods This study was an epidemiological, cross-sectional, and multi-centered study. Patients ≥40 years old with a post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio of <0.7 and who were smokers or former smokers (with at least 10 pack-years) were included. The availability of diagnostic tools to classify COPD phenotypes was assessed by an ad hoc questionnaire. Results A total of 647 patients (294 primary care [PC], 353 pulmonology centers) were included. Most patients were male (80.8%), with a mean age (SD) of 68.2 (9.2) years, mean post-bronchodilator FEV1 was 53.2% (18.9%) and they suffered a mean of 2.2 (2.1) exacerbations in the last year. NE was the most frequent phenotype (47.5%) found, followed by ECB (29.1%), EE (17.0%), and ACO (6.5%). Significant differences between the four phenotypes were found regarding age; sex; body mass index; FEV1; body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE)/body mass index, airflow obstruction, dyspnea and exacerbations (BODEx) index; modified Medical Research Council dyspnea scale; respiratory symptoms; comorbidi-ties; hospitalizations; and exacerbations in the last year. Physicians considered that >80% of the diagnostic tools needed to classify COPD phenotypes were available, with the exception of computed tomography (26.9%) and carbon monoxide transfer test (13.5%) in PC, and sputum eosinophilia count in PC and pulmonology centers (40.4% and 49.4%, respectively). Conclusion In Spanish clinical practice, almost half of the patients with COPD presented with NE phenotype. The prevalence of ACO according to the Spanish consensus definition was very low. In general, physicians indicated that they had the necessary tools for diagnosing COPD phenotypes.
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Affiliation(s)
- Myriam Calle Rubio
- Pulmonary Department, Hospital Clínico San Carlos.,Department of Medicine, Faculty of Medicine, University Complutense of Madrid, Research Institute of Hospital Clínico San Carlos (IdISSC), Madrid
| | | | - Marc Miravitlles
- Pneumology Department, University Hospital Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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García García S, Carazo Fernández L, Juan García J, Naveiro Rilo JC. [Chronic obstructive pulmonary disease in real life. LEONPOC study]. Aten Primaria 2017; 49:603-610. [PMID: 28292581 PMCID: PMC6876058 DOI: 10.1016/j.aprim.2017.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/22/2016] [Accepted: 01/02/2017] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate different characteristics of COPD patients according to phenotypes and GOLD guidelines.according to GesEPOC phenotypes and GOLD 2011 ABCD guidelines and pharmacological treatment agreement. DESIGN Cross-sectional survey. LOCATION COPD patients aged 40-85 from León were randomly selected from Primary Care database, MEDORA. PARTICIPANTS 5222 eligible COPD patients were collected from MEDORA database. We calculated a sample size of 734 patients and finally studied 577 of them. MAIN MEASUREMENTS Patientś clinical, functional and health related quality of life information were collected. Spirometry and postbroncodilator test were performed. RESULTS A total of 577 patients were included in this study. 28.7% of them did not have a spirometry recorded in their files. 123 patients had a normal or non-obstructive spirometry pattern, so they were excluded from a COPD diagnostic. With regard to treatments, there was an overprescribing of inhaled steroids in patients from GOLD A and B groups, and also in patients with the called exacerbator phenotype (GesEPOC). CONCLUSION Although there have been several published guidelines, management of COPD patients in real life should be improved.
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Affiliation(s)
- Silvia García García
- Sección de Neumología, Complejo Asistencial Universitario de León, León, España.
