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Wang C, Siff J, Greco PJ, Warren E, Thornton JD, Tarabichi Y. The Impact of an Electronic Health Record Intervention on Spirometry Completion in Patients with Chronic Obstructive Pulmonary Disease. COPD 2022; 19:142-148. [PMID: 35392743 PMCID: PMC9202241 DOI: 10.1080/15412555.2022.2049736] [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: 10/04/2021] [Revised: 02/07/2022] [Accepted: 02/25/2022] [Indexed: 11/12/2022]
Abstract
Spirometry is necessary to diagnose chronic obstructive pulmonary disease (COPD), yet a large proportion of patients are diagnosed and treated without having received testing. This study explored whether the effects of interventions using the electronic health record (EHR) to target patients diagnosed with COPD without confirmatory spirometry impacted the incidence rates of spirometry referrals and completions. This retrospective before and after study assessed the impact of provider-facing clinical decision support that identified patients who had a diagnosis of COPD but had not received spirometry. Spirometry referrals, completions, and results were ascertained 1.5 years prior to and 1.5 years after the interventions were initiated. Inhaler prescriptions by class were also tallied. There were 10,949 unique patients with a diagnosis of COPD who were eligible for inclusion. 4,895 patients (44.7%) were excluded because they had completed spirometry prior to the cohort start dates. The pre-intervention cohort consisted of 2,622 patients, while the post-intervention cohort had 3,392. Spirometry referral rates pre-intervention were 20.2% compared to 31.6% post-intervention (p < 0.001). Spirometry completion rates rose from 13.2% pre-intervention to 19.3% afterwards (p < 0.001). 61.7% (585 of 948) had no evidence of airflow obstruction. After excluding patients with a diagnosis of asthma, 25.8% (126 of 488) patients who had no evidence of airflow obstruction had prescriptions for long-acting bronchodilators or inhaled steroids. A concerted EHR intervention modestly increased spirometry referral and completion rates in patients with a diagnosis of COPD without prior spirometry and decreased misclassification of disease.
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Affiliation(s)
- Christine Wang
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jonathan Siff
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
| | - Peter J. Greco
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
| | - Edward Warren
- Division of Pulmonary, Critical Care, and Sleep Medicine, The MetroHealth System, Cleveland, OH, USA
| | - J. Daryl Thornton
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, The MetroHealth System, Cleveland, OH, USA
- Center for Reducing Health Disparities, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, USA
| | - Yasir Tarabichi
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
- The Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, The MetroHealth System, Cleveland, OH, USA
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Metting EI, in ’t Veen JC, Dekhuijzen PR, van Heijst E, Kocks JW, Muilwijk-Kroes JB, Chavannes NH, van der Molen T. Development of a diagnostic decision tree for obstructive pulmonary diseases based on real-life data. ERJ Open Res 2016; 2:00077-2015. [PMID: 27730177 PMCID: PMC5005160 DOI: 10.1183/23120541.00077-2015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 11/21/2015] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to develop and explore the diagnostic accuracy of a decision tree derived from a large real-life primary care population. Data from 9297 primary care patients (45% male, mean age 53±17 years) with suspicion of an obstructive pulmonary disease was derived from an asthma/chronic obstructive pulmonary disease (COPD) service where patients were assessed using spirometry, the Asthma Control Questionnaire, the Clinical COPD Questionnaire, history data and medication use. All patients were diagnosed through the Internet by a pulmonologist. The Chi-squared Automatic Interaction Detection method was used to build the decision tree. The tree was externally validated in another real-life primary care population (n=3215). Our tree correctly diagnosed 79% of the asthma patients, 85% of the COPD patients and 32% of the asthma-COPD overlap syndrome (ACOS) patients. External validation showed a comparable pattern (correct: asthma 78%, COPD 83%, ACOS 24%). Our decision tree is considered to be promising because it was based on real-life primary care patients with a specialist's diagnosis. In most patients the diagnosis could be correctly predicted. Predicting ACOS, however, remained a challenge. The total decision tree can be implemented in computer-assisted diagnostic systems for individual patients. A simplified version of this tree can be used in daily clinical practice as a desk tool.
