Why is spirometry underused in the diagnosis of the breathless patient: a qualitative study

Chronic Obstructive Pulmonary Disease Overdiagnosis and Overtreatment: A Meta-Analysis

This meta-analysis of observational studies aimed at estimating the overall prevalence of overdiagnosis and overtreatment in subjects with a clinical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). MedLine, Scopus, Embase and Cochrane databases were searched, and random-effect meta-analyses of proportions were stratified by spirometry criteria (Global Initiative for COPD (GOLD) or Lower Limit of Normal (LLN)), and setting (hospital or primary care). Forty-two studies were included. Combining the data from 39 datasets, including a total of 23,765 subjects, the pooled prevalence of COPD overdiagnosis, according to the GOLD definition, was 42.0% (95% Confidence Interval (CI): 37.3-46.8%). The pooled prevalence according to the LLN definition was 48.2% (40.6-55.9%). The overdiagnosis rate was higher in primary care than in hospital settings. Fourteen studies, including a total of 8183 individuals, were included in the meta-analysis estimating the prevalence of COPD overtreatment. The pooled rates of overtreatment according to GOLD and LLN definitions were 57.1% (40.9-72.6%) and 36.3% (17.8-57.2%), respectively. When spirometry is not used, a large proportion of patients are erroneously diagnosed with COPD. Approximately half of them are also incorrectly treated, with potential adverse effects and a massive inefficiency of resources allocation. Strategies to increase the compliance to current guidelines on COPD diagnosis are urgently needed.

Spirometry in atrial fibrillation: what's the catch?

INTRODUCTION

People with COPD rarely have COPD alone, and the commonest co-morbidities occurring with COPD are cardiovascular. Whilst multiple studies have explored the association between major cardiovascular events and COPD, less attention has been paid to arrhythmias, specifically atrial fibrillation (AF). AF and COPD frequently occur together, posing challenges in diagnosis and management. In this review, we describe the relationship between AF and COPD epidemiologically and physiologically, demonstrating the role of spirometry as a diagnostic and disease management tool.

AREAS COVERED

We provide epidemiological evidence that COPD and AF are independent risk factors for one another, that either disease is highly prevalent amongst people with the other, and that they have shared risk factors; all of which contribute to adverse prognostic. We elucidated common pathophysiological mechanisms implicated in AF-COPD. We ultimately present the epidemiological and physiological evidence with a view to highlight specific areas where we feel spirometry is of value in the management of AF-COPD.

EXPERT OPINION

AF and COPD commonly co-occur, there is often diagnostic delay, increased risk of reduced cardioversion success, and missed opportunity to intervene to reduce stroke risk. Greater awareness and timelier diagnosis and guideline directed management may improve outcomes for people with both diseases.

Inhaled Medications in Chronic Respiratory Diseases: Analysis of Real-Life Use in Puglia (Apulia), Italy

BACKGROUND

Chronic respiratory diseases (CRDs) are common diseases with a heterogeneous distribution worldwide. Due to their impact on disability, weight assistance and pharmaceutical spending, they represent an important global burden for national health systems. However, few studies have investigated the use and consumption of inhaled drugs in real life in patients with CRDs.

OBJECTIVE

This study aimed to investigate the real-life consumption of health care resources of main CRDs through an analysis of the administrative databases of the local health authority (ASL) in the Puglia region (Italy).

METHODS

The present study is an observational study that longitudinally reviewed the administrative and health databases associated with patients' consumption of health resources between 2017 and 2018.

RESULTS

The first important finding is a marked underestimation of the true incidence of CRDs despite the search for disease-specific exemption codes. Another important result is that the real-life consumption of inhaled drugs among these patients is well below the minimum acceptable values for adherence. The most commonly used inhaled drugs, for which at least one pack was withdrawn, were inhaled steroids (61.6%), followed by the ICS/LABA combination (43.7%) and LABAs (32.4%). However, less than one-third of patients (31%) withdrew at least three packages of ICS or ICS/LABA during the year, while the percentage was reduced to less than 15% for other combinations. Another alarming finding is that only 8.4% of patients taking CRDs drugs reported at least one spirometry during the study period.