| | | | - Javier Juan García
- Sección de Neumología, Complejo Asistencial Universitario de León, León, España
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Calle Rubio M, Alcázar Navarrete B, Soriano JB, Soler-Cataluña JJ, Rodríguez González-Moro JM, Fuentes Ferrer ME, López-Campos JL. Clinical audit of COPD in outpatient respiratory clinics in Spain: the EPOCONSUL study. Int J Chron Obstruct Pulmon Dis 2017; 12:417-426. [PMID: 28182155 PMCID: PMC5279956 DOI: 10.2147/copd.s124482] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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
BACKGROUND Chronic obstructive pulmonary disease (COPD) outpatients account for a large burden of usual care by respirologists. EPOCONSUL is the first national clinical audit conducted in Spain on the medical care for COPD patients delivered in outpatient respiratory clinics. We aimed to evaluate the clinical interventions and the degree of adherence to recommendations in outpatients of current COPD clinical practice guidelines. METHODOLOGY This is an observational study with prospective recruitment (May 2014-May 2015) of patients with a COPD diagnosis as seen in outpatient respiratory clinics. The information collected was historical in nature as for the clinical data of the last and previous consultations, and the information concerning hospital resources was concurrent. RESULTS A total of 17,893 clinical records of COPD patients in outpatient respiratory clinics from 59 Spanish hospitals were evaluated. Of the 5,726 patients selected, 4,508 (78.7%) were eligible. Overall, 12.1% of COPD patients did not fulfill a diagnostic spirometry criteria. Considerable variability existed in the available resources and work organization of the hospitals, although the majority were university hospitals with respiratory inpatient units. There was insufficient implementation of clinical guidelines in preventive and educational matters. In contrast, quantitative evaluation of dyspnea grade (81.9%) and exacerbation history (70.9%) were more frequently performed. Only 12.4% had COPD severity calculated according to the Body mass index, airflow Obstruction, Dyspnoea and Exercise capacity (BODE) index. Phenotype characteristics according to Spanish National Guideline for COPD were determined in 46.3% of the audited patients, and the risk evaluation according to Global initiative for chronic Obstructive Lung Disease was estimated only in 21.9%. CONCLUSION The EPOCONSUL study reports the current situation of medical care for COPD patients in outpatient clinics in Spain, revealing its variability, strengths, and weaknesses. This information has to be accounted for by health managers to define corrective strategies and maximize good clinical practice.
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Affiliation(s)
- Myriam Calle Rubio
- Pulmonary Department, Hospital Clínico San Carlos
- Department of Medicine, Faculty of Medicine, University Complutense of Madrid
- Research Institute of Hospital Clínico San Carlos (IdISSC), Madrid
| | | | - Joan B Soriano
- Research Institute of Hospital University La Princesa (IISP), University Autónoma of Madrid
| | | | | | - Manuel E Fuentes Ferrer
- Department of Medicine, Faculty of Medicine, University Complutense of Madrid
- Research Institute of Hospital Clínico San Carlos (IdISSC), Madrid
- UGC of Preventive Medicine and Research Institute of Hospital Clínico San Carlos, Madrid
| | - José Luis López-Campos
- Pulmonary Department, Hospital University Virgen del Rocio, Institute of Biomedicine of Sevilla (IBiS), Sevilla, Spain
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Román-Rodríguez M, van Boven JFM, Vargas F, Contreras CC, Lamelas G, Gestoso S, Góngora M, Corredor M, Esteva M. Factors associated with inhaled corticosteroids prescription in primary care patients with COPD: A cross-sectional study in the Balearic Islands (Spain). Eur J Gen Pract 2016; 22:232-239. [PMID: 27597172 DOI: 10.1080/13814788.2016.1212011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND There is a worldwide over-prescription of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD), off-label prescribing, and unnecessary prescription of high doses. OBJECTIVES Our aim was to assess the prescription rate of ICS and to identify sociodemographic and clinical factors associated with ICS prescription among patients with COPD, treated in Balearic primary healthcare. METHODS This cross-sectional study included all patients with a clinical COPD diagnosis, who attended a primary care centre of the Balearic Islands (Spain) during 2012. Also, a sub-population with spirometry-confirmed COPD was defined. Data were obtained on patient demographics, smoking status, spirometry, ICS prescriptions, other respiratory medication, exacerbations and comorbidities. Associations with ICS and high-dose ICS prescription were assessed using multivariate regression analyses. RESULTS In total, 15,440 patients were included (70% men, mean age 68.6 years), and 44.6% were prescribed ICS. The largest association with ICS prescription was asthma comorbidity (OR: 3.50; 95%CI: 3.12-3.92), followed by exacerbation history (OR: 2.23; 95%CI: 2.07-2.47). In addition, smoking status, spirometry, atopic dermatitis, allergic rhinitis and mean age were significantly (P < 0.001) associated with ICS treatment. In the spirometry-confirmed population, asthma (OR: 2.89; 95%CI: 2.29-3.64) and exacerbations were also the major factors (OR: 2.85; 95%CI: 2.45-3.32) followed by severe bronchial-obstruction (OR: 2.63; 95%CI: 2.24-3.08). High-dose ICS prescription was mainly associated with severe obstruction (OR: 2.27; 95%CI: 1.93-2.68). CONCLUSION The percentage of COPD patients prescribed ICS in Balearic primary care is relatively low. Asthma comorbidity, exacerbation history, severe bronchial-obstruction, smoking status and a spirometry-confirmed COPD diagnosis were significantly associated with ICS prescription. [Box: see text].
