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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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Annangi S, Coz-Yataco AO. Clinical Implications of Bronchodilator Testing: Diagnosing and Differentiating COPD and Asthma-COPD Overlap. Respir Care 2022; 67:440-447. [PMID: 35338095 PMCID: PMC9994008 DOI: 10.4187/respcare.09215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Bronchodilation testing is an important component of spirometry testing, and omitting this procedure has potential clinical implications toward diagnosing respiratory diseases. We aimed to estimate the impact of bronchodilator testing in accurately diagnosing COPD and differentiating COPD from asthma-COPD overlap (ACO). METHODS The National Health and Nutrition Examination Survey data were analyzed from 2007-2012. Airflow limitation was defined by FEV1/FVC < 0.7. Subjects with pre-bronchodilator airflow limitation were classified into pre-but-not-post-bronchodilator airflow limitation and post-bronchodilator airflow limitation groups. Spirometry-confirmed COPD was defined by persistent airflow limitation on post-bronchodilator spirometry. The American Thoracic Society (ATS) and the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) definitions were used to identify possible ACO subjects. RESULTS We identified 11,763 subjects ≥ 40 y of age eligible for spirometry; 625 of them had a pre-bronchodilator FEV1/FVC < 0.7 and completed post-bronchodilator spirometry that met ATS spirometry quality standards. A total of 244 (39%) of these subjects had only pre-not-post-bronchodilator airflow limitation, thereby not meeting the definition of spirometrically confirmed COPD. The prevalence of ACO was 7.6% using the modified ATS definition and 19.8% using the modified SEPAR criteria. When bronchodilator testing-based criteria were excluded from ATS and SEPAR definitions, the number of ACO subjects decreased by 39.3% and 12.3%, respectively. CONCLUSIONS Spirometry with bronchodilation is an important element in the accurate diagnosis of ACO and COPD. Spirometry performed without bronchodilator testing may lead to an estimated misclassification of ACO by 7.6% to 19.8% and overdiagnosis of COPD by 39%.
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Affiliation(s)
- Srinadh Annangi
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Kentucky College of Medicine, Lexington, Kentucky; and Division of Pulmonary and Critical Care Medicine, Harrison Memorial Hospital, Cynthiana, Kentucky.
| | - Angel O Coz-Yataco
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Kentucky College of Medicine, Lexington, Kentucky; and Division of Pulmonary and Critical Care Medicine, Harrison Memorial Hospital, Cynthiana, Kentucky
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3
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Warner JS, Bryan JM, Paulin LM. The Effect of Rurality and Poverty on COPD Outcomes in New Hampshire: An Analysis of Statewide Hospital Discharge Data. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2022; 9:500-509. [PMID: 35905747 PMCID: PMC9718582 DOI: 10.15326/jcopdf.2022.0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose Individuals in rural areas of the United States have a greater risk of chronic obstructive pulmonary disease (COPD) and have worse COPD outcomes. New Hampshire (NH) is split between non-rural and rural counties. Methods We examined differences in COPD exacerbation rates ([encounters per county/county population of 35 years of age and older] × 100), length of stay (LOS), and total charges by rurality, determined by the 2013 National Center for Health Statistics rural-urban classification. Linear regression analysis determined the association of rural status on COPD outcomes, adjusting for age, gender, insurance status, and county-level smoking prevalence. Findings A total of 15,916 encounters were analyzed, of which 5805 were inpatient and 10,111 were from the emergency department, 7058 (44%) were male, and the mean age was 65.6. A total of 31% were from large, fringe metro counties, 25.9% were from medium metro counties, 37.6% were from micropolitan counties, and 5.5% were from non-core counties. In multivariable regression, rural counties had higher COPD exacerbation rates compared to urban counties (non-core beta=0.18, [confidence interval (CI) 0.16, 0.20]; micropolitan beta=0.02, CI [0.01, 0.03]); medium metro counties (beta=-0.07, Cl [-0.09, -0.06]) had lower rates of COPD exacerbations (P < 0.001 for all). Compared to urban counties, encounters from rural counties had lower total charges (medium metro beta=-1695 [-2410, -980]; micropolitan beta=-2701 [-3315, -2088]; non-core beta=-4453 [-5646, -3260], all p<0.001). LOS did not differ by rurality. Conclusions Accounting for poverty and other sociodemographic factors, the rates of COPD exacerbation encounters were higher in rural versus non-rural NH counties. Additionally, non-rural areas carried higher total charges, potentially due to more resource availability. These results support the need for future interventions to improve outcomes in rural COPD patients.