CONCLUSIONS

The wide availability of computerized systems may be an important tool for increasing therapeutic adherence and optimizing the resources of health systems in the diagnosis, treatment and management of patients with CRDs.

Ever Smoking is Not Associated with Performed Spirometry while Occupational Exposure and Respiratory Symptoms are

Objective

Despite recommendations, assessment using spirometry or peak expiratory flow is insufficient in the clinical evaluation of suspected obstructive pulmonary disease. The aim was to investigate factors associated with performing spirometry or peak flow expiratory flow assessment.

Methods

Randomly selected subjects from the general population aged 50-65 completed a respiratory questionnaire with items about the history of previously performed spirometry or peak expiratory flow. The association between ever having had spirometry or peak expiratory flow performed was analyzed for smoking, age, sex, occupational exposures, dyspnea, wheeze, self-reported physician diagnosed asthma and COPD using multivariable logistic regression models. The results are presented as odds ratios (OR) with 95% confidence intervals (95% CIs).

Results

Of the 1105 participants, 43.4% (n=479) had a history of previously performed spirometry or peak expiratory flow. Occupational exposure (OR 1.72, [95% CI] 1.30-2.27), wheeze (OR 2.29, 1.41-3.70), and dyspnea (OR 1.70, 1.11-2.60) were associated with previously performed spirometry. Compared to men, women had spirometry or peak expiratory flow performed less often (OR 0.67, 0.51-0.86). Neither current smoking (OR 0.83, 0.57-1.20) or former smoking (OR 1.27, 0.96-1.67) were associated with performed spirometry or peak expiratory flow.

Conclusion

We found no relation between smoking status and a history of previously performed spirometry or peak expiratory flow in a population-based sample of middle-aged people. This is surprising regarding the strong guidelines which highlight the importance for spirometry surveillance on current smokers due to their increased risk of lung disease. Male sex, respiratory symptoms and occupational exposures to air pollution were associated with previously performed spirometry or peak expiratory flow. The association with occupational exposure may be an effect of pre-employment screening and workplace surveillance, and the findings indicate that females do not receive the same attention regarding spirometry or peak expiratory flow.

Guideline based knowledge and practice of physicians in the management of COPD in a low- to middle-income country

Background

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death, with 80% of the total death occurring in low‐ to middle‐income countries (LMICs). Nepal is one of the LMIC; COPD is a highly prevalent and significant public health issue often underdiagnosed. Medical physicians' good knowledge and practice to diagnose and treat COPD can help reduce the disease burden.

Objectives

To determine the level of knowledge, practice and factors influencing the practice of physicians regarding COPD management based on GOLD guidelines.

Design

A cross‐sectional descriptive study using a structured questionnaire was conducted among medical physicians working in Bagmati and Gandaki province of Nepal. Out of total scores, physicians knowledge and practice were graded according to Bloom's original cut‐off point for good (≥80%), satisfactory (60%–78%) and poor (<60%).

Result

A total of 152 medical physicians participated in this study. Out of the possible total score 20, the mean score on knowledge was 17.8 ± 2.4, and out of possible total score eight, the mean score on practice was 5.3 ± 1.3. The correlation test between total knowledge and practice scores showed r = 0.18 and p value <0.02. The most selected factors hindering the appropriate management of COPD was lack of patient follow up and lack of professional training in COPD. Other factors included patient unwillingness to discuss smoking quit plan, lack of screening tool, unavailability of spirometry and physician unawareness of available medicine to treat COPD.

Conclusion

Despite physicians having good knowledge in COPD, the practice in COPD management is below guideline‐recommended. There is a significant, very low positive correlation between total knowledge score and practice score. Proper COPD training to physicians, disease awareness among patients, easy availability of diagnostic equipment and medication can help improve physicians' practice and appropriately manage COPD patients.

