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Locke BW, Brown JP, Sundar KM. The Role of Obstructive Sleep Apnea in Hypercapnic Respiratory Failure Identified in Critical Care, Inpatient, and Outpatient Settings. Sleep Med Clin 2024; 19:339-356. [PMID: 38692757 PMCID: PMC11068091 DOI: 10.1016/j.jsmc.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
An emerging body of literature describes the prevalence and consequences of hypercapnic respiratory failure. While device qualifications, documentation practices, and previously performed clinical studies often encourage conceptualizing patients as having a single "cause" of hypercapnia, many patients encountered in practice have several contributing conditions. Physiologic and epidemiologic data suggest that sleep-disordered breathing-particularly obstructive sleep apnea (OSA)-often contributes to the development of hypercapnia. In this review, the authors summarize the frequency of contributing conditions to hypercapnic respiratory failure among patients identified in critical care, emergency, and inpatient settings with an aim toward understanding the contribution of OSA to the development of hypercapnia.
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Affiliation(s)
- Brian W Locke
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Jeanette P Brown
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Krishna M Sundar
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Cadham CJ, Oh H, Han MK, Mannino D, Cook S, Meza R, Levy DT, Sánchez-Romero LM. The prevalence and mortality risks of PRISm and COPD in the United States from NHANES 2007-2012. Respir Res 2024; 25:208. [PMID: 38750492 PMCID: PMC11096119 DOI: 10.1186/s12931-024-02841-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND We estimated the prevalence and mortality risks of preserved ratio impaired spirometry (PRISm) and chronic obstructive pulmonary disease (COPD) in the US adult population. METHODS We linked three waves of pre-bronchodilator spirometry data from the US National Health and Nutritional Examination Survey (2007-2012) with the National Death Index. The analytic sample included adults ages 20 to 79 without missing data on age, sex, height, BMI, race/ethnicity, and smoking status. We defined COPD (GOLD 1, 2, and 3-4) and PRISm using FEV1/FVC cut points by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). We compared the prevalence of GOLD stages and PRISm by covariates across the three waves. We estimated adjusted all-cause and cause-specific mortality risks by COPD stage and PRISm using all three waves combined. RESULTS Prevalence of COPD and PRISm from 2007-2012 ranged from 13.1%-14.3% and 9.6%-10.2%, respectively. We found significant differences in prevalence by sex, age, smoking status, and race/ethnicity. Males had higher rates of COPD regardless of stage, while females had higher rates of PRISm. COPD prevalence increased with age, but not PRISm, which was highest among middle-aged individuals. Compared to current and never smokers, former smokers showed lower rates of PRISm but higher rates of GOLD 1. COPD prevalence was highest among non-Hispanic White individuals, and PRISm was notably higher among non-Hispanic Black individuals (range 31.4%-37.4%). We found associations between PRISm and all-cause mortality (hazard ratio [HR]: 2.3 95% CI: 1.9-2.9) and various cause-specific deaths (HR ranges: 2.0-5.3). We also found associations between GOLD 2 (HR: 2.1, 95% CI: 1.7-2.6) or higher (HR: 4.2, 95% CI: 2.7-6.5) and all-cause mortality. Cause-specific mortality risk varied within COPD stages but typically increased with higher GOLD stage. CONCLUSIONS The prevalence of COPD and PRISm remained stable from 2007-2012. Greater attention should be paid to the potential impacts of PRISm due to its higher prevalence in minority groups and its associations with mortality across various causes including cancer.
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Affiliation(s)
- Christopher J Cadham
- School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Hayoung Oh
- Georgetown University-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - MeiLan K Han
- Division of Pulmonary and Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
| | - David Mannino
- Division of Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY, USA
- COPD Foundation, Miami, FL, USA
| | - Steven Cook
- School of Public Health, Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Rafael Meza
- BC Cancer Research Institute, Vancouver, Canada
| | - David T Levy
- Georgetown University-Lombardi Comprehensive Cancer Center, Washington, DC, USA
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Álvarez-Dobaño JM, Rodríguez-García C, Atienza G, Toubes ME, Rodríguez-Núñez N, Zamarrón C, Novo-Platas JÁ, Soto-Feijóo R, Landín E, Carreiras-Cuiña M, Martínez-Martínez HJ, Carbajales MC, Otero B, Valdés L. Analysis of the quality of e-Consultations in chronic obstructive pulmonary disease. Respir Med 2024; 222:107514. [PMID: 38171405 DOI: 10.1016/j.rmed.2023.107514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/22/2023] [Accepted: 12/25/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION The quality of e-Consultations in the COPD is unknown. The objectives of this study were (i) to evaluate the quality of referrals; (ii) to define the characteristics of patients referred from Primary Care (PC) to the Unit of Pulmonology; and (iii) to describe differences between accepted and rejected patients. METHODS A retrospective, observational study of e-Consultations requested by PC for suspected COPD throughout 2022. To quantify the quality of the e-Consultations, an arbitrary scale of 12 variables (score 0-10) was created. RESULTS In total, 384 e-Consultations were reviewed, of which 167 (43.5 %) resulted in a face-to-face visit, and 217 (56.5 %) were rejected. No differences were observed between the two types of patients, except for confirmations of diagnostic suspicion of COPD [significantly higher in accepted patients (p = 0.042)]; physical examination data of rejected patients (more data provided; p = 0.015); and lung function (significantly better in rejected patients). The mean quality of referrals was acceptable (5.6 ± 2.1 score): 121 (31.3 %) had insufficient quality; 118 (30.5 %) acceptable; 75 (19.4 %) good, and 30 (7.8 %) excellent. Quality was low in half of the variables analyzed (6/12); acceptable in 3, and good in another 3. The capacity of resolution of referrals was good (one e-Consultation) in 199 requests (66.1 %); deficient (two e-Consultations) in 72 (23.9 %), and poor (≥3 e-Consultations) in 30 (10 %). Overdiagnosis was 40.2 % (86/214 e-Consultations). The risk could be classified in 247 patients (64.3 %; 135 low-risk; 90 high-risk). CONCLUSIONS When adequate information is provided, e-Consultations help identify different levels of severity. However, the quality and capacity of resolution of referrals were suboptimal, with a high percentage of overdiagnoses.
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Affiliation(s)
- José M Álvarez-Dobaño
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Spain.
| | - Carlota Rodríguez-García
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Spain.
| | - Gerardo Atienza
- Unidad de Calidad y Seguridad Del Paciente, Subdirección de Calidad, Gerencia Área Sanitaria de Santiago de Compostela y Barbanza, Spain.
| | - María E Toubes
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Nuria Rodríguez-Núñez
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Carlos Zamarrón
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - José Ángel Novo-Platas
- Servicio de Control y Gestión, Gerencia Área Sanitaria de Santiago de Compostela y Barbanza, Spain.
| | - Roi Soto-Feijóo
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - Elisa Landín
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | - María Carreiras-Cuiña
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain.
| | | | | | | | - Luis Valdés
- Servicio de Neumología, Hospital Clínico-Universitario de Santiago, Santiago de Compostela, Spain; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Santiago de Compostela, Spain.