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Affiliation(s)
- Jacob S. Warner
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Jane M. Bryan
- Dartmouth College, Hanover, New Hampshire, United States
| | - Laura M. Paulin
- Department of Pulmonary and Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
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Habteslassie D, Khorramnia S, Muruganandan S, Romeo N, See K, Hannan LM. Missed diagnosis or misdiagnosis: How often do hospitalised patients with a diagnosis of chronic obstructive pulmonary disease (COPD) have spirometry that supports the diagnosis? Intern Med J 2021; 53:510-516. [PMID: 34719093 DOI: 10.1111/imj.15607] [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: 06/20/2021] [Revised: 09/30/2021] [Accepted: 10/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease is one of the most common clinical diagnoses among hospital inpatients. Diagnosis requires the demonstration of post-bronchodilator airflow obstruction. However, it is uncertain how often spirometry results are available at the time a diagnostic label of COPD is applied. AIM To identify how frequently spirometry results were available following an inpatient admission with a clinical diagnosis of COPD, and to determine how often the available spirometry results supported a clinical diagnosis of COPD. Inhaler prescription, at discharge, was also evaluated to determine one of the potential implications of diagnostic inaccuracy. METHODS A single centre retrospective observational study was undertaken at a 400-bed metropolitan health service between October 2016 and March 2018. RESULTS A total of 2239 inpatient separations occurred in 1469 individuals who had a clinical diagnosis of COPD during the study. Spirometry results were not available in 43.6% (n = 641) of those with a diagnosis of COPD. A further 19.7% (n = 289) had spirometry results available at the time of admission, that did not demonstrate fixed airflow obstruction. The available prescribing data (n = 443) demonstrated that inhaled medications were prescribed in a similar pattern, regardless of the availability of spirometry, or whether the results supported a clinical diagnosis of COPD. CONCLUSIONS Inpatients with a clinical diagnosis of COPD frequently did not have supportive spirometry results that confirmed the diagnosis or had results inconsistent with COPD. Misdiagnosis and inappropriate prescribing require further attention to improve the quality of care in this setting. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Sadie Khorramnia
- Department of Respiratory Medicine, Northern Health, Victoria, Australia
| | | | - Nicholas Romeo
- Department of Respiratory Medicine, Northern Health, Victoria, Australia
| | - Katharine See
- Department of Respiratory Medicine, Northern Health, Victoria, Australia.,Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Liam M Hannan
- Department of Respiratory Medicine, Northern Health, Victoria, Australia.,Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
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Dement JM, Cloeren M, Ringen K, Quinn P, Chen A, Cranford K, Haas S, Hines S. COPD risk among older construction workers-Updated analyses 2020. Am J Ind Med 2021; 64:462-475. [PMID: 33728649 DOI: 10.1002/ajim.23244] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/05/2021] [Accepted: 03/02/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND A 2010 study of construction workers participating in medical screening programs at the Department of Energy (DOE) nuclear facilities demonstrated increased chronic obstructive pulmonary disease (COPD) risk. The current study of a larger worker cohort allowed for a more nuanced analysis of COPD risk, including for employment beginning after the mid-1990s. METHODS Study participants included 17,941 workers with demographic and smoking data and spirometry with a minimum of three recorded expiratory efforts and reproducibility of forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1 ) of 0.2 L or less. COPD was defined as a FEV1 /FVC ratio below the lower limit of normal using established prediction equations without use of bronchodilation. Stratified analyses explored COPD prevalence by demographic variables and trade. Logistic regression analyses assessed risks by trade and time periods of trade and DOE site work, controlling for age, gender, race/ethnicity, body mass index, and smoking. RESULTS Overall COPD prevalence was 13.4% and 67.4% of cases were classified as moderate to severe. Compared to nonconstruction workers, construction trade workers were at significantly increased risk of all COPD (OR = 1.34, 95% CI = 1.29-1.79) and even more so for severe COPD (OR = 1.61, 95% CI = 1.32-1.96). The highest risk trades were cement masons/bricklayers (OR = 2.36; 95% CI = 1.71-3.26) and roofers (OR = 2.22; 95% CI = 1.48-3.32). Risk among workers employed after 1995 was elevated but not statistically significant. CONCLUSIONS Construction workers are at increased COPD risk. Results support the prevention of both smoking and occupational exposures to reduce these risks. While the number of participants employed after 1995 was small, patterns of risk were consistent with findings in the overall cohort.