Diagnostic approach to chronic dyspnoea in adults

Chronic dyspnoea, or breathlessness for more than four weeks duration, is a common symptom in adults presenting to primary and tertiary care. It often presents a diagnostic challenge due to the wide spectrum of underlying disease, which is multifactorial in approximately one third of cases. Challenges in diagnosis include an often non-diagnostic clinical assessment, difficulty in selecting the most appropriate investigations and correct speciality referral for further diagnostic assessment. In patients presenting with chronic dyspnoea, history and physical examination are often non-specific with key findings more useful as negative predictive factors. There is a broad range of simple to specialised investigations that may be utilised in the diagnostic workup. Several diagnostic algorithms incorporating different tiers of investigations have been tested in studies of chronic dyspnoea patients but there is currently very limited data that test a diagnostic algorithm against standard clinical care. In this review we propose a diagnostic pathway with primary, secondary and tertiary level investigations for patients with chronic dyspnoea. This pathway is based on the combination of previously tested diagnostic algorithms in the literature, to assist clinicians in their diagnostic workup of chronic dyspnoea patients. Further research is needed to further evaluate diagnostic algorithms in this setting and to test this diagnostic pathway in clinical practice.

Spirometry in patients screened for coronary artery disease: is it useful?

Objective:

To determine the prevalence of spirometric abnormalities in patients screened for coronary artery disease (CAD) and the risk factors for lung function impairment.

Methods:

Patients referred for cardiac CT underwent spirometry and were subsequently divided into two groups, namely normal lung function and abnormal lung function. The prevalence of spirometric abnormalities was calculated for the following subgroups of patients: smokers, patients with metabolic syndrome, elderly patients, and patients with obstructive coronary lesions. All groups and subgroups were compared in terms of the coronary artery calcium score and the Duke CAD severity index.

Results:

A total of 205 patients completed the study. Of those, 147 (72%) had normal lung function and 58 (28%) had abnormal lung function. The median coronary artery calcium score was 1 for the patients with normal lung function and 36 for those with abnormal lung function (p = 0.01). The mean Duke CAD severity index was 15 for the former and 27 for the latter (p < 0.01). Being a smoker was associated with the highest OR for abnormal lung function, followed by being over 65 years of age and having obstructive coronary lesions.

Conclusions:

The prevalence of spirometric abnormalities appears to be high in patients undergoing cardiac CT for CAD screening. Smokers, elderly individuals, and patients with CAD are at an increased risk of lung function abnormalities and therefore should undergo spirometry. (ClinicalTrials.gov identifier: NCT01734629 [http://www.clinicaltrials.gov/])

Quantitative determination of potential urine biomarkers of respiratory illnesses using new targeted metabolomic approach

The diagnosis of asthma and chronic obstructive pulmonary disease (COPD) can be challenging due to the overlap in their clinical presentations in some patients. There is a need for a more objective clinical test that can be routinely used in primary care settings. Through an untargeted ¹H NMR urine metabolomic approach, we identified a set of endogenous metabolites as potential biomarkers for the differentiation of asthma and COPD. A subset of these potential biomarkers contains 7 highly polar metabolites of diverse physicochemical properties. To the best of our knowledge, there is no liquid chromatography-tandem mass spectrometry (LC-MS/MS) method that evaluated more than two of the target metabolites in a single analytical run. The target metabolites belong to the families of monosaccharides, organic acids, amino acids, quaternary ammonium compounds and nucleic acids, rendering hydrophilic interaction liquid chromatography (HILIC) an ideal technology for their quantification. Since a clinical decision is to be made from patients data, a fully validated analytical method is required for biomarker validation. Method validation for endogenous metabolites is a daunting task since current guidelines were designed for exogenous compounds. As such, innovative approaches were adopted to meet the validation requirements. Herein, we describe a sensitive HILIC-MS/MS method for the quantification of the 7 endogenous urinary metabolites. Detection was achieved in the multiple reaction monitoring (MRM) mode with polarity switching, using quadrupole-linear ion trap instrument (QTRAP 6500) as well as single ion monitoring in the negative-ion mode. The method was fully validated according to the regulatory guidelines. Linearity was established between 6 and 21000 ng/mL and quality control samples demonstrated acceptable intra- and inter-day accuracy (85.7%-112%), intra- and inter-day precision (CV% <11.5%) as well as stability under various storage and sample processing conditions. To illustrate the method's applicability, the validated method was applied to the analysis of a small set of urine samples collected from asthma and COPD patients. Preliminary modelling of separation was generated using partial least square discriminant analysis (R² 0.752 and Q² 0.57). The adequate separation between patient samples confirms the diagnostic potential of these target metabolites as a proof-of-concept for the differentiation between asthma and COPD. However, more patient urine samples are needed in order to increase the statistical power of the analytical model.