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Fiore M, Ricci M, Rosso A, Flacco ME, Manzoli L. Chronic Obstructive Pulmonary Disease Overdiagnosis and Overtreatment: A Meta-Analysis. J Clin Med 2023; 12:6978. [PMID: 38002593 PMCID: PMC10672453 DOI: 10.3390/jcm12226978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
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.
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Affiliation(s)
- Matteo Fiore
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
| | - Matteo Ricci
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
| | - Annalisa Rosso
- Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy; (A.R.); (M.E.F.)
| | - Maria Elena Flacco
- Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy; (A.R.); (M.E.F.)
| | - Lamberto Manzoli
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
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Zhang SJ, Qin XZ, Zhou J, He BF, Shrestha S, Zhang J, Hu WP. Adipocyte dysfunction promotes lung inflammation and aberrant repair: a potential target of COPD. Front Endocrinol (Lausanne) 2023; 14:1204744. [PMID: 37886639 PMCID: PMC10597776 DOI: 10.3389/fendo.2023.1204744] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023] Open
Abstract
Background Obesity and chronic obstructive pulmonary disease (COPD) are prevailing worldwide, bringing a heavy medical burden. Clinical and pathophysiological relationship between obesity and COPD is paradoxical and elusive. We aim to explore their inherent associations from clinical, genetic, and animal levels. Methods We performed literature review and cohort analysis of patients with COPD to compare lung function, symptom, and prognosis among different weight groups. After retrieving datasets of obesity and COPD in Gene Expression Omnibus (GEO) database, we carried out differentially expressed gene analysis, functional enrichment, protein-protein interactions network, and weighted gene co-expression network analysis. Then, we acquired paraffin-embedded lung tissues of fatty acid-binding protein 4-Cre-BMPR2fl/fl conditional knockout (CKO) mice that were characterized by adipocyte-specific knockout of bone morphogenetic protein receptor 2 (BMPR2) for staining and analysis. Results Our cohort study reports the effect of obesity on COPD is inconsistent with previous clinical studies. Lung function of overweight group was statistically superior to that of other groups. We also found that the inflammatory factors were significantly increased hub genes, and cytokine-associated pathways were enriched in white adipose tissue of patients with obesity. Similarly, injury repair-associated genes and pathways were further enhanced in the small airways of patients with COPD. CKO mice spontaneously developed lung injury, emphysema, and pulmonary vascular remodeling, along with increased infiltration of macrophages. BMPR2-defiecient adipocytes had dysregulated expression of adipocytokines. Conclusion Inflammation and abnormal repair might be potential mechanisms of the pathological association between obesity and COPD. BMPR2-associated adipocyte dysfunction promoted lung inflammation and aberrant repair, in which adipocytokines might play a role and thus could be a promising therapeutic target.
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Affiliation(s)
- Si-jin Zhang
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xian-zheng Qin
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Zhou
- Department of Hematology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Bin-feng He
- Department of Hematology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Tongji University, Shanghai, China
| | | | - Jing Zhang
- Department of Hematology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Wei-ping Hu
- Department of Hematology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Tongji University, Shanghai, China
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Caspersen NF, Søyseth V, Lyngbakken MN, Berge T, Ariansen I, Tveit A, Røsjø H, Einvik G. Treatable Traits in Misdiagnosed Chronic Obstructive Pulmonary Disease: Data from the Akershus Cardiac Examination 1950 Study. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2022; 9:165-180. [PMID: 35158418 PMCID: PMC9166336 DOI: 10.15326/jcopdf.2021.0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is often misdiagnosed. We aimed to estimate the prevalence of misdiagnosed COPD in middle-aged Norwegians, and to assess potentially treatable clinical traits in over- and undiagnosed individuals. METHODS AND FINDINGS The Akershus Cardiac Examination (ACE) 1950 Study is a population-based study of the 1950 birth cohort of Akershus county including 3706 participants aged 62-65 years at baseline. COPD was defined as a forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio < lower limit of normal (LLN). Misdiagnosed COPD was defined according to self-reported COPD. A total of 259 (7.1%) participants had spirometry confirmed COPD. Of these, only 72 (28%) reported having COPD, thus 187 (72%) were undiagnosed. A total of 92 (2.5%) of the 164 particpants who reported having COPD had an FEV1/FVC ratio ≥ LLN and were overdiagnosed. They had lower lung function, and more respiratory symptoms, self-reported asthma, eosinophils, and sleep apnea than other non-COPD participants . The main predictor of being overdiagnosed was overweight. Spirometry in participants reporting wheezing or cough and current smokers or participants with ≥20 tobacco pack-year history would have identified 85% of the undiagnosed cases. CONCLUSION Both over- and underdiagnosis of COPD is frequent. Undiagnosed individuals have better lung function and less symptoms, but similar prevalence of comorbidities and systemic inflammation. Overdiagnosed individuals have treatable traits including asthma, eosinophilic inflammation, and sleep apnea. The main predictor of being overdiagnosed was being overweight.
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Affiliation(s)
- Nina Faksvåg Caspersen
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Vidar Søyseth
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Magnus Nakrem Lyngbakken
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trygve Berge
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Inger Ariansen
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Arnljot Tveit
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Helge Røsjø
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division for Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Gunnar Einvik
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Strong J, Weems L, Burgon T, Branch J, Martin J, Paculdo D, Tamondong-Lachica D, Cruz J, Peabody J. Initiative to Improve Evidence-Based Chronic Obstructive Pulmonary Disease Hospitalist Care Using a Novel On-Line Gamification Patient Simulation Tool: A Prospective Study. Healthcare (Basel) 2021; 9:1267. [PMID: 34682947 PMCID: PMC8535603 DOI: 10.3390/healthcare9101267] [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: 08/23/2021] [Revised: 09/16/2021] [Accepted: 09/22/2021] [Indexed: 12/02/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality. Much of the disease burden comes from exacerbations requiring hospitalization. Unwarranted care variation and divergence from evidence-based COPD management guidelines among hospitalists is a leading driver of the poor outcomes and excess costs associated with COPD-related hospitalizations. We engaged with Novant Health hospitalists to determine if measurement and feedback using fixed-choice simulated patients improves evidence-based care delivery and reduces costs. We created a series of gamified acute-care COPD case simulations with real-time feedback over 16 weeks then performed a year-over-year analytic comparison of the cost, length of stay (LOS), and revisits over the six months prior to the introduction of the simulated patients, the four months while caring for the simulated patients, and the six months after. In total, 245 hospitalists from 15 facilities at Novant Health participated. At baseline, the overall quality-of-care was measured as 58.4% + 12.3%, with providers correctly identifying COPD exacerbation in 92.4% of cases but only identifying the grade and group in 61.9% and 49.5% of cases, respectively. By the study end, the quality-of-care had improved 10.5% (p < 0.001), including improvements in identifying the grade (+9.7%, p = 0.044) and group (+8.4%, p = 0.098). These improvements correlated with changes in real-world performance data, including a 19% reduction in COPD-related pharmacy costs. Overall, the annualized impact of COPD improvements led to 233 fewer inpatient days, 371 fewer revisit days, and inpatient savings totaling nearly $1 million. Engaging practicing providers with patient simulation-based serial measurements and gamified evidence-based feedback potentially reduces inpatient costs while simultaneously reducing patient LOS and revisit rates.