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Affiliation(s)
- John M. Dement
- Division of Occupational and Environmental Medicine, Department of Family Medicine and Community Health Duke University Medical Center Durham North Carolina USA
| | - Marianne Cloeren
- Division of Occupational and Environmental Medicine, School of Medicine University of Maryland Baltimore Maryland USA
| | - Knut Ringen
- Energy Workers Department CPWR—The Center for Construction Research and Training Silver Spring Maryland USA
| | - Patricia Quinn
- Energy Workers Department CPWR—The Center for Construction Research and Training Silver Spring Maryland USA
| | - Anna Chen
- Government Services Department Zenith American Solutions Seattle Washington USA
| | - Kim Cranford
- Government Services Department Zenith American Solutions Seattle Washington USA
| | - Scott Haas
- Government Services Department Zenith American Solutions Seattle Washington USA
| | - Stella Hines
- Division of Occupational and Environmental Medicine, School of Medicine University of Maryland Baltimore Maryland 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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Petrie K, Toelle BG, Wood-Baker R, Maguire GP, James AL, Hunter M, Johns DP, Marks GB, George J, Abramson MJ. Undiagnosed and Misdiagnosed Chronic Obstructive Pulmonary Disease: Data from the BOLD Australia Study. Int J Chron Obstruct Pulmon Dis 2021; 16:467-475. [PMID: 33658776 PMCID: PMC7920499 DOI: 10.2147/copd.s287172] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/30/2020] [Indexed: 12/18/2022] Open
Abstract
Purpose Spirometry is necessary to confirm COPD, but many patients are diagnosed based on clinical presentation and/or chest x-ray. There are also those who do not present to primary care for case finding and remain undiagnosed. We aimed to identify: (a) factors that are associated with undiagnosed COPD; and (b) factors that are associated with a potential misdiagnosis of COPD. Patients and Methods This analysis used data from the Burden of Obstructive Lung Disease (BOLD), a cross-sectional study of community dwelling adults randomly selected from six study sites, chosen to provide a representative sample of the Australian population (n= 3357). Participants were grouped by COPD diagnostic criteria based on spirometry and self-reported diagnosis. Odds ratios for predictors of undiagnosed and misdiagnosed were estimated using logistic regression. Results Of the BOLD Australia sample, 1.8% had confirmed COPD, of whom only half self-reported a diagnosis of COPD. A further 6.9% probably had COPD, but were undiagnosed. The priority target population for case finding of undiagnosed COPD was aged ≥60 years (particularly those ≥75 years), with wheezing, shortness of breath and a body mass index (BMI) <25kg/m2. The priority target population for identifying and reviewing misdiagnosed COPD was aged <60 years, female, with no wheezing and a BMI ≥25kg/m2. Conclusion Challenges continue in accurately diagnosing COPD and greater efforts are needed to identify undiagnosed and misdiagnosed individuals to ensure an accurate diagnosis and the initiation of appropriate management in order to reduce the burden of COPD.
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Affiliation(s)
- Kate Petrie
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Brett G Toelle
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.,Sydney Local Health District, Sydney, NSW, Australia
| | - Richard Wood-Baker
- College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Graeme P Maguire
- Western Clinical School, University of Melbourne, Melbourne, Australia and General Internal Medicine, Western Health, Melbourne, VIC, Australia
| | - Alan L James
- Sir Charles Gairdner Hospital, West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Perth, WA, Australia.,University of Western Australia, Medical School, Perth, WA, Australia
| | - Michael Hunter
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia.,Busselton Population Medical Research Institute, Busselton, WA, Australia
| | - David P Johns
- College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael J Abramson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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DeLapp DA, Glick C, Furmanek S, Ramirez JA, Cavallazzi R. Patients with Obesity Have Better Long-Term Outcomes after Hospitalization for COPD Exacerbation. COPD 2020; 17:373-377. [PMID: 32586139 DOI: 10.1080/15412555.2020.1781805] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Obesity has been shown to have a paradoxical benefit in a number of conditions, but the long-term effects in obesity after chronic obstructive pulmonary disease (COPD) exacerbation is still unclear. In this study, the effects of obesity on short- and long-term outcomes after a COPD exacerbation were evaluated. This was a secondary analysis of the Rapid Empiric Treatment with Oseltamivir Study (RETOS): a prospective, randomized, unblinded clinical trial. Patients were included in the study if they were hospitalized for acute exacerbation of COPD. Obesity was noted as patients with BMI >30. Clinical outcomes of time to clinical stability, length of stay, and mortality were compared. A total of 301 patients were included in the study, 122 (41%) patients were obese. There was no significant difference in the length of stay and time to clinical stability between patients with and without obesity. Mortality for patients with and without obesity was 3% and 3% at 30 days, 7% and 18% at six months, and 8% and 28% at one year, respectively. After adjusting with multivariable regression analysis, patients with obesity had a significant reduction in odds of dying at one year (adjusted odds ratio (aOR): 0.18; 95% CI: 0.06-0.58; p = .004) and at six months (aOR: 0.28; 95% CI: 0.09-0.89; p = .031). Our study showed that obesity was associated with reduced mortality at one year and six months after a COPD exacerbation. Although patients with obesity had higher rates of comorbidities, they had reduced mortality at one year after multivariable regression analysis.