Misdiagnosis of asthma and COPD and underuse of spirometry in primary care unselected patients

BACKGROUND

The diagnosis of both asthma and chronic obstructive pulmonary disease (COPD) consists of a combination of classical symptoms and signs, and the evidence of consistent lung function abnormalities. Spiromety has been reported to be underused, possibly for practical difficulties in accessing to a lung function lab. This may lead to misdiagnosis of both asthma and COPD. We aimed to evaluate the frequency of spirometry use and the concordance between doctor-diagnosed asthma and COPD and spirometric patterns, in an unselected cohort of patients sent by general practitioners to perform a spirometry.

METHODS

The first 300 patients consecutively enrolled patients performed spirometry and bronchodilator test with salbutamol 400 mcg. Demographic, clinical and lung function data have been collected.

RESULTS

128 patients (42.7%) declared a doctor-diagnosed asthma and 75 (25%) a doctor-diagnosis of COPD; the remaining subjects never had received any respiratory diagnosis. Only 112 patients with doctor-diagnosed asthma (55.2%) and 114 (56.2%) with doctor-diagnosed COPD have ever performed a spirometry in their entire life (average time since the last spirometry was about 47.0 months). Eighty-nine (69.5%) and 10 (13.3%) patients with respectively doctor-diagnosed asthma and COPD had concordant spirometric patterns with their known diseases.

DISCUSSION

we described a worrying lack of use of spirometry and a high proportion of misdiagnosis, in patients with suspect chronic airway inflammatory diseases and cared by primary care physicians. Novel strategies to overcome this situation include should be implemented to give a better care to our patients.

Spirometry in Asthma Care: A Review of the Trends and Challenges in Pediatric Practice

BACKGROUND

Given the rising incidence of noncommunicable diseases (NCDs) globally, especially bronchial asthma, there is the need to reduce the associated morbidity and mortality by adopting an objective means of diagnosis and monitoring.

AIM

This article aims to review the trends and challenges in the use of spirometry for managing childhood bronchial asthma especially in developing countries.

METHODS

We conducted a literature search of published data on the use of spirometry for the diagnosis of childhood bronchial asthma with special emphasis resource-poor countries.

RESULTS

Guidelines for the diagnosis and treatment of childhood asthma recommend the use of spirometry, but this is currently underused in both tertiary and primary care settings especially in developing countries. Lack of spirometers and proper training in their use and interpretation of findings as well as a dearth of asthma guidelines remains core to the underuse of spirometry in managing children with asthma. Targeting education of health care staff was, however, observed to improve its utility, and practical implementable strategies are highlighted.

CONCLUSIONS

Spirometry is not frequently used for asthma diagnosis in pediatric practice especially in resource-poor countries where the NCD burden is higher. Strategies to overcome the obstacles are implementable and can make a difference in reducing the burden of NCD.

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background

Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings.

Objectives

Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.

Review methods

We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.

Results

We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.

Conclusions

In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.

Limitations

We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.