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Affiliation(s)
- Jodi Strong
- Novant Health, 2085 Frontis Plaza Blvd, Winston Salem, NC 27103, USA; (J.S.); (L.W.); (J.B.); (J.M.)
| | - Larry Weems
- Novant Health, 2085 Frontis Plaza Blvd, Winston Salem, NC 27103, USA; (J.S.); (L.W.); (J.B.); (J.M.)
| | - Trever Burgon
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94133, USA; (T.B.); (D.P.); (D.T.-L.); (J.C.)
| | - Jeremy Branch
- Novant Health, 2085 Frontis Plaza Blvd, Winston Salem, NC 27103, USA; (J.S.); (L.W.); (J.B.); (J.M.)
| | - Jenny Martin
- Novant Health, 2085 Frontis Plaza Blvd, Winston Salem, NC 27103, USA; (J.S.); (L.W.); (J.B.); (J.M.)
| | - David Paculdo
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94133, USA; (T.B.); (D.P.); (D.T.-L.); (J.C.)
| | - Diana Tamondong-Lachica
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94133, USA; (T.B.); (D.P.); (D.T.-L.); (J.C.)
- College of Medicine, University of the Philippines, Manila, Metro Manila 1000, Philippines
| | - Jamielyn Cruz
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94133, USA; (T.B.); (D.P.); (D.T.-L.); (J.C.)
| | - John Peabody
- QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA 94133, USA; (T.B.); (D.P.); (D.T.-L.); (J.C.)
- Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th St, San Francisco, CA 94158, USA
- Fielding School of Public Health, University of California, Los Angeles, 650 Charles E. Young Dr. South, Los Angeles, CA 90095, USA
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R Arnold N, S Wan E, Hersh CP, Schwartz A, Kinney G, Young K, Hokanson J, Regan EA, P Comellas A, Fortis S. Inhaled Medication Use in Smokers With Normal Spirometry. Respir Care 2021; 66:652-660. [PMID: 33563793 PMCID: PMC9993991 DOI: 10.4187/respcare.08016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The objective of our study was to identify variables associated with inhaled medication use in smokers with normal spirometry (GOLD-0) and to examine the association of inhaled medication use with development of exacerbations and obstructive spirometry in the future. METHODS We performed a retrospective multivariable analysis of GOLD-0 subjects identified in data from the COPDGene study to examine factors associated with medication use. Five categories were identified: (1) no medications, (2) short-acting bronchodilator, (3) long-acting bronchodilator; long-acting muscarinic antagonists and/or long-acting β agonist, (4) inhaled corticosteroids (ICS) with or without long-acting bronchodilator, and (5) dual bronchodilator with ICS. Sensitivity analysis was performed excluding subjects with history of asthma. We also evaluated whether long-acting inhaled medication use was associated with exacerbations and obstructive spirometry at the follow-up visit 5 y after enrollment. RESULTS Of 4,303 GOLD-0 subjects within the analysis, 541 of them (12.6%) received inhaled medications. Of these, 259 (6%) were using long-acting inhaled medications and 282 (6.6%) were taking short-acting bronchodilator. Female sex (odds ratio [OR] 1.47, P = .003), numerous medical comorbidities, radiographic emphysema (OR 2.22, P = .02), chronic bronchitis (OR 1.77, P < .001), dyspnea (OR 2.24, P < .001), asthma history (OR 15.56, P < .001), prior exacerbation (OR 8.45, P < .001), and 6-min walk distance (OR 0.9, P < .001) were associated with medication use. Minimal changes were noted in a sensitivity analysis. Additionally, inhaled medications were associated with increased total (incidence rate ratio 2.83, P < .001) and severe respiratory exacerbations (incidence rate ratio 3.64, P < .001) and presence of obstructive spirometry (OR 2.83, P = .002) at follow-up. CONCLUSIONS Respiratory symptoms, history of asthma, and radiographic emphysema were associated with inhaled medication use in smokers with normal spirometry. These individuals were more likely to develop obstructive spirometry, which suggests that health care providers may be able to identify obstructive lung disease prior to meeting the current criteria for COPD.
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Affiliation(s)
- Nicholas R Arnold
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | - Emily S Wan
- Channing Laboratory and Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, Massachusetts.,Jamaica Plain Campus, VA Boston Health Care System, Boston, Massachusetts
| | - Craig P Hersh
- Channing Laboratory and Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrei Schwartz
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | - Greg Kinney
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Kendra Young
- Department of Biostatistics and Informatics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - John Hokanson
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth A Regan
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado.,Department of Medicine, Division of Rheumatology, National Jewish Health, Denver, Colorado
| | - Alejandro P Comellas
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Spyridon Fortis
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa. .,Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
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Hegewald MJ. Impact of obesity on pulmonary function: current understanding and knowledge gaps. Curr Opin Pulm Med 2021; 27:132-140. [PMID: 33394747 DOI: 10.1097/mcp.0000000000000754] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Obesity is an increasing world-wide public health concern. Obesity both causes respiratory symptoms and contributes to many cardiorespiratory diseases. The effects of obesity on commonly used lung function tests are reviewed. RECENT FINDINGS The effects of obesity on lung function are attributed both to mechanical factors and to complex metabolic effects that contribute to a pro-inflammatory state. The effects of obesity on lung function correlate with BMI and correlate even better when the distribution of excess adipose tissue is taken into account, with central obesity associated with more prominent abnormalities. Obesity is associated with marked decreases in expiratory reserve volume and functional residual capacity. Total lung capacity, residual volume, and spirometry are less affected by obesity and are generally within the normal range except with severe obesity. Obesity decreases total respiratory system compliance primarily because of decreased lung compliance, with only mild effects on chest wall compliance. Obesity is associated with impaired gas transfer with decreases in oxygenation and varied but usually mild effects on diffusing capacity for carbon monoxide, while the carbon monoxide transfer coefficient is often increased. SUMMARY Obesity has significant effects on lung function. The relative contribution of the mechanical effects of obesity and the production of inflammatory cytokines by adipose tissue on lung function needs further study.