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Affiliation(s)
- David A DeLapp
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Connor Glick
- Department of Medicine, Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY, USA
| | - Stephen Furmanek
- Department of Medicine, Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY, USA
| | - Julio A Ramirez
- Department of Medicine, Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rodrigo Cavallazzi
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville School of Medicine, Louisville, KY, USA
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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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10
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Ratz D, Wiitala W, Badr MS, Burns J, Chowdhuri S. Correlates and consequences of central sleep apnea in a national sample of US veterans. Sleep 2019; 41:4955788. [PMID: 29608761 DOI: 10.1093/sleep/zsy058] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Indexed: 11/14/2022] Open
Abstract
The prevalence and consequences of central sleep apnea (CSA) in adults are not well described. By utilizing the large Veterans Health Administration (VHA) national administrative databases, we sought to determine the incidence, clinical correlates, and impact of CSA on healthcare utilization in Veterans. Analysis of a retrospective cohort of patients with sleep disorders was performed from outpatient visits and inpatient admissions from fiscal years 2006 through 2012. The CSA group, defined by International Classification of Diseases-9, was compared with a comparison group. The number of newly diagnosed CSA cases increased fivefold during this timeframe; however, the prevalence was highly variable depending on the VHA site. The important predictors of CSA were male gender (odds ratio [OR] = 2.31, 95% confidence interval [CI]: 1.94-2.76, p < 0.0001), heart failure (HF) (OR = 1.78, 95% CI: 1.64-1.92, p < 0.0001), atrial fibrillation (OR = 1.83, 95% CI: 1.69-2.00, p < 0.0001), pulmonary hypertension (OR = 1.38, 95% CI:1.19-1.59, p < 0.0001), stroke (OR = 1.65, 95% CI: 1.50-1.82, p < 0.0001), and chronic prescription opioid use (OR = 1.99, 95% CI: 1.87-2.13, p < 0.0001). Veterans with CSA were at an increased risk for hospital admissions related to cardiovascular disorders compared with the comparison group (incidence rate ratio [IRR] = 1.50, 95% CI: 1.16-1.95, p = 0.002). Additionally, the effect of prior HF on future admissions was greater in the CSA group (IRR: 4.78, 95% CI: 3.87-5.91, p < 0.0001) compared with the comparison group (IRR = 3.32, 95% CI: 3.18-3.47, p < 0.0001). Thus, CSA in veterans is associated with cardiovascular disorders, chronic prescription opioid use, and increased admissions related to the comorbid cardiovascular disorders. Furthermore, there is a need for standardization of diagnostics methods across the VHA to accurately diagnose CSA in high-risk populations.