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Affiliation(s)
- Esther I. Metting
- Dept of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | - Janwillem W.H. Kocks
- Dept of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Niels H. Chavannes
- Leiden University Medical Center, Dept of Public Health and Primary Care, Leiden, The Netherlands
| | - Thys van der Molen
- Dept of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Lee YS, Baek S, Ko Y, Kim MY, Lee HK, Kim TB, Cho YS, Moon HB, Lee SD, Oh YM. New scoring system for the differentiation of chronic obstructive pulmonary disease and asthma. Respirology 2015; 20:626-32. [PMID: 25823440 DOI: 10.1111/resp.12511] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 11/03/2014] [Accepted: 01/18/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE It remains difficult to differentiate between chronic obstructive pulmonary disease (COPD) and asthma in clinical practice, especially in a primary care setting. The purpose of this study was to develop a new scoring system for differentiating between COPD and asthma, and to evaluate its effectiveness. METHODS First, to identify important variables differentiating COPD from asthma, the data of 197 patients with COPD and 138 patients with asthma were assessed retrospectively. Secondly, a scoring system that was based on these variables was then developed, and its performance was internally validated using a bootstrapping-based method. Thirdly, the scoring system was externally validated using prospectively collected data from patients with COPD (n = 104) or asthma (n = 96). RESULTS The final scoring system was composed of the four variables: age of onset of breathlessness (<40 years, 0 points; 40-60 years, 2 points; >60 years, 4 points), continuous breathlessness (no, 0 points; yes, 1 point), diurnal variation of breathlessness (yes, 0 points; no, 1 point) and emphysematous change in chest X-ray (no, 0 points; yes, 1 point). The patients were classified by their total score into three categories: 0-2 points, probable asthma; 3-4 points, difficult-to-differentiate; 5-7 points, probable COPD. The new scoring system performed well in the external validation dataset (area under the curve, 0.86; 95% confidence interval: 0.813-0.911; P < 0.001). CONCLUSIONS The new scoring system that was developed in this study may be a useful tool for differentiating between COPD and asthma in primary care.
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Affiliation(s)
- Young Seok Lee
- Division of Pulmonary Allergy and Critical Care Medicine, Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea; Division of Pulmonology, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Wang M, Huang Y, Liang Z, Liu D, Lu Y, Dai Y, Feng G, Wang C. Plasma miRNAs might be promising biomarkers of chronic obstructive pulmonary disease. CLINICAL RESPIRATORY JOURNAL 2014; 10:104-11. [PMID: 25102970 DOI: 10.1111/crj.12194] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 08/01/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS We previously showed that microRNAs (miRNAs) in plasma are potential biomarkers for cigarette smoking-related lung fibrosis. Here, we want to find out promising miRNAs for early detection of chronic obstructive pulmonary disease (COPD). METHODS AND RESULTS Plasma miRNAs profiling was performed in COPD patients, asthma patients, and matched healthy controls. There was a >2-fold changes for all signature miRNAs between the COPD and control samples, with P values of < 0.05. Pathway analysis, taking into account enriched target mRNAs for these signature miRNAs, was also carried out. We found seven miRNAs were special expression in the COPD patients. Furthermore, changes of miR-145-5p, miR-338-3p and miR-3620-3p were consistent with the classification of new ABCD classification of COPD. Targeted gene promising proved those miRNAs acted in inflammatory mediators, regulation of proliferation and differentiation, oxidative stress and so on. CONCLUSIONS These results suggested that plasma miRNAs could be potential specific biomarker for early detection COPD.
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Affiliation(s)
- Maoyun Wang
- Department of Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Yuchuan Huang
- Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China.,Harmful Components and Tar Reduction in Cigarette, Sichuan Key Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China
| | - Zong'an Liang
- Department of Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Liu
- Department of Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Yanrong Lu
- Department of Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Ya Dai
- Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China.,Harmful Components and Tar Reduction in Cigarette, Sichuan Key Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China
| | - Guanglin Feng
- Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China.,Harmful Components and Tar Reduction in Cigarette, Sichuan Key Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China
| | - Changguo Wang
- Toxicology Joint Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China.,Toxicology Joint Laboratory, West China Hospital, Sichuan University, Chengdu, China.,Harmful Components and Tar Reduction in Cigarette, Sichuan Key Laboratory, China Tobacco of Chuanyu Industrial Corporation, Chengdu, China
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Weiss G, Steinacher I, Lamprecht B, Schirnhofer L, Kaiser B, Sönnichsen A, Studnicka M. Detection of chronic obstructive pulmonary disease in primary care in Salzburg, Austria: findings from the real world. ACTA ACUST UNITED AC 2013; 87:136-43. [PMID: 24296512 DOI: 10.1159/000354796] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 07/22/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a major public health burden and profoundly affects individuals suffering from the disease. However, the majority of subjects with COPD are still undiagnosed. OBJECTIVES To evaluate COPD prevalence and detection strategies for COPD in the primary-care setting. METHODS The study was conducted in a random sample of general practitioner (GP) offices in Salzburg (Austria). A questionnaire and post-bronchodilator (PBD) spirometry was administered to patients aged ≥ 40 years. Nonreversible airway obstruction was considered when PBD FEV1/FVC was <0.70. Severity of spirometrically defined COPD was graded according to the GOLD recommendations. RESULTS 60 GP offices were randomly selected for study participation, however only 30 (50.0%) were willing to participate. 1,230 of 9,820 (12.52%) patients consented to the protocol. Quality of PBD spirometry was evaluated, and 882 (71.7%) met ATS/ERS quality criteria. 7.5% (95% CI: 5.7-9.4%) of the patients had COPD grade II+ (FEV1/FVC <0.7 and FEV1 <80% of predicted), but only 22.4% of them reported a prior physician's diagnosis of COPD. Similar results were seen for the 2005 Salzburg BOLD (Burden of Obstructive Lung Disease) sample with regard to COPD GOLD II+ prevalence (10.7%) and proportion of underdiagnosis (82.3%). CONCLUSION COPD in the primary-care setting is as prevalent and underdiagnosed as reported recently for the BOLD study. The surprisingly low participation rate of GPs and patients indicates that prevention of COPD is not a health priority, and that awareness for COPD has to heightened before case-finding strategies will be successful.