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Affiliation(s)
- Matthew J Hegewald
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray
- Division of Respiratory, Critical Care, & Occupational Pulmonary Medicine, University of Utah, Salt Lake City, Utah, USA
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Macrea M, Oczkowski S, Rochwerg B, Branson RD, Celli B, Coleman JM, Hess DR, Knight SL, Ohar JA, Orr JE, Piper AJ, Punjabi NM, Rahangdale S, Wijkstra PJ, Yim-Yeh S, Drummond MB, Owens RL. Long-Term Noninvasive Ventilation in Chronic Stable Hypercapnic Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 202:e74-e87. [PMID: 32795139 PMCID: PMC7427384 DOI: 10.1164/rccm.202006-2382st] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Noninvasive ventilation (NIV) is used for patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnia. However, evidence for clinical efficacy and optimal management of therapy is limited. Target Audience: Patients with COPD, clinicians who care for them, and policy makers. Methods: We summarized evidence addressing five PICO (patients, intervention, comparator, and outcome) questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to evaluate the certainty in evidence and generate actionable recommendations. Recommendations were formulated by a panel of pulmonary and sleep physicians, respiratory therapists, and methodologists using the Evidence-to-Decision framework. Recommendations:1) We suggest the use of nocturnal NIV in addition to usual care for patients with chronic stable hypercapnic COPD (conditional recommendation, moderate certainty); 2) we suggest that patients with chronic stable hypercapnic COPD undergo screening for obstructive sleep apnea before initiation of long-term NIV (conditional recommendation, very low certainty); 3) we suggest not initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure, favoring instead reassessment for NIV at 2–4 weeks after resolution (conditional recommendation, low certainty); 4) we suggest not using an in-laboratory overnight polysomnogram to titrate NIV in patients with chronic stable hypercapnic COPD who are initiating NIV (conditional recommendation, very low certainty); and 5) we suggest NIV with targeted normalization of PaCO2 in patients with hypercapnic COPD on long-term NIV (conditional recommendation, low certainty). Conclusions: This expert panel provides evidence-based recommendations addressing the use of NIV in patients with COPD and chronic stable hypercapnic respiratory failure.
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Griffith MF, Feemster LC, Zeliadt SB, Donovan LM, Spece LJ, Udris EM, Au DH. Overuse and Misuse of Inhaled Corticosteroids Among Veterans with COPD: a Cross-sectional Study Evaluating Targets for De-implementation. J Gen Intern Med 2020; 35:679-686. [PMID: 31713043 PMCID: PMC7080925 DOI: 10.1007/s11606-019-05461-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/20/2019] [Accepted: 09/12/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Inhaled corticosteroid (ICS) use among patients with COPD increases the risk of pneumonia and other complications. Current recommendations limit ICS use to patients with frequent or severe COPD exacerbations. However, use of ICS among patients with COPD is common and may be occurring both among those with mild disease (overuse) and those misdiagnosed with COPD (misuse). OBJECTIVE To identify patients without identifiable indication for ICS and assess patient and provider characteristics associated with potentially inappropriate to targeted in de-implementation efforts DESIGN: We performed a cross-sectional study of patients with COPD in the Veterans Affairs (VA) system with recent spirometry. PARTICIPANTS After setting an index date, we identified individuals with a clinical diagnosis of COPD who had spirometry completed in the prior 5 years. We excluded individuals with an appropriate indication for ICS based on the 2017 GOLD statement, including asthma and a recent history of frequent or severe exacerbations. MAIN MEASURES ICS use without identifiable indication KEY RESULTS: We identified 26,536 patients with COPD without an identifiable indication for ICS. Nearly ¼ of patients (n = 6330) filled ≥2 prescriptions for ICS in the year prior to the index date. We found that older age (adjusted prevalence ratio [APR] 1.06 per decade, 95% confidence interval [CI] 1.04-1.08), white race (APR 1.11, 95% CI 1.05-1.19), and more primary care visits (APR 1.05 per visit, 95% CI 1.03-1.07) were associated with increased likelihood of potentially inappropriate use. Primary care clinic complexity and provider training were not associated with ICS use. Among patients misdiagnosed with COPD, we found that 14% used ICS. CONCLUSIONS Potentially inappropriate ICS use is common among patients with and without airflow obstruction who are diagnosed with COPD. We identified patient comorbidities and patterns of healthcare utilization that increase the likelihood of ICS use that could be targeted for system-level de-implementation interventions.
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Affiliation(s)
- Matthew F Griffith
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA.
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Laura C Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Steven B Zeliadt
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Lucas M Donovan
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Laura J Spece
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Edmunds M Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
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12
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Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne ST, Wiener RS, Feemster L, Udris E, Au DH, Helfrich CD. De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives. J Gen Intern Med 2020; 35:51-56. [PMID: 31396814 PMCID: PMC6957635 DOI: 10.1007/s11606-019-05193-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/21/2018] [Accepted: 05/23/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. OBJECTIVE We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. DESIGN We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. PARTICIPANTS We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. MAIN MEASURES Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. KEY RESULTS Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. CONCLUSIONS Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.
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Affiliation(s)
- Krysttel Stryczek
- VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Colby Lea
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Chris Gillespie
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
| | - George Sayre
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | | | - Seppo T Rinne
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Laura Feemster
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Edmunds Udris
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - David H Au
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
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13
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Role of Comorbidities in Treatment and Outcomes after Chronic Obstructive Pulmonary Disease Exacerbations. Ann Am Thorac Soc 2019; 15:1033-1038. [PMID: 30079748 DOI: 10.1513/annalsats.201804-255oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Hospital readmissions are an important cause of morbidity and mortality among patients with chronic obstructive pulmonary disease (COPD). Although comorbidities are associated with outcomes in COPD, it is unknown how they affect treatment choices. OBJECTIVES We sought to examine whether comorbidity was associated with readmission, mortality, and delivery of in-hospital treatment for COPD exacerbations. METHODS We performed a cohort study of veterans hospitalized with a COPD exacerbation to six Veterans Affairs hospitals between 2005 and 2011. We collected comorbidities in the year before hospitalization. We defined our primary outcome as readmission and/or mortality within 30 days of discharge, and treatment quality as receipt of systemic corticosteroids and respiratory antibiotics during the index hospitalization. RESULTS A total of 2,391 patients were included. Each one-point increase in Charlson index was associated with greater odds of readmission or death (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.18-1.30) and reduced odds of receiving treatment with steroids and antibiotics (aOR, 0.90; 95% CI, 0.85-0.95), in adjusted analyses. Patients with comorbid congestive heart failure (aOR, 0.64; 95% CI, 0.52-0.79), coronary artery disease (aOR, 0.73; 95% CI, 0.60-0.89), and chronic kidney disease (aOR, 0.74; 95% CI, 0.55-0.99) were less likely to receive corticosteroids and antibiotic treatment than patients without those comorbidities. We did not identify any comorbidity that was associated with increased odds of receiving appropriate therapies. CONCLUSIONS Comorbidity was associated with 30-day readmission and mortality, and with delivery of fewer treatments known to be beneficial among patients with COPD exacerbation.