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Affiliation(s)
- David Ratz
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Wyndy Wiitala
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - M Safwan Badr
- Sleep Medicine Section, Medical Service, John D. Dingell Veterans Affairs Medical Center, Detroit, MI.,Department of Medicine, Wayne State University, Detroit, MI
| | - Jennifer Burns
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Susmita Chowdhuri
- Sleep Medicine Section, Medical Service, John D. Dingell Veterans Affairs Medical Center, Detroit, MI.,Department of Medicine, Wayne State University, Detroit, MI
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11
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Berenson R, Singh H. Payment Innovations To Improve Diagnostic Accuracy And Reduce Diagnostic Error. Health Aff (Millwood) 2019; 37:1828-1835. [PMID: 30395510 DOI: 10.1377/hlthaff.2018.0714] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diagnostic accuracy is essential for treatment decisions but is largely unaccounted for by payers, including in fee-for-service Medicare and proposed Alternative Payment Models (APMs). We discuss three payment-related approaches to reducing diagnostic error. First, coding changes in the Medicare Physician Fee Schedule could facilitate the more effective use of teamwork and information technology in the diagnostic process and better support the cognitive work and time commitment that physicians make in the quest for diagnostic accuracy, especially in difficult or uncertain cases. Second, new APMs could be developed to focus on improving diagnostic accuracy in challenging cases and make available support resources for diagnosis, including condition-specific centers of diagnostic expertise or general diagnostic centers of excellence that provide second (or even third) opinions. Performing quality improvement activities that promote safer diagnosis should be a part of the accountability of APM recipients. Third, the accuracy of diagnoses that trigger APM payments and establish payment amounts should be confirmed by APM recipients. Implementation of these multipronged approaches can make current payment models more accountable for addressing diagnostic error and position diagnostic performance as a critical component of quality-based payment.
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Affiliation(s)
- Robert Berenson
- Robert Berenson ( ) is an institute fellow at the Urban Institute, in Washington, D.C
| | - Hardeep Singh
- Hardeep Singh is chief of the Health Policy, Quality, and Informatics Program, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and a professor of medicine at the Baylor College of Medicine, both in Houston, Texas
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12
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Crothers K, Rodriguez C, Nance RM, Akgun K, Shahrir S, Kim J, Hoo GS, Sharafkhaneh A, Crane HM, Justice AC. Accuracy of electronic health record data for the diagnosis of chronic obstructive pulmonary disease in persons living with HIV and uninfected persons. Pharmacoepidemiol Drug Saf 2019; 28:140-147. [PMID: 29923258 PMCID: PMC6309326 DOI: 10.1002/pds.4567] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/05/2018] [Accepted: 05/07/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE No prior studies have addressed the performance of electronic health record (EHR) data to diagnose chronic obstructive pulmonary disease (COPD) in people living with HIV (PLWH), in whom COPD could be more likely to be underdiagnosed or misdiagnosed, given the higher frequency of respiratory symptoms and smoking compared with HIV-uninfected (uninfected) persons. METHODS We determined whether EHR data could improve accuracy of ICD-9 codes to define COPD when compared with spirometry in PLWH vs uninfected, and quantified level of discrimination using the area under the receiver-operating curve (AUC). The development cohort consisted of 350 participants who completed research spirometry in the Examinations of HIV Associated Lung Emphysema (EXHALE) study, a pulmonary substudy of the Veterans Aging Cohort Study. Results were externally validated in 294 PLWH who performed spirometry for clinical indications from the University of Washington (UW) site of the Centers for AIDS Research Network of Integrated Clinical Systems cohort. RESULTS ICD-9 codes performed similarly by HIV status, but alone were poor at discriminating cases from non-cases of COPD when compared with spirometry (AUC 0.633 in EXHALE; 0.651 in the UW cohort). However, algorithms that combined ICD-9 codes with other clinical variables available in the EHR-age, smoking, and COPD inhalers-improved discrimination and performed similarly in EXHALE (AUC 0.771) and UW (AUC 0.734). CONCLUSIONS These data support that EHR data in combination with ICD-9 codes have moderately good accuracy to identify COPD when spirometry data are not available, and perform similarly in PLWH and uninfected individuals.