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Affiliation(s)
- Miguel Román-Rodríguez
- a Son Pisa Health Center. Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain.,b Instituto de Investigación Sanitaria de Palma (IdISPa) , Palma de Mallorca , Spain
| | - Job F M van Boven
- b Instituto de Investigación Sanitaria de Palma (IdISPa) , Palma de Mallorca , Spain.,c Primary Care Research Unit, Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
| | - Freya Vargas
- a Son Pisa Health Center. Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
| | - Cecilia C Contreras
- a Son Pisa Health Center. Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
| | - Gema Lamelas
- a Son Pisa Health Center. Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
| | - Salvador Gestoso
- a Son Pisa Health Center. Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
| | - Miguel Góngora
- a Son Pisa Health Center. Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
| | - Maite Corredor
- a Son Pisa Health Center. Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
| | - Magdalena Esteva
- b Instituto de Investigación Sanitaria de Palma (IdISPa) , Palma de Mallorca , Spain.,c Primary Care Research Unit, Majorca Primary Care Department , Balearic Institute of Health , Palma de Mallorca , Spain
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Alcázar Navarrete B, Casanova C, Miravitlles M, de Lucas P, Riesco JA, Rodríguez González-Moro JM. “Correct Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease”: A Consensus Document. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2015.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Alcázar Navarrete B, Casanova C, Miravitlles M, de Lucas P, Riesco JA, Rodríguez González-Moro JM. "Correct use of inhaled corticosteroids in chronic obstructive pulmonary disease": a consensus document. Arch Bronconeumol 2014; 51:193-8. [PMID: 25540900 DOI: 10.1016/j.arbres.2014.11.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 11/02/2014] [Accepted: 11/06/2014] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Indications for inhaled corticosteroids (IC) in combination with long-acting bronchodilators (LABD) are well defined in clinical practice guidelines. However, there are some doubts about their efficacy and safety. The aim of this document is to establish an expert consensus to clarify these issues. METHOD A coordinator group was formed, which systematically reviewed the scientific evidence with the aim of identifying areas of uncertainty about the efficacy of ICs, the adverse effects associated with their use and criteria for withdrawal. Their proposals were submitted to a panel of experts and the Delphi technique was used to test the level of consensus. RESULTS Twenty-five experts participated in the panel, and consensus was reached on the use of IC in the mixed chronic obstructive pulmonary disease (COPD)-asthma phenotype and in frequent exacerbators, and on not using IC in association with LABD for improving lung function in COPD. There was no general consensus on restricting the use of IC to prevent adverse effects. The panel did agree that IC withdrawal is feasible but should be undertaken gradually, and patients who have discontinued must be evaluated in the short term. CONCLUSIONS Consensus was reached regarding the indication of IC in mixed COPD-asthma and frequent exacerbator phenotypes. The potential for adverse effects must be taken into consideration, but there is no consensus on whether limiting use is justified. The withdrawal of ICs was uniformly agreed to be feasible.
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Affiliation(s)
- Bernardino Alcázar Navarrete
- Neumología, Área integrada de gestión de Medicina, Hospital de Alta Resolución de Loja, APES Hospital de Poniente, Granada, España.
| | - Ciro Casanova
- Servicio de Neumología, Unidad de Investigación, Hospital Universitario Nuestra Señora de la Candelaria, Tenerife, España
| | - Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Pilar de Lucas
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Sellares J, López-Giraldo A, Lucena C, Cilloniz C, Amaro R, Polverino E, Ferrer M, Menéndez R, Mensa J, Torres A. Influence of previous use of inhaled corticoids on the development of pleural effusion in community-acquired pneumonia. Am J Respir Crit Care Med 2013; 187:1241-8. [PMID: 23590264 DOI: 10.1164/rccm.201209-1732oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE Previous use of inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease has been associated with increased risk of community-acquired pneumonia. However, ICS have been associated with fewer pneumonia complications and decreased risk of pneumonia-related mortality. OBJECTIVES The objective of the study was to assess the influence of previous use of ICS on the incidence of parapneumonic effusion in patients with different baseline respiratory disorders. METHODS We conducted a single-center cohort study of 3,612 consecutively collected patients diagnosed with community-acquired pneumonia. We assessed clinical, radiographic, and pleural-fluid chemistry and microbiologic variables. Patients were classified according to whether or not they received prior ICS treatment. MEASUREMENTS AND MAIN RESULTS A total of 633 patients (17%) were treated with corticosteroids before the diagnosis of pneumonia (chronic obstructive pulmonary disease, 54%; asthma, 13%). Incidence of parapneumonic effusion was lower in patients with ICS use compared with non-ICS patients (5% vs. 12%; P < 0.001). After matching according to propensity scores (n = 640), prior treatment with corticosteroids was still significantly associated with a lower incidence of parapneumonic effusion (odds ratio, 0.40; 95% confidence interval, 0.23-0.69; P = 0.001) compared with patients without ICS treatment. Prior ICS treatment was associated with higher levels of glucose (P = 0.003) and pH (P = 0.02), and lower levels of protein (P = 0.01) and lactic acid dehydrogenase (P = 0.007) in the pleural fluid. CONCLUSIONS Prior treatment with ICS in a population of patients with different respiratory chronic disorders who develop pneumonia is associated with lower incidence of parapneumonic effusion.