Future work

There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A summary of the new GINA strategy: a roadmap to asthma control

Over the past 20 years, the Global Initiative for Asthma (GINA) has regularly published and annually updated a global strategy for asthma management and prevention that has formed the basis for many national guidelines. However, uptake of existing guidelines is poor. A major revision of the GINA report was published in 2014, and updated in 2015, reflecting an evolving understanding of heterogeneous airways disease, a broader evidence base, increasing interest in targeted treatment, and evidence about effective implementation approaches. During development of the report, the clinical utility of recommendations and strategies for their practical implementation were considered in parallel with the scientific evidence.This article provides a summary of key changes in the GINA report, and their rationale. The changes include a revised asthma definition; tools for assessing symptom control and risk factors for adverse outcomes; expanded indications for inhaled corticosteroid therapy; a framework for targeted treatment based on phenotype, modifiable risk factors, patient preference, and practical issues; optimisation of medication effectiveness by addressing inhaler technique and adherence; revised recommendations about written asthma action plans; diagnosis and initial treatment of the asthma-chronic obstructive pulmonary disease overlap syndrome; diagnosis in wheezing pre-school children; and updated strategies for adaptation and implementation of GINA recommendations.

The reliability and utility of spirometry performed on people with asthma in community pharmacies

OBJECTIVE

To investigate the reliability and the utility of spirometry generated by community pharmacists participating in two large asthma intervention trials of 892 people.

METHODS

The Pharmacy Asthma Care Program (PACP) and the Pharmacy Asthma Management Service (PAMS) involved up to four visits to the pharmacy over 6 months for counseling and goal setting. Pharmacists performed spirometry according to ATS/ERS guidelines to inform management. The proportion of A-E, F quality tests, as per EasyOne QC grades, were recorded. Lung function results between visits and for participants referred/not referred to their general practitioner on the basis of spirometry were compared.

RESULTS

Complete data from 2593 spirometry sessions were recorded, 68.5% of spirometry sessions achieved three acceptable tests with between-test repeatability of 150 ml or less (A or B quality), 96% of spirometry sessions included at least one test that met ATS/ERS acceptability criteria. About 39.1% of participants had FEV1/FVC values below the lower limit of normal (LNN), indicating a respiratory obstruction. As a result of the service, there was a significant increase in FEV1 and FEV1/FVC and asthma control. Lung function values were significantly poorer for participants referred to their general practitioner, compared with those not referred, on the basis of spirometry.

CONCLUSIONS

Community pharmacists are able to reliably achieve spirometry results meeting ATS/ERS guidelines in people with asthma. Significant improvements in airway obstruction were demonstrated with the pharmacy services. Pharmacists interpreted lung function results to identify airway obstruction for referral, making this a useful technique for review of people with asthma in the community.

Misdiagnosis Among Frequent Exacerbators of Clinically Diagnosed Asthma and COPD in Absence of Confirmation of Airflow Obstruction

PURPOSE

Clinical diagnosis of severe asthma and chronic obstructive lung disease (COPD) remains a challenge and often flawed with lack of objective confirmation of airflow obstruction (AO). Misdiagnosis of asthma and COPD has been reported in stable disease, data are non-existent in frequent exacerbators. We investigated misdiagnosis and its predictors in frequent exacerbators.

METHODS

The cohort comprised of frequent severe exacerbators (requiring ≥2 emergency room (ER) visits or hospitalizations) of physician diagnosed (PD)-asthma and PD-COPD. All patients underwent a rigorous diagnostic algorithm over a follow-up period of 10 ± 6 months. Two board-certified pulmonologists ascertained final diagnosis. Patients with persistent absence of AO were identified to have misdiagnosis. Multivariate logistic regression analyses were used to identify predictors of misdiagnoses.

RESULTS

Among 333 frequent exacerbators analyzed (171 patients with PD-asthma, 162 with PD-COPD, mean annual exacerbations 3.4 ± 2.8), 24 % of patients had a baseline post-bronchodilator spirometry. Misdiagnosis was found in 26 % (87 of 333) of patients. Another 12 % (41 of 333) of patients had obstructive lung diseases other than asthma and COPD. Independent risk factors for misdiagnosis were spirometry underutilization (PD-asthma: OR = 2.8, 95 % CI 1.16-6.78, p = 0.02 and PD-COPD: OR = 10.7, 95 % CI 2.05-56.27, p = 0.005) and pack years of smoking (PD-COPD: OR = 1.05, 95 % CI 1.01-1.11, p = 0.03).