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Affiliation(s)
| | - Carla Rodriguez
- Department of Medicine, University of Washington, Seattle, WA
- Center for Health Research, Kaiser Permanente Mid-Atlantic Research Institute, Rockville, MD
| | - Robin M. Nance
- Department of Medicine, University of Washington, Seattle, WA
| | - Kathleen Akgun
- Department of Medicine, Veterans Affairs (VA) Connecticut Healthcare System and Yale University, West Haven, CT
| | - Shahida Shahrir
- Department of Medicine, University of Washington, Seattle, WA
| | - Joon Kim
- Department of Medicine, James J. Peters VA Medical Center and Icahn School of Medicine at Mt. Sinai, New York, NY
| | - Guy Soo Hoo
- Department of Medicine, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Amir Sharafkhaneh
- Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX
| | - Heidi M. Crane
- Department of Medicine, University of Washington, Seattle, WA
| | - Amy C. Justice
- Department of Medicine, Veterans Affairs (VA) Connecticut Healthcare System and Yale University, West Haven, CT
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13
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Chapron A, Pelé F, Andres É, Fiquet L, Laforest C, Veislinger A, Fougerou C, Turmel V, Fouchard J, Yourish B, Oumari S, Allory E, Banâtre A, Schweyer FX, Pommier J, Brinchault G, Guillot S, Laviolle B, Jouneau S. [Targeted screening of COPD in primary care: Feasibility and effectiveness]. Rev Mal Respir 2019; 36:162-170. [PMID: 30686560 DOI: 10.1016/j.rmr.2018.08.023] [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: 03/01/2018] [Accepted: 08/14/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a common but under-diagnosed pathology in primary care. The objective was to study the feasibility of a randomized controlled trial in general practice to detect new cases of COPD at an earlier stage. METHODS A cluster randomized, controlled, multicenter intervention study comparing, according to a 2×2 factorial plan, two case finding strategies: a systematic GOLD-HAS hetero-questionnaire and coordination of the patient's path to facilitate access to spirometry. The PIL-DISCO pilot study took place in 2017. Patients between 40 and 80 years old, with no previous history of COPD, consulting their GP on a given day regardless of the reason, were included. RESULTS 176 patients were included in 1.5 days. Spirometry was performed in none of the control arm, in 13 (29.5%) of the questionnaire arm, in 22 (50%) in the coordination arm and in 32 (72.7%) with the combination of the two strategies. Two cases of stage 2 COPD and thirteen other respiratory diseases were diagnosed. CONCLUSIONS This study confirms the feasibility of the protocol in primary care in terms of speed of inclusion and acceptability. An extension phase aiming to include 3200 patients will assess the diagnostic value of the two strategies tested in general practice.
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Affiliation(s)
- A Chapron
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France; Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France; Université Rennes, CNRS, ARENES - UMR 6051, 35000 Rennes, France.
| | - F Pelé
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France; Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France; Irset, institut de recherche en santé, environnement et travail, université Rennes, UMR_S 1085, 35000 Rennes, France
| | - É Andres
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France
| | - L Fiquet
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France; Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - C Laforest
- Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - A Veislinger
- Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - C Fougerou
- Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - V Turmel
- Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - J Fouchard
- Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - B Yourish
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France
| | - S Oumari
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France
| | - E Allory
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France; Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - A Banâtre
- Département de médecine générale, université Rennes, 2, avenue du Pr-Léon-Bernard, 35000 Rennes, France; Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - F-X Schweyer
- EHESP, école des hautes études en santé publique, université Rennes, 35000 Rennes, France
| | - J Pommier
- Université Rennes, CNRS, ARENES - UMR 6051, 35000 Rennes, France; EHESP, école des hautes études en santé publique, université Rennes, 35000 Rennes, France
| | - G Brinchault
- Services de pneumologie et explorations fonctionnelles respiratoires, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - S Guillot
- Services de pneumologie et explorations fonctionnelles respiratoires, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - B Laviolle
- Inserm, CIC 1414, centre d'investigation clinique de Rennes, université Rennes, CHU de Rennes, 35000 Rennes, France
| | - S Jouneau
- Irset, institut de recherche en santé, environnement et travail, université Rennes, UMR_S 1085, 35000 Rennes, France; Services de pneumologie et explorations fonctionnelles respiratoires, université Rennes, CHU de Rennes, 35000 Rennes, France
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14
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Fisk M, McMillan V, Brown J, Holzhauer-Barrie J, Khan MS, Baxter N, Roberts CM. Inaccurate diagnosis of COPD: the Welsh National COPD Audit. Br J Gen Pract 2019; 69:e1-e7. [PMID: 30559109 PMCID: PMC6301368 DOI: 10.3399/bjgp18x700385] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/20/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The diagnosis of chronic obstructive pulmonary disease (COPD) is confirmed with spirometry demonstrating persistent airflow obstruction. AIM To evaluate the clinical characteristics and management of patients in primary care on COPD registers with spirometry incompatible with COPD. DESIGN AND SETTING A primary care audit of Welsh COPD Read-Coded patient data from the Quality and Outcomes Framework (QOF) COPD register in Wales. METHOD Patients on the QOF COPD register with incompatible spirometry (post-bronchodilator forced expiratory lung volume in 1 second/forced vital capacity [FEV1/FVC] ratio ≥0.70) were compared with those with compatible spirometry (FEV1/FVC <0.70). RESULTS This audit included 63% of Welsh practices contributing 48 105 patients. Only 19% (n = 8957) of patients were post-bronchodilator FEV1/FVC Read-Coded and were included in this study. Of these, 75% (n = 6702) had compatible spirometry and 25% (n = 2255) did not. Patients with incompatible spirometry were more likely female (P = 0.009), never-smokers (P<0.001), had higher body mass index (P<0.001), and better mean FEV1 (P<0.001). Medical Research Council (MRC) breathlessness scores, exacerbation frequency, and asthma co-diagnosis were similar between groups. Patients in both groups were just as likely to receive inhaled corticosteroid (ICS) and long-acting beta-agonists (LABAs), but patients with incompatible spirometry were less likely to receive long-acting muscarinic antagonists (LAMAs) (P<0.001) or LABA/ICS (P = 0.002) combinations. CONCLUSION Patients on the COPD QOF register with spirometry incompatible with COPD are symptomatic and managed using significant resources. If quality of care and effective resource use are to be improved, focus must be given to correct diagnosis in this group.