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14
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COPD overdiagnosis in primary care: a UK observational study of consistency of airflow obstruction. NPJ Prim Care Respir Med 2019; 29:33. [PMID: 31417094 PMCID: PMC6695394 DOI: 10.1038/s41533-019-0145-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/10/2019] [Indexed: 02/08/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is heterogeneous, but persistent airflow obstruction (AFO) is fundamental to diagnosis. We studied AFO consistency from initial diagnosis and explored factors associated with absent or inconsistent AFO. This was a retrospective observational study using patient-anonymised routine individual data in Care and Health Information Analytics (CHIA) database. Identifying a prevalent COPD cohort based on diagnostic codes in primary care records, we used serial ratios of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC%) from time of initial COPD diagnosis to assign patients to one of three AFO categories, according to whether all (persistent), some (variable) or none (absent) were <70%. We described respiratory prescriptions over 3 years (2011-2013) and used multivariable logistic regression to estimate odds of absent or variable AFO and potential predictors. We identified 14,378 patients with diagnosed COPD (mean ± SD age 68.8 ± 10.7 years), median (IQR) COPD duration of 60 (25,103) months. FEV1/FVC% was recorded in 12,491 (86.9%) patients: median (IQR) 5 (3, 7) measurements. Six thousand five hundred and fifty (52.4%) had persistent AFO, 4507 (36.1%) variable AFO and 1434 (11.5%) absent AFO. Being female, never smoking, having higher BMI or more comorbidities significantly predicted absent and variable AFO. Despite absent AFO, 57% received long-acting bronchodilators and 60% inhaled corticosteroids (50% and 49%, respectively, in those without asthma). In all, 13.1% of patients diagnosed with COPD had unrecorded FEV1/FVC%; 11.5% had absent AFO on repeated measurements, yet many received inhalers likely to be ineffective. Such prescribing is not evidence based and the true cause of symptoms may have been missed.
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15
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Bollmeier SG, Seaton TL, Prosser TR, Chou YT, Reckenberg K, Hahn B, Stanford RH, Ray R. Assessment of symptom burden and adherence to respiratory medications in individuals self-reporting a diagnosis of COPD within a community pharmacy setting. J Am Pharm Assoc (2003) 2019; 59:479-488.e1. [PMID: 31126830 DOI: 10.1016/j.japh.2019.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 03/07/2019] [Accepted: 04/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Data on symptom burden or medication adherence in patients with chronic obstructive pulmonary disease (COPD) within a community pharmacy setting are limited. This study assessed symptom burden and adherence to respiratory medications in individuals reporting COPD, chronic bronchitis, or emphysema diagnoses visiting community pharmacies. DESIGN This cross-sectional study enrolled participants visiting 35 community pharmacies in Missouri (October 2016 to April 2017). PARTICIPANTS Eligible participants (aged 40 years or more with a self-reported history of COPD, prescription for at least 1 COPD maintenance medication during the previous 12 months, and able to complete an English questionnaire) were identified from pharmacy dispensing records. MAIN OUTCOME MEASURES Participants completed a questionnaire assessing demographics, clinical characteristics, health literacy, COPD Assessment Test (CAT) modified Medical Research Council (mMRC) dyspnea scale scores, and exacerbation history. Recent spirometry data were obtained, if available, from participants' physicians. COPD was classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016 criteria. Medication adherence was assessed as proportion of days covered (PDC) from dispensing records. RESULTS Of 682 participants (mean age 63.0 years; 57% female) with available pharmacy data, 251 (36.8%) had available spirometry data. Most participants had mMRC scores ≥ 2 (60.9%) and CAT scores ≥ 10 (90.2%); 57.2% reported at least 2 moderate or 1 or more severe exacerbations within the previous 12 months. GOLD classifications varied depending on the scale used (mMRC vs. CAT); more participants were classified as group C/D than group A/B, with the highest proportion classified as group D (higher symptom burden and exacerbation risk). Mean PDC was 0.46 ± 0.37; only 28.7% of participants were adherent (PDC ≥ 80%) to at least 1 COPD maintenance medication. CONCLUSION Individuals self-reporting a COPD diagnosis receiving respiratory medications from community pharmacies in Missouri have a high symptom burden and low medication adherence. Further research should determine reasons for low adherence and ways to reduce COPD symptoms.
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16
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Abstract
RATIONALE Obesity is relatively common among individuals with chronic obstructive pulmonary disease (COPD). However, little is known about the association of obesity with severity of acute exacerbation of COPD and in-hospital mortality. OBJECTIVES To examine the association of obesity with markers of severity of acute exacerbation of COPD and in-hospital mortality. METHODS This is a population-based, retrospective cohort study using the 2012-2013 State Inpatient Databases of seven U.S. states (Arkansas, Florida, Iowa, Nebraska, New York, Utah, and Washington). We included adults (aged ≥40 yr) hospitalized for acute exacerbation of COPD. Obesity, use of noninvasive positive pressure ventilation (NIPPV), and use of invasive mechanical ventilation were determined by International Classification of Diseases, Ninth Revision codes. To examine associations between obesity and each outcome (NIPPV, invasive mechanical ventilation, hospital length of stay (LOS), and in-hospital mortality), we fit unadjusted and adjusted logistic regression models using generalized estimating equations to account for patient clustering within hospitals. We adjusted for age, sex, race/ethnicity, primary payer, median household income, patient residence, hospitalization year, chronic comorbidities, and hospital state. In the sensitivity analysis, we used stabilized inverse probability weighting to estimate the causal relation of obesity with outcomes in this observational study. RESULTS Of 187,647 patients hospitalized for an acute exacerbation of COPD, 17% were obese. Obesity was associated with increased use of both NIPPV (12.0% vs. 6.5%; adjusted odds ratio [OR] = 1.86; 95% confidence interval [CI] = 1.77-1.95; P < 0.001) and invasive mechanical ventilation (3.5% vs. 2.8%; adjusted OR = 1.13; 95% CI = 1.04-1.22; P = 0.003). Similarly, obese patients were more likely to have a hospital LOS of 4 days or longer (57.9% vs. 50.3%; adjusted OR = 1.37; 95% CI = 1.33-1.41; P < 0.001). In contrast, obesity was associated with a lower in-hospital mortality (0.9% vs. 1.4%; unadjusted OR = 0.63; 95% CI = 0.56-0.72; P < 0.001). After adjusting for potential confounders, this association was no longer statistically significant (adjusted OR = 0.86; 95% CI = 0.75-1.00; P = 0.06). Results were similar in sensitivity analyses using stabilized inverse probability weighting. CONCLUSIONS In this population-based study of adults hospitalized with an acute exacerbation of COPD, obesity was associated with increased use of noninvasive and invasive ventilation, increased hospital LOS, but was not associated with increased in-hospital mortality.