CONCLUSIONS

Objective confirmation of AO is essential in preventing misdiagnosis in frequent severe exacerbators of clinically diagnosed asthma and COPD, a third of whom have neither. Spirometry utilization is strongly associated with a reduced risk of misdiagnosis. Smoking is associated with increased risk of misdiagnosis in severe COPD, but not asthma.

Depression's influence on the Asthma Control Test, Japanese version

BACKGROUND

Depression has been linked to poorer asthma control in asthmatic patients. Although the Japanese version of the Asthma Control Test (ACT-J) is frequently used as a simple, practical evaluation tool in clinical care settings in Japan, knowledge regarding its efficacy for assessing asthma control in asthmatic patients with depression is limited. Thus, we retrospectively investigated cut-off values of the ACT-J for well-controlled asthma, and explored depression's influence on the test with a questionnaire survey.

METHODS

Data were analyzed on 1,962 adult asthmatic patients who had completed both the ACT-J and the Japanese version of the Patient Health Questionnaire-9 (J-PHQ-9) in 2008 questionnaire survey conducted by the Niigata Asthma Treatment Study Group. Patients were classified into low (LD: J-PHQ-9 score of 0-4) or high depression (HD: J-PHQ-9 score of 5-27) groups. In both groups, the efficacy of the ACT-J was confirmed. We then compared the optimal cut-off points for uncontrolled asthma in both groups by performing a receiver operating characteristic (ROC) analysis, using the original classification referred to the GINA classification as the "true" classification.

RESULTS

Cronbach's alpha in the LD and HD group was 0.808 and 0.740 respectively. In both groups, the sub-group with existence of work absenteeism or frequent attacks during the previous 12 months scored lower on the ACT-J. The area under the curve and optimal cut-off point for patients with LD and HD were 0.821 and 0.846, and 23 and 20 respectively.

CONCLUSIONS

The efficacy of the ACT-J was confirmed in depressive patients with asthma. Because asthma control as evaluated with the ACT-J can be worse than actual control under depressive states, physicians should also pay attention to a patient's depressive state at evaluation. Further investigations focus on the association between the ACT-J and depression are required.

Accuracy of diagnosis and classification of COPD in primary and specialist nurse-led respiratory care in Rotherham, UK: a cross-sectional study

BACKGROUND

Studies have suggested that chronic obstructive pulmonary disease (COPD) is commonly misdiagnosed and misclassified in primary care, but less is known about the quality of diagnosis in specialist respiratory care.

AIMS

To measure the accuracy of COPD diagnosis and classification of airway obstruction in primary care and at a specialist respiratory centre, and to explore associations between misdiagnosis and misclassification and a range of explanatory factors.

METHODS

Data were obtained for 1,205 referrals to a specialist respiratory centre between 2007 and 2010. Standard analysis methods were used.

RESULTS

The majority of patients were referred for pulmonary rehabilitation (676/1,205, 56%). Of 1,044 patients with a primary care diagnosis of COPD, 211 (20%) had spirometry inconsistent with COPD. In comparison, of 993 specialist centre diagnoses, 65 (6.5%) had inconsistent spirometry. There was poor agreement between the airflow obstruction grade recorded on the referral and that based on spirometry (kappa=0.26, n=448), whereas agreement between the respiratory centre assessment of airflow obstruction and spirometry was good (kappa=0.88, n=1,016). Referral by practice nurse was associated with accuracy of airflow obstruction classification in primary care (OR 1.85, 95% CI 1.33 to 2.57). Males were more likely than females to have an accurate specialist care classification of airway obstruction (OR 1.40, 95% CI 1.01 to 1.93). Grade of airway obstruction changed between referral and assessment in 56% of cases.