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Affiliation(s)
- Jacobo Sellares
- Servei de Pneumologia, Institut del Torax, Hospital Clínic, Institut d'Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
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12
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The Excessive Use of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.arbr.2012.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Izquierdo Alonso JL, De Lucas Ramos P, Rodríguez Glez-Moro JM. The use of the lower limit of normal as a criterion for COPD excludes patients with increased morbidity and high consumption of health-care resources. Arch Bronconeumol 2012; 48:223-8. [PMID: 22480962 DOI: 10.1016/j.arbres.2012.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 02/05/2012] [Accepted: 02/13/2012] [Indexed: 11/18/2022]
Abstract
The objective of this study is to analyze the clinical characteristics of two COPD patient populations: one diagnosed using the lower limit of normal (LLN) and another diagnosed by the GOLD criteria. We also compared the population excluded by the LLN criterion with a non-COPD control population. The COPD patients determined with the LLN criterion presented significantly lower levels of FEV1/FVC at 0.55 (0.8) vs. 0.66 (0.2), P=.000; FEV1 44.9% (14) vs. 53.8% (13), P=.000, and FVC 64.7% (17) vs. 70.4% p 0.04. The two COPD groups presented more frequent ER visits in the last year (57% and 52% of the patients, respectively, compared with 11.9% of the control group), without any statistically significant differences between the two. This same pattern was observed in the number of ER visits in the last year: 1.98 (1.6), 1.84 (1.5) and 1.18 (0.7), respectively. When we analyzed the prevalence of the comorbidities that are most frequently associated COPD, there was a clear increase in the percentage of patients who presented associated disorders compared with the control group. Nevertheless, these differences were not very relevant between the two COPD groups. The differences also were not relevant between both COPD groups in the pharmacological prescription profile. In conclusion, the use of the LLN as a criterion for establishing the diagnosis of COPD, compared with the GOLD criteria, excludes a population with important clinical manifestations and with a high consumption of health-care resources. Before its implementation, the relevance of applying this criterion in clinical practice should be analyzed.
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Izquierdo Alonso JL, Rodríguez Glez-Moro JM. The excessive use of inhaled corticosteroids in chronic obstructive pulmonary disease. Arch Bronconeumol 2012; 48:207-12. [PMID: 22385832 DOI: 10.1016/j.arbres.2012.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Accepted: 01/08/2012] [Indexed: 01/04/2023]
Abstract
Despite the fact that the recommendations of the main clinical guidelines have restricted the indications for inhaled corticosteroids in chronic obstructive pulmonary disease (COPD), currently more than 80% of patients are receiving this treatment in Spain, mostly with high doses. A detailed review of the literature does not justify the use of these high doses, a position that agrees with the recommendations of the FDA. A re-evaluation of their safety, the consistency of the data on their efficacy showing similar results with moderate doses and a better patient selection require the use of this treatment in COPD patients to be reconsidered.