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Affiliation(s)
- Marie Fisk
- Experimental Medicine and Immunotherapeutics (EMIT) Department, University of Cambridge, Cambridge
| | | | - James Brown
- Royal Free London NHS Foundation Trust and UCL Respiratory, Division of Medicine, University College London, London
| | | | | | - Noel Baxter
- National COPD Audit Programme Primary Care Workstream, Royal College of Physicians, London
| | - C Michael Roberts
- National COPD Audit Programme; associate director, Clinical Effectiveness and Evaluation Unit, Care Quality Improvement Department, Royal College of Physicians, London
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15
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Schneiderman AI, Dougherty DD, Fonseca VP, Wolters CL, Bossarte RM, Arjomandi M. Diagnosing Chronic Obstructive Pulmonary Disease Among Afghanistan and Iraq Veterans: Veterans Affair's Concordance With Clinical Guidelines for Spirometry Administration. Mil Med 2018; 182:e1993-e2000. [PMID: 28885968 DOI: 10.7205/milmed-d-16-00332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Early diagnosis and treatment of chronic obstructive pulmonary disease (COPD) can slow disease progression. The Department of Veterans Affairs (VA)/Department of Defense Clinical Practice Guidelines (CPG), established to improve patient outcomes, recommend the use of spirometry in the COPD diagnostic process. The aims of this study were to assess VA health care providers' performance related to CPG-recommended spirometry administration in the evaluation of newly diagnosed COPD among veterans, determine the patient characteristics that may influence the adherence rate, and compare VA concordance rates to those of other health plans. METHODS Administrative health care data related to Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans was used to identify newly diagnosed COPD cases and the proportion of cases receiving spirometry. Cases were defined as veterans who had their first medical encounter with a coded diagnosis of COPD ≥ 6 months after their initial VA health care evaluation. The relationship between prediagnostic and comorbid conditions and the administration of CPG-concordant spirometry was examined using regression analyses. FINDINGS Among the 923,646 OEF/OIF/OND veterans receiving VA health care between January 2002 and December 2014, 32,076 (3%) had a coded diagnosis of COPD. Among those, 22,156 (69%) were identified as newly diagnosed COPD cases; only 6,827 (31%) had CPG-concordant spirometry. Concordant spirometry was more likely to occur in veterans aged ≥40. A pre-existing tobacco use disorder marginally changed the concordance rate. DISCUSSION VA provider adherence to CPG-concordant spirometry would decrease the prevalence of false-positive COPD cases and lead to more targeted disease treatment. Future research should focus on such cases by assessing the association between COPD diagnosis and bronchodilator responsiveness.