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17
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Ho T, Cusack RP, Chaudhary N, Satia I, Kurmi OP. Under- and over-diagnosis of COPD: a global perspective. Breathe (Sheff) 2019; 15:24-35. [PMID: 30838057 PMCID: PMC6395975 DOI: 10.1183/20734735.0346-2018] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Globally, chronic obstructive pulmonary disease (COPD) is the fourth major cause of mortality and morbidity and projected to rise to third within a decade as our efforts to prevent, identify, diagnose and treat patients at a global population level have been insufficient. The European Respiratory Society and American Thoracic Society, along with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document, have highlighted key pathological risk factors and suggested clinical treatment strategies in order to reduce the mortality and morbidity associated with COPD. This review focuses solely on issues related to the under- and over-diagnosis of COPD across the main geographical regions of the world and highlights some of the associated risk factors. Prevalence of COPD obtained mainly from epidemiological studies varies greatly depending on the clinical and spirometric criteria used to diagnose COPD, i.e. forced expiratory volume in 1 s to forced vital capacity ratio <0.7 or 5% below the lower limit of normal, and this subsequently affects the rates of under- and over-diagnosis. Although under-utilisation of spirometry is the major reason, additional factors such as exposure to airborne pollutants, educational level, age of patients and language barriers have been widely identified as other potential risk factors. Co-existent diseases, such as asthma, bronchiectasis, heart failure and previously treated tuberculosis, are reported to be the other determinants of under- and over-diagnosis of COPD. COPD is a major cause of morbidity and mortality, but misdiagnosis of COPD is a huge problem worldwide. Its main causes are under-utilisation of spirometry and lack of uniformity in diagnosis criteria, particularly in resource poor settings.http://ow.ly/KfP330nonkh
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Affiliation(s)
- Terence Ho
- Firestone Institute of Respiratory Health, Division of Respirology, Dept of Medicine, McMaster University, Hamilton, ON, Canada.,All authors contributed equally
| | - Ruth P Cusack
- Division of Respirology, Dept of Medicine, McMaster University, Hamilton, ON, Canada.,All authors contributed equally
| | - Nagendra Chaudhary
- Dept of Paediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal.,All authors contributed equally
| | - Imran Satia
- Division of Respirology, Dept of Medicine, McMaster University, Hamilton, ON, Canada.,All authors contributed equally
| | - Om P Kurmi
- Population Health Research Institute, Division of Respirology, Dept of Medicine, McMaster University, Hamilton, ON, Canada.,All authors contributed equally
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18
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Diab N, Gershon AS, Sin DD, Tan WC, Bourbeau J, Boulet LP, Aaron SD. Underdiagnosis and Overdiagnosis of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2018; 198:1130-1139. [DOI: 10.1164/rccm.201804-0621ci] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Nermin Diab
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrea S. Gershon
- Department of Medicine, The University of Toronto, Toronto, Ontario, Canada
| | - Don D. Sin
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wan C. Tan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean Bourbeau
- Department of Medicine, McGill University, Montreal, Quebec, Canada; and
| | | | - Shawn D. Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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19
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Pu CY, Quesada N, Nunez Lopez R, Aryal K, Tulaimat A. The clinical implications of tests confirming COPD in subjects hospitalized with exacerbations. Hosp Pract (1995) 2018; 47:59-65. [PMID: 29757037 DOI: 10.1080/21548331.2018.1475998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The diagnosis of COPD in patients hospitalized for AECOPD can be confirmed by spirometry showing obstruction or radiographs showing emphysema. The evidence for COPD is sometimes absent or contradicts this diagnosis. The inaccurate attribution of the exacerbation to COPD can lead to suboptimal care and worse outcome. OBJECTIVES We determined if the presence of tests that confirm the diagnosis of COPD has any implications on the course of the hospitalization and readmission rate. METHODS We selected subjects hospitalized between 2012 and 2014 for AECOPD. We divided them into four hierarchical, mutually exclusive groups based on the presence of tests that confirm the diagnosis of COPD: spirometry (COPDSPIRO), radiology (COPDRAD), clinical diagnosis (COPDCLIN), and no COPD by spirometry (NotCOPD). We compared the presentation, hospital course, outcome, and readmission rate between the four groups. RESULTS We identified 974 subjects: COPDSPIRO 22%, COPDRAD 24%, COPDCLIN 46% and 7% NotCOPD. The vital signs, use of respiratory support, admission to the MICU, and length of stay were similar between the groups. The age, gender, BMI, presence of comorbidities, and readmission rate were different between the groups. The NotCOPD group had the highest BMI (38 kg/m2), comorbidities, and 30-day all-cause readmission (17%). Logistic regression showed that serum creatinine and presence of any comorbidity were the independent predictors of 30-day all-cause readmission. CONCLUSION COPD was confirmed by spirometry or radiographs in half of the subjects hospitalized for AECOPD. The presence of confirmation did not influence the hospital course. The presence of confirmation was associated with different readmission rate, but was accounted for by the presence of comorbidities.
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Affiliation(s)
- Chan Yeu Pu
- a Department of Medicine , Cook County Health and Hospitals System , Chicago , Illinois , USA
| | - Nancy Quesada
- b Division of Pulmonary , Critical Care and Sleep Medicine, Cook County Health and Hospitals System , Chicago , Illinois , USA
| | - Richard Nunez Lopez
- a Department of Medicine , Cook County Health and Hospitals System , Chicago , Illinois , USA
| | - Karmapath Aryal
- a Department of Medicine , Cook County Health and Hospitals System , Chicago , Illinois , USA
| | - Aiman Tulaimat
- b Division of Pulmonary , Critical Care and Sleep Medicine, Cook County Health and Hospitals System , Chicago , Illinois , USA
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20
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Helfrich CD, Rose AJ, Hartmann CW, van Bodegom-Vos L, Graham ID, Wood SJ, Majerczyk BR, Good CB, Pogach LM, Ball SL, Au DH, Aron DC. How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution. J Eval Clin Pract 2018; 24:198-205. [PMID: 29314508 PMCID: PMC5900912 DOI: 10.1111/jep.12855] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. RESULTS We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. CONCLUSIONS By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.
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Affiliation(s)
- Christian D Helfrich
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Department of Health Services, University of Washington School of Public Health, Seattle, USA
| | - Adam J Rose
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR) Bedford VA Medical Center, Bedford, USA.,Boston University School of Public Health, Boston, USA
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Suzanne J Wood
- Graduate Program in Health Services Administration, Department of Health Sciences, School of Public Health, University of Washington, Seattle, USA
| | - Barbara R Majerczyk
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh healthcare System, Department of Veterans Affairs, Pittsburgh, USA.,Medical Advisory Panel for Pharmacy Benefits Management, Department of Veterans Affairs, Washington, USA.,University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Leonard M Pogach
- Office of Specialty Care, Veterans Health Administration, Washington, USA.,VA New Jersey Health Care System, East Orange, USA
| | - Sherry L Ball
- Louis Stokes Cleveland VA Medical Center, Department of Veterans Affairs, Cleveland, USA
| | - David H Au
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, USA
| | - David C Aron
- Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, USA.,Division of Clinical and Molecular Endocrinology and Adjunct Professor Dept. of Organizational Behavior, Weatherhead School of Management, Case Western Reserve University, Cleveland, USA
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21
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Dai J, Yang P, Cox A, Jiang G. Lung cancer and chronic obstructive pulmonary disease: From a clinical perspective. Oncotarget 2017; 8:18513-18524. [PMID: 28061470 PMCID: PMC5392346 DOI: 10.18632/oncotarget.14505] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/27/2016] [Indexed: 12/18/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) and lung cancer are devastating pulmonary diseases that commonly coexist and present a number of clinical challenges. COPD confers a higher risk for lung cancer development, but available chemopreventive measures remain rudimentary. Current studies have shown a marked benefit of cancer screening in the COPD population, although challenges remain, including the common underdiagnosis of COPD. COPD-associated lung cancer presents distinct clinical features. Treatment for lung cancer coexisting with COPD is challenging as COPD may increase postoperative morbidities and decrease survival. In this review, we outline current progress in the understanding of the clinical association between COPD and lung cancer, and suggest possible cancer prevention strategies in this patient population.