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Miravitlles M, Andreu I, Romero Y, Sitjar S, Altés A, Anton E. Difficulties in differential diagnosis of COPD and asthma in primary care. Br J Gen Pract 2012; 62:e68-75. [PMID: 22520766 PMCID: PMC3268496 DOI: 10.3399/bjgp12x625111] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 11/01/2011] [Accepted: 11/15/2011] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) and asthma treatment must be based on appropriate diagnosis. However, patients receiving inhaled therapy in primary care may not be accurately diagnosed according to current guidelines. AIM To analyse the characteristics of patients treated with inhaled medication, the concordance of tools for differential diagnosis, and the adequacy of prescription of inhaled corticosteroids (ICs) in primary care. DESIGN AND SETTING Cross-sectional, multicentre, non-interventional study conducted in 10 primary care centres in Barcelona, Spain. METHOD Patients with chronic respiratory disease, aged >40 years were treated with ICs. They provided sociodemographic and clinical information and performed forced spirometry with a bronchodilator test (BDT). The diagnostic accuracy of asthma and COPD diagnoses were tested using two differential diagnosis questionnaires. RESULTS A total of 328 patients were initially classified as having COPD (64.8%), asthma (15.4%), or indeterminate (19.8%) by their GPs. After spirometry, 40% of patients had moderate-severe airflow obstruction according to the GOLD classification; mean reversibility of forced expiratory volume in 1 second (FEV1) was 8.4%; 18.6% had a positive BDT; and 39.8% had post-bronchodilator FEV1/forced vital capacity >0.7. Concordance of the differential diagnosis tools was moderate (clinical diagnosis versus spirometry and between the two questionnaires), low (clinical diagnosis versus questionnaires), and very low (spirometry versus differential diagnosis). Of the patients diagnosed with COPD, 71.4% were treated with ICs, and 12% of those classified as having asthma were not receiving ICs. CONCLUSION Most patients can be classified as having COPD or asthma by primary care physicians. The use of the two questionnaires did not provide a better differential diagnostic compared with symptoms and spirometry with a BDT. Misdiagnosis may lead to inadequate treatment.
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Affiliation(s)
- Marc Miravitlles
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Ciber de Enfermedades Respiratorias (CIBERES), Hospital Clinic, Barcelona, Spain.
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Izquierdo JL, Martín A, de Lucas P, Rodríguez-González-Moro JM, Almonacid C, Paravisini A. Misdiagnosis of patients receiving inhaled therapies in primary care. Int J Chron Obstruct Pulmon Dis 2010; 5:241-9. [PMID: 20714378 PMCID: PMC2921692 DOI: 10.2147/copd.s11123] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Indexed: 11/23/2022] Open
Abstract
Aim: To analyze the accuracy of diagnosis in a population receiving inhaled therapies due to respiratory diseases in a primary care setting. Method: Noninterventional, multicenter, cross-sectional, observational epidemiologic study methodology. Results: A total of 9752 subjects were evaluated. Of these, 4188 (42.9%) patients were diagnosed with asthma, 4175 (42.8%) with chronic obstructive pulmonary disease (COPD), and 1389 had a diagnosis of disease of unknown origin. Of those over the age of 40 years, 4079 (50.9%) had COPD and 2877 (35.9%) had asthma. Sixty percent of the subjects were men, and the proportion of men was higher in patients with COPD (83.2%) than in the group with asthma (39.8%, P < 0.0001). Of subjects with COPD, 17.3% had mild, 55.3% had moderate, 24.1% had severe, and 3.2% had very severe disease. With regard to the level of severity of asthma, 34.9% of subjects had intermittent, 34.6% had mild persistent, 27.1% had moderate persistent, and 3.5% had severe persistent disease. Only 13.9% of patients in the COPD group had all the characteristics of COPD based on the Global Initiative for Chronic Obstructive Lung Disease criteria and an absence of the characteristics of asthma. Conclusions: The majority of patients receiving inhaled therapy in primary care did not have an accurate diagnosis according to current international guidelines for COPD and asthma. More initiatives for improving diagnostic accuracy in respiratory diseases must be implemented in primary care.
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Affiliation(s)
- José Luis Izquierdo
- Pneumology Department, University Hospital of Guadalajara, 19002 Guadalajara, Spain.