CONCLUSIONS

In primary care, a proportion of patients diagnosed with COPD do not have COPD, and misclassification of grade of airflow obstruction is common. Misdiagnosis and misclassification is less common in the specialist care setting of BreathingSpace.

General practice variation in spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease in Denmark: a population-based observational study

Background

Spirometry testing is essential to confirm an obstructive lung disease, but studies have reported that a large proportion of patients diagnosed with COPD or asthma have no history of spirometry testing. Also, it has been shown that many patients are prescribed medication for obstructive lung disease without a relevant diagnosis or spirometry test registered. General practice characteristics have been reported to influence diagnosis and management of several chronic diseases. However, these findings are inconsistent, and it is uncertain whether practice characteristics influence spirometry testing among patients receiving medication for obstructive lung disease. The aim of this study was therefore to examine if practice characteristics are associated with spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease.

Methods

A national register-based cohort study was performed. All patients over 18 years receiving first-time prescriptions for medication targeting obstructive lung disease in 2008 were identified and detailed patient-specific data on sociodemographic status and spirometry tests were extracted. Information on practice characteristics like number of doctors, number of patients per doctor, training practice status, as well as age and gender of the general practitioners was linked to each medication user.

Results

Partnership practices had a higher odds ratio (OR) of performing spirometry compared with single-handed practices (OR 1.24, CI 1.09-1.40). We found a significant association between increasing general practitioner age and decreasing spirometry testing. This tendency was most pronounced among partnership practices, where doctors over 65 years had the lowest odds of spirometry testing (OR 0.25, CI 0.10-0.61). Training practice status was significantly associated with spirometry testing among single-handed practices (OR 1.40, CI 1.10-1.79).

Conclusion

Some of the variation in spirometry testing among patients receiving first-time prescriptions for medication targeting obstructive lung disease was associated with practice characteristics. This variation in performance may indicate a potential for quality improvement.

The Asthma Control Test, Japanese version (ACT-J) as a predictor of Global Initiative for Asthma (GINA) guideline-defined asthma control: analysis of a questionnaire-based survey

BACKGROUND

The 2006 Global Initiative for Asthma (GINA 2006) guidelines emphasize the importance of evaluating the control rather than the severity of asthma. The Asthma Control Test (ACT) is well known to be an excellent tool for evaluating asthma control in the clinical setting. This study aimed to evaluate the ACT, Japanese version (ACT-J) as a predictor of asthma control as defined by the GINA 2006 guidelines in actual clinical practice.

METHODS

A cross-sectional analysis comparing the ACT-J score and GINA classification of asthma control among 419 patients of primary care physicians and specialists was performed using the data from a 2010 questionnaire-based survey conducted by the Niigata Asthma Treatment Study Group.

RESULTS

The optimal cut-off point of the ACT-J score for predicting GINA-defined asthma control was 23, with ACT-J scores of ≥23 and ≤22 predicting controlled and uncontrolled asthma with area under the receiver operating characteristics curve values of 0.76 [95% confidence interval (CI): 0.72-0.81] and 0.93 [95% CI: 0.90-0.97], respectively.

CONCLUSIONS

ACT scores of ≥23 and ≤22 are useful for identifying patients with controlled and uncontrolled asthma, respectively, as defined by GINA 2006, and the latter is more strongly predictive than the former. The reason for the higher cut-off point of the ACT-J relative to other versions of the ACT is unclear and warrants further investigation.

Efficacy of using the Japanese version of the asthma control test for determing the level of asthma control in clinical settings

BACKGROUND

The Asthma Control Test (ACT) is frequently used for the evaluation of asthma control in clinical care setting because it does not require the use of pulmonary function tests, which can be difficult for general practitioners to use. However, few large-scale studies have investigated the efficacy of the Japanese version ACT (J-ACT) in actual use during clinical care.