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Affiliation(s)
- Jie Dai
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, Minnesota, United States of America
| | - Angela Cox
- Department of Oncology, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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22
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Spero K, Bayasi G, Beaudry L, Barber KR, Khorfan F. Overdiagnosis of COPD in hospitalized patients. Int J Chron Obstruct Pulmon Dis 2017; 12:2417-2423. [PMID: 28860736 PMCID: PMC5565250 DOI: 10.2147/copd.s139919] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The diagnosis of chronic obstructive pulmonary disease (COPD) is usually made based on history and physical exam alone. Symptoms of dyspnea, cough, and wheeze are nonspecific and attributable to a variety of diseases. Confirmatory testing to verify the airflow obstruction is available but rarely used, which may result in substantial misdiagnoses of COPD. The aim of this study is to evaluate the use of confirmatory testing and assess the accuracy of the diagnosis. Methods From January 2011 through December 2013, 6,018 patients with COPD as a principal or leading diagnosis were admitted at a community teaching hospital. Of those, only 504 (8.4%) patients had spirometry performed during hospitalization. The studies were reviewed by two board-certified pulmonologists to verify presence of persistent airflow obstruction. Charts of these patients were then examined to determine if the spirometry results had changed the diagnosis or the treatment plan for these patients. Results Spirometry confirmed the diagnosis of COPD in 270 patients (69.2%) treated as COPD during their hospitalization. Restrictive lung disease was found to be present in 104 patients (26.6%) and normal in 16 patients (4.2%). Factors predictive of airflow obstruction included smoking status and higher pack-year history. Negative predictive factors included higher body mass index (BMI) and other medical comorbidities. These patients were significantly more likely to be misdiagnosed and mistreated as COPD. Conclusion Up to a third of patients diagnosed and treated as COPD in the hospital may be inaccurately diagnosed as COPD based on confirmatory spirometry testing. Factors contributing to the inaccuracy of diagnosis include less smoking history, high BMI, and associated comorbidities.
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Affiliation(s)
- Kerry Spero
- Department of Medical Education, Genesys Regional Medical Center, Grand Blanc
| | - Ghiath Bayasi
- Department of Pulmonary and Critical Care Medicine, Michigan State University, East Lansing
| | | | - Kimberly R Barber
- Department of Research, Genesys Regional Medical Center, Grand Blanc, MI, USA
| | - Fahim Khorfan
- Department of Pulmonary and Critical Care Medicine, Michigan State University, East Lansing
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23
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Hangaard S, Helle T, Nielsen C, Hejlesen OK. Causes of misdiagnosis of chronic obstructive pulmonary disease: A systematic scoping review. Respir Med 2017; 129:63-84. [DOI: 10.1016/j.rmed.2017.05.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 05/16/2017] [Accepted: 05/27/2017] [Indexed: 12/11/2022]
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24
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Izquierdo Alonso JL. Comorbilidades de la enfermedad pulmonar obstructiva crónica. Arch Bronconeumol 2016; 52:547-548. [DOI: 10.1016/j.arbres.2016.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 05/08/2016] [Indexed: 10/21/2022]
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25
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26
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Jalota L, Jain VV. Action plans for COPD: strategies to manage exacerbations and improve outcomes. Int J Chron Obstruct Pulmon Dis 2016; 11:1179-88. [PMID: 27330286 PMCID: PMC4898028 DOI: 10.2147/copd.s76970] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
COPD is the third-largest killer in the world, and certainly takes a toll on the health care system. Recurrent COPD exacerbations accelerate lung-function decline, worsen mortality, and consume over US$50 billion in health care spending annually. This has led to a tide of payment reforms eliciting interest in strategies reducing preventable COPD exacerbations. In this review, we analyze and discuss the evidence for COPD action plan-based self-management strategies. Although action plans may provide stabilization of acute symptomatology, there are several limitations. These include patient-centered attributes, such as comprehension and adherence, and nonadherence of health care providers to established guidelines. While no single intervention can be expected independently to translate into improved outcomes, structured together within a comprehensive integrated disease-management program, they may provide a robust paradigm.
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Affiliation(s)
- Leena Jalota
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, USA
| | - Vipul V Jain
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, USA; Chronic Lung Disease Program, UCSF-Fresno, Community Regional Medical Center, Fresno, CA, USA
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27
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Melzer AC, Feemster LC, Collins MP, Au DH. Predictors of Pharmacotherapy for Tobacco Use Among Veterans Admitted for COPD: The Role of Disparities and Tobacco Control Processes. J Gen Intern Med 2016; 31:623-9. [PMID: 26902236 PMCID: PMC4870422 DOI: 10.1007/s11606-016-3623-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/11/2015] [Accepted: 02/04/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many smokers admitted for chronic obstructive pulmonary disease (COPD) are not given smoking cessation medications at discharge. The reasons behind this are unclear, and may reflect an interplay of patient characteristics, health disparities, and the receipt of inpatient tobacco control processes. OBJECTIVES We aimed to assess potential disparities in treatment for tobacco use following discharge for COPD, examined in the context of inpatient tobacco control processes. PARTICIPANTS Smokers aged ≥ 40 years, admitted for treatment of a COPD exacerbation within the VA Veterans Integrated Service Network 20, identified using ICD-9 discharge codes and admission diagnoses from 2005-2012. MAIN MEASURES The outcome was any tobacco cessation medication dispensed within 48 hours of discharge. We assessed potential predictors administratively up to 1 year prior to admission. We created the final logistic regression model using manual model building, clustered by site. Variables with p < 0.2 in biviariate models were considered for inclusion in the final model. RESULTS We identified 1511 subjects. 16.9 % were dispensed a medication at discharge. In the adjusted model, several predictors were associated with decreased odds of receiving medications: older age (OR per year older 0.96, 95 % CI 0.95-0.98), black race (OR 0.34, 95 % CI 0.12-0.97), higher comorbidity score (OR 0.89, 95 % CI 0.82-0.96), history of psychosis (OR 0.40, 95 % CI 0.31-0.52), hypertension (OR 0.75, 95 % CI 0.62-0.90), and treatment with steroids in the past year (OR 0.80, 95 % CI 0.70-0.90). Inpatient tobacco control processes were associated with increased odds of receiving medications: documented brief counseling at discharge (OR 3.08, 95 % CI 2.02-4.68) and receipt of smoking cessation medications while inpatient (OR 5.95, 95 % CI 3.19-11.10). CONCLUSIONS Few patients were treated with tobacco cessation medications at discharge. We found evidence for disparities in treatment, but also potentially beneficial effects of inpatient tobacco control measures. Further focus should be on using novel processes of care to improve provision of medications and decrease the observed disparities.