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Jebrak G. [COPD routine management in France: are guidelines used in clinical practice?]. Rev Mal Respir 2009; 27:11-8. [PMID: 20146947 DOI: 10.1016/j.rmr.2009.08.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 08/13/2009] [Indexed: 11/17/2022]
Abstract
INTRODUCTION COPD management guidelines have been proposed to improve the major outcomes for COPD patients. In clinical practice, COPD treatment is only partially consistent with current guidelines and recommendations. OBJECTIVE Global initiative for chronic obstructive lung disease (GOLD) guidelines are based on a COPD severity scale and are subject to change as the evidence based evolves. The main purpose of our study was to access whether the treatments prescribed to patients with COPD were consistent with these guidelines. METHODS Treatments prescribed by French physicians to 542 patients with COPD in stable conditions were recorded according to the severity of obstruction, using GOLD classification. We compared our prescription data base with the GOLD guidelines. RESULTS Forty percent of the initial physicians were chest specialists. PATIENTS 78.3 % men, (64.8+/-10.8years) and 25 % were still smokers at inclusion. We found an important discrepancy between recommended treatment and COPD severity. Bronchodilators were commonly prescribed, but 11 % in severe COPD (stages III and IV) did not receive them. Inhaled steroids (ICS) were used respectively in 55.2 %, 59.4 % of patients in stages I, II (FEV1>50 %) (for whom they are not recommended) and 77.4 and 85.3 % in stages III and IV. Only 30 % of patients used ICS+beta2 agonists in the same device. Influenza vaccination had been performed in only half of patients whatever the severity of COPD. Pulmonary rehabilitation had been used by 10 % of patients, (stage II: 6.4 %, stage III: 9.6 %, stage IV: 20.6 %). CONCLUSIONS We confirmed that there are discrepancies between COPD guidelines and routine treatments. Some treatments such as ICS were overused in mild phenotypes, whereas in a high proportion of cases influenza immunisation and rehabilitation were omitted.
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Affiliation(s)
- G Jebrak
- Service de pneumologie B, hôpital Bichat, 46, rue Henri-Huchard, 75018 Paris, France
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Valero C, Monteagudo M, Llagostera M, Bayona X, Granollers S, Acedo M, Ferro JJ, Rodríguez-Latre L, Almeda J, Muñoz L. Evaluation of a combined strategy directed towards health-care professionals and patients with chronic obstructive pulmonary disease (COPD): information and health education feedback for improving clinical monitoring and quality-of-life. BMC Public Health 2009; 9:442. [PMID: 20128887 PMCID: PMC2799410 DOI: 10.1186/1471-2458-9-442] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 12/01/2009] [Indexed: 11/30/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a health problem that is becoming increasingly attended-to in Primary Care (PC). However, there is a scarcity of health-care programs and studies exploring the implementation of Clinical Practice Guidelines (CPG). The principal objective of the present study is to evaluate the effectiveness of a combined strategy directed towards health-care professionals and patients to improve the grade of clinical control and the quality-of-life (QoL) of the patients via a feedback on their state-of-health. A training plan for the health-care professionals is based on CPG and health education. Method/Design Multi-centred, before-after, quasi experimental, prospective study involving an intervention group and a control group of individuals followed-up for 12 months. The patients receive attention from urban and semi-urban Primary Care Centres (PCC) within the administrative area of the Costa de Ponent (near Barcelona). All the pacients corresponding to the PCC of one sub-area were assigned to the intervention group and patients from the rest of sub-areas to the group control. The intervention includes providing data to the health-care professionals (clinician/nurse) derived from a clinical history and an interview. A course of training focused on aspects of CPG, motivational interview and health education (tobacco, inhalers, diet, physical exercise, physiotherapy). The sample random includes a total of 801 patients (≥ 40 years of age), recorded as having COPD, receiving attention in the PCC or at home, who have had at least one clinical visit, and who provided written informed consent to participation in the study. Data collected include socio-demographic characteristics, drug treatment, exacerbations and hospital admissions, evaluation of inhaler use, tobacco consumption and life-style and health-care resources consumed. The main endpoints are dyspnoea, according to the modified scale of the Medical Research Council (MRC) and the QoL, evaluated with the St George's Respiratory Questionnaire (SGRQ). The variables are obtained at the start and the end of the intervention. Information from follow-up visits focuses on the changes in life-style activities of the patient. Discussion This study is conducted with the objective of generating evidence that shows that implementation of awareness programs directed towards health-care professionals as well as patients in the context of PC can produce an increase in the QoL and a decrease in the disease exacerbation, compared to standard clinical practice. Trial Registration Clinical Trials.gov Identifier: NCT00922545;
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Affiliation(s)
- Carles Valero
- Unit Methodology, Assessment and Quality, SAP Dreta, Catalan Health Institute, 08025 Barcelona, Spain.
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Miravitlles M, Brosa M, Velasco M, Crespo C, Gobartt E, Diaz S, González-Rojas N. An economic analysis of pharmacological treatment of COPD in Spain. Respir Med 2009; 103:714-21. [PMID: 19168340 DOI: 10.1016/j.rmed.2008.11.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Revised: 11/16/2008] [Accepted: 11/27/2008] [Indexed: 11/27/2022]
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