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Ghattas C, Dai A, Gemmel DJ, Awad MH. Over diagnosis of chronic obstructive pulmonary disease in an underserved patient population. Int J Chron Obstruct Pulmon Dis 2013; 8:545-9. [PMID: 24348030 PMCID: PMC3848507 DOI: 10.2147/copd.s45693] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction While cross-national studies have documented rates of chronic obstructive pulmonary disease
(COPD) misdiagnosis among patients in primary care, US studies are scarce. Studies investigating
diagnosis among uninsured patients are lacking. Objective The purpose of this study is to identify patients who are over diagnosed and thus, mistreated,
for COPD in a federally qualified health center. Methods A descriptive study was conducted for a retrospective cohort from February 2011 to June 2012.
Spirometry was performed by trained personnel following American Thoracic Society recommendations.
Patients were referred for spirometry to confirm previous COPD diagnosis or to assess uncontrolled
COPD symptoms. Airway obstruction was defined as a forced expiratory volume in the first second of
expiration (FEV1) to forced vital capacity ratio less than 0.7. Reversibility was defined
as a postbronchodilator increase in FEV1 greater than 200 mL and greater than 12%. Results Eighty patients treated for a previous diagnosis of COPD (n = 72) or on anticholinergic inhalers
(n = 8) with no COPD diagnosis were evaluated. The average age was 52.9 years; 71% were uninsured.
Only 17.5% (14/80) of patients reported previous spirometry. Spirometry revealed that 42.5% had no
obstruction, 22.5% had reversible obstruction, and 35% had non-reversible obstruction. Conclusion Symptoms and smoking history are insufficient to diagnose COPD. Prevalence of COPD over diagnosis
among uninsured patient populations may be higher than previously reported. Confirming previous COPD
diagnosis with spirometry is essential to avoid unnecessary and potentially harmful treatment.
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Affiliation(s)
- Christian Ghattas
- Department of Internal Medicine, St Elizabeth Health Center, Youngstown, OH, USA
| | - Allen Dai
- Northeast Ohio Medical University College of Pharmacy, Rootstown, OH, USA
| | - David J Gemmel
- Department of Medical Education and Research, St Elizabeth Health Center, Youngstown, OH, USA
| | - Magdi H Awad
- Northeast Ohio Medical University College of Pharmacy, Rootstown, OH, USA
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Koefoed MM, dePont Christensen R, Søndergaard J, Jarbøl DE. Lack of spirometry use in Danish patients initiating medication targeting obstructive lung disease. Respir Med 2012; 106:1743-8. [PMID: 23044193 DOI: 10.1016/j.rmed.2012.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 06/13/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Research indicates that a large proportion of patients using medication targeting obstructive lung disease have no history of spirometry testing. OBJECTIVE To investigate the use of spirometry when initiating pulmonary medication targeting obstructive lung disease and to explore possible patient characteristics associated with undergoing spirometry. METHODS Population-based cohort study. Three Danish National registers were linked enabling a retrieval of data on all primary and secondary healthcare services provided in the time period 2007-2010. RESULTS In 2008 a total of 40,969 patients were registered as first time users of pulmonary medication targeting obstructive lung disease. The mean age of the study cohort was 55.6 yrs (SD 18.7). Spirometry test had been performed in 20,262 (49.5%) of the study cohort in the period from 6 months before to 12 months after their first prescription. Just above one third of the cohort, 14,275 (34.8%), had undergone spirometry in the two-month period close to redemption of their first prescription. Women and patients in the oldest age categories were less likely to have spirometry performed. CONCLUSIONS Many patients initiate medication targeting obstructive pulmonary disease without having airway obstruction confirmed through spirometry. Only one third of the study cohort had a spirometry performed when initiating medication and half had still not undergone spirometry after a year. There should be an increased focus on confirming airway obstruction when initiating medication.
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Affiliation(s)
- Mette Marie Koefoed
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 1, DK-5000 Odense C, Denmark.
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