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Affiliation(s)
- Anne C Melzer
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA.
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA.
| | - Laura C Feemster
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA
| | - Margaret P Collins
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA
| | - David H Au
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Mailstop S-152, Seattle, WA, 98108, USA
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28
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Marik PE, Chen C. The clinical characteristics and hospital and post-hospital survival of patients with the obesity hypoventilation syndrome: analysis of a large cohort. Obes Sci Pract 2016; 2:40-47. [PMID: 27812378 PMCID: PMC5067555 DOI: 10.1002/osp4.27] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/04/2015] [Accepted: 12/16/2015] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The worldwide prevalence of obesity has reached epidemic proportions. Obesity hypoventilation syndrome (OHS) is a common yet largely undiagnosed and mistreated condition that likely carries a high mortality. The aim of this study was to determine the clinical characteristics, hospital outcome, outcome following hospital discharge and predictors of death in a large cohort of patients hospitalized with OHS. OHS is an important condition as many patients with this syndrome are misdiagnosed and receive inappropriate treatment. METHODS We reviewed the electronic medical records of patients with unequivocal OHS admitted to a 525-bed tertiary-care teaching hospital over a 5-year period. Demographic and clinical data as well as hospital disposition were recorded. In order to determine the patients' post-discharge status, we linked our database to the database of death certificates of the State Registrar of Vital Records. RESULTS We identified 600 patients who met the inclusion criteria for this study. The patients' mean age was 58 ± 15 years with a mean body mass index of 48.2 ± 8.3 kg m-2; 64% were women. Thirty-seven percent had a history of diabetes and 43% had been misdiagnosed as having chronic obstructive pulmonary disease, while none had been previously diagnosed with OHS. The most common admission diagnoses were respiratory failure, heart failure and sepsis. Ninety (15%) patients died during the index hospitalization. The patients' age, S-creatinine, respiratory failure, sepsis and admission to the ICU were independent predictors of hospital mortality. The hospital survivors were followed for a mean of 1,174 ± 501 d (3.2 ± 1.3 years) from the index hospitalization. On follow-up, 98 of the 510 (19%) hospital survivors died, with an overall cumulative mortality of 31.3%. The patients' age, S-creatinine and admission to the ICU were independent predictors of post-hospital mortality. CONCLUSION Obesity hypoventilation syndrome is a common disease that is frequently misdiagnosed and mistreated and carries a 3-year morality, which is significantly worse than that for most cancers combined. Considering the high mortality of this disease, all patients with a body mass index > 35 kg m-2 should be screened for OHS; those patients with both early and established OHS should be referred to a pulmonary and/or sleep specialist for evaluation for non-invasive positive pressure ventilation, to a dietician for dietary counseling and lifestyle modification and to a bariatric surgeon for evaluation for bariatric surgery.
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Affiliation(s)
- P E Marik
- Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School Norfolk VA USA
| | - C Chen
- Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School Norfolk VA USA
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29
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Fernández-Villar A, López-Campos JL, Represas Represas C, Marín Barrera L, Leiro Fernández V, López Ramírez C, Casamor R. Factors associated with inadequate diagnosis of COPD: On-Sint cohort analysis. Int J Chron Obstruct Pulmon Dis 2015; 10:961-7. [PMID: 26028969 PMCID: PMC4441359 DOI: 10.2147/copd.s79547] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the frequency of inadequate diagnosis and factors predictive of this in patients with chronic obstructive pulmonary disease (COPD) participating in the On-Sint study. METHODS The On-Sint cohort was recruited for a multicenter observational study in which 356 physicians (71.6% from primary care) included adult patients who had been diagnosed with COPD. Patients' clinical and functional information since diagnosis and details for the recruiting physicians were collected from patient files and at the inclusion visit. We performed a multivariate analysis to evaluate the influence of these variables on diagnostic inadequacy (absence of postbronchodilator forced expiratory volume in one second/forced vital capacity [FEV1/FVC] <0.70 or, if this value was missing, prebronchodilator FEV1/FVC <0.70). RESULTS In total, 1,214 patients were included in the study. The patients had a mean age of 66.4±9.7 years and 78.8% were male. In total, 51.3% of patients did not have an obstructive spirometry performed, and 21.4% had a normal or non-obstructive spirometry pattern. Patient-related factors associated with inadequate diagnosis were: years since diagnosis (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05), number of exacerbations in the previous year (OR 1.01, 95% CI 1.01-1.02), comorbidities (OR 1.05, 95% CI 1.01-1.015), and obesity (OR 1.06, 95% CI 1.02-1.10 per kg/m(2) of body mass index), while a longer smoking history (OR 0.98, 95% CI 0.97-0.99 for each pack/year) and short-acting or long-acting bronchodilator therapy (OR 0.61, 95% CI 0.44-0.76 and OR 0.46, 95% CI 0.27-0.76, respectively) were inversely related. With regard to physician-related variables, being followed up by primary care physicians (OR 3.0, 95% CI 2.11-4.34) and in rural centers (OR 1.63, 95% CI 1.12-2.38) were positively associated with an inadequate diagnosis, while having regular follow-ups in the most severe cases (OR 0.66, 95% CI 0.46-0.93) and use of quality of life questionnaires (OR 0.55, 95% CI 0.40-0.76) were negatively associated. CONCLUSION Diagnosis of COPD was inadequate in half of the patients from the On-Sint cohort. There were multiple factors, both patient-related and physician-related, associated with this misdiagnosis.
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Affiliation(s)
- Alberto Fernández-Villar
- Department of Pneumology, Complexo Hospitalario de Vigo, Instituto de Investigación Biomédica de Vigo, Vigo, Spain
| | - José Luis López-Campos
- Medical-Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain ; Centro de Investigación Biomédica en Red de Respiratorio, Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Represas Represas
- Department of Pneumology, Complexo Hospitalario de Vigo, Instituto de Investigación Biomédica de Vigo, Vigo, Spain
| | - Lucía Marín Barrera
- Centro de Investigación Biomédica en Red de Respiratorio, Instituto de Salud Carlos III, Madrid, Spain
| | - Virginia Leiro Fernández
- Department of Pneumology, Complexo Hospitalario de Vigo, Instituto de Investigación Biomédica de Vigo, Vigo, Spain
| | - Cecilia López Ramírez
- Centro de Investigación Biomédica en Red de Respiratorio, Instituto de Salud Carlos III, Madrid, Spain
| | - Ricard Casamor
- Medical Department, Novartis Farmacéutica, Barcelona, Spain
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Misdiagnosis Among Frequent Exacerbators of Clinically Diagnosed Asthma and COPD in Absence of Confirmation of Airflow Obstruction. Lung 2015; 193:505-12. [PMID: 25921015 DOI: 10.1007/s00408-015-9734-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
Abstract
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.
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31
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Franssen FME. Overweight and obesity are risk factors for COPD misdiagnosis and overtreatment. Chest 2015; 146:1426-1428. [PMID: 25451339 DOI: 10.1378/chest.14-1308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Frits M E Franssen
- CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands.
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