METHODS

The aim of this study was to analyze the efficacy of the J-ACT in a clinical care setting. Using data from a 2008 questionnaire survey including the J-ACT by the Niigata Asthma Treatment Study Group, we compared the ACT scores of 2233 patients with respect to multiple parameters, including the severity by Japanese Society of Allergology and the attack frequency. Using the definition of asthma control partially referred to Global Initiative for Asthma (GINA) guidelines from the survey data, the accuracy screening and determination of optimal ACT cutpoints were performed by retrospective analysis.

RESULTS

Cronbach's α for the J-ACT was 0.785. Patients with more severe asthma and more frequent asthma attacks had lower ACT scores than did patients with less severe, less frequent attacks. The optimal ACT cutpoints were 24 for the controlled asthma and 20 for the uncontrolled asthma.

CONCLUSIONS

Our study, the first large-scale investigation of the efficacy of the J-ACT, determined that this evaluation tool is highly efficacious in establishing the level of asthma control. However, the determination of accurate cutpoints for the J-ACT will require more clear definitions of asthma control in future prospective studies.

A centralised respiratory diagnostic service for primary care: a 4-year audit

BACKGROUND

The literature shows that delayed or erroneous diagnosis of respiratory conditions may be common in primary care due to underuse of spirometry or poor spirometric technique. The Community Respiratory Assessment Unit (CRAU) was established to optimise diagnosis and treatment of respiratory disease by providing focused history-taking, quality-assured spirometry, and evidence-based guideline-derived management advice.

AIMS

To review the service provided by the CRAU to primary care health professionals.

METHODS

Data from 1,156 consecutive GP referrals over 4 years were analysed.

RESULTS

From the 1,156 referrals, 666 were referred for one of five common reasons: suspected asthma, confirmed asthma, suspected chronic obstructive pulmonary disease (COPD), confirmed COPD, or unexplained breathlessness. COPD was the most prevalent referral indication (445/666, 66.8%), but one-third of suggested diagnoses of COPD by the GP were found to be incorrect (161/445, 36%) with inappropriate prescribing of inhaled therapies resulting from this misdiagnosis. Restrictive pulmonary defects (56/666, 8% of referrals) were overlooked and often mistaken for obstructive conditions. The potential for obesity to cause breathlessness may not be fully appreciated.

CONCLUSIONS

Misdiagnosis has significant financial, ethical, and safety implications. This risk may be minimised by better support for primary care physicians such as diagnostic centres (CRAU) or alternative peripatetic practice-based services operating to quality-controlled standards.

Accuracy of asthma and COPD diagnosis in Australian general practice: a mixed methods study

BACKGROUND

Spirometry is the 'gold standard' for diagnosing asthma and chronic obstructive pulmonary disease (COPD) but is rarely used in general practice.

AIMS

To compare doctor diagnoses with patient reports/spirometry and to determine doctors' perceptions of spirometry.

METHODS

Patients prescribed inhaled medication were recruited from 31 practices. Doctor diagnoses were extracted from practice records. Patients completed a questionnaire and spirometry before and after bronchodilator. In-depth interviews were conducted with a sample of doctors.

RESULTS

Doctor diagnoses were available for 278 patients: asthma 192 (69%), COPD 38 (14%), asthma/COPD 40 (14%), and eight patients (3%) with other conditions. The diagnosis of asthma was correctly reported by 93% of patients, but only by 61% of those with COPD alone. Among those with both diagnoses, 83% reported asthma and 48% reported COPD. Of those with a diagnosis of COPD, 65% had fixed airflow limitation. Conversely, only 14% of those had been diagnosed with COPD alone. There was no significant difference in reversibility in forced expiratory volume in 1 second between diagnoses. While recognising the value of spirometry in differentiating between asthma and COPD, most general practices only used spirometry in diagnostically difficult cases.

CONCLUSIONS

Doctor-diagnosed asthma is accurately reported by patients. However, COPD remains substantially under-diagnosed. Spirometry needs to be more widely used to improve the accuracy of respiratory diagnoses in general practice.