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Affiliation(s)
- Aaron I Schneiderman
- Department of Veterans Affairs (10P4Q), Post-Deployment Health Services, Epidemiology Program, 810 Vermont Avenue, Washington, DC 20420
| | - Deborah D Dougherty
- Under Contract to Intellica Corporation, 8521 Leesburg Pike Suite 600, Vienna, VA 22182
| | - Vincent P Fonseca
- Intellica Corporation, 209 West Poplar Street, San Antonio, TX 78212
| | - Charles L Wolters
- Under Contract to Intellica Corporation, 8521 Leesburg Pike Suite 600, Vienna, VA 22182
| | - Robert M Bossarte
- West Virginia University Injury Control Research Center, Research Ridge Suite 201, 3606 Collins Ferry Road, Morgantown, WV 26505
| | - Mehrdad Arjomandi
- San Francisco VAMC and University of California San Francisco, 4150 Clement Street, San Francisco, CA 94121
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16
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Naveiro-Rilo JC, García García S, Flores-Zurutuza L, Carazo Fernández L, Domínguez Fernández C, Palomo García JL. [Utility of normality low limit of spirometry in diagnosed COPD patients]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2017; 32:262-268. [PMID: 28863965 DOI: 10.1016/j.cali.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/02/2017] [Accepted: 05/05/2017] [Indexed: 06/07/2023]
Abstract
AIM To evaluate the differences in COPD patients below the lower limit of normal (LLN) of the fixed ratio FEV1/FVC < 0.70 and those above this limit. PATIENTS AND METHODS Cross-sectional study. COPD patients between 40 and 85 years old included in primary care clinical record database were randomly selected. Baseline and postbronchodilator spirometries were performed. Two groups of patients were established: FEV1/FVC<0.70 and ≤LIN (group1) and FEV/FVC<0.70 and >LIN (group 2). Sociodemographic, clinical, pulmonary obstruction, quality of life and attendance to health services variables were measured. The results of both groups were compared. RESULTS 22.3% of the subjects were misdiagnosed FEV1/FVC < 0,70. Patients in group 2 (FEV1/FVC<0.70 y > LLN) are diagnosed at an older age, they have a lower exposure to tobacco and better pulmonary function (FEV1: 74.9% vs 54.6%). 35.5% of those patients belong to stage i of GOLD, vs 8.5%, this patients have an increased comorbidity. Patients in group 1 have more COPD exacerbations, worse quality of life, a higher BODEx index 2,3 (1.8) vs 1.1 (1.5); 55.1% of those patients were high risk patients (GoldC or Gold D). Diagnose before being 56 years old, an increased exposure to tobacco, the FEV>50%, and a lower comorbidity are associated with a greater chance of suffering COPD with LLN criteria. CONCLUSION We obtain two groups of patients with differentiated clinical characteristics if we use LLN. Subjects with FEV1/FVC<0.7 and >LLN have less obstruction, less severity and more comorbidity, suggesting the possibility of overdiagnosis or misdiagnosis. On the other hand, younger age at the time of diagnosis, higher tobacco consumption and more severe obstruction are related with FEV1/FVC >0.70 and<LLN (group 1).
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17
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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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18
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Gershon A, Mecredy G, Croxford R, To T, Stanbrook MB, Aaron SD. Outcomes of patients with chronic obstructive pulmonary disease diagnosed with or without pulmonary function testing. CMAJ 2017; 189:E530-E538. [PMID: 28396329 PMCID: PMC5386846 DOI: 10.1503/cmaj.151420] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 09/14/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A small number of people with chronic obstructive pulmonary disease (COPD) receive pulmonary function testing around the time of diagnosis. Because omitting testing increases misdiagnosis, we sought to determine whether health outcomes differed between patients whose COPD was diagnosed with or without pulmonary function testing. METHODS We conducted a longitudinal population study of patients with physician-diagnosed COPD from 2005 to 2012 using health administrative data from Ontario, Canada. We assessed whether having pulmonary function testing around the time of diagnosis was associated with the composite outcome of admission to hospital for COPD or all-cause death, using adjusted survival analysis. RESULTS Chronic obstructive pulmonary disease was diagnosed in 68 898 patients during the study period; 41.2% of patients received peridiagnostic pulmonary function testing. In adjusted analysis, patients who underwent testing were less likely to die or be admitted to hospital for COPD (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.89-0.94) and were more likely to be prescribed an inhaled long-acting bronchodilator than patients who did not undergo testing. Subgroup analysis suggested that the association of testing and outcomes was confined to patients with COPD diagnosed in the ambulatory care setting (adjusted HR 0.80, 95% CI 0.76-0.84). INTERPRETATION Confirmation of a COPD diagnosis using pulmonary function testing is associated with a decreased risk of death and admission to hospital for COPD. In ambulatory patients, this effect may be from increased use of appropriate COPD medications. The findings of this study validate current guideline recommendations that encourage pulmonary function testing for diagnosis in all patients with suspected COPD.
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Affiliation(s)
- Andrea Gershon
- Institute for Clinical Evaluative Sciences (Gershon, Mecredy, Croxford, To, Stanbrook); Sunnybrook Health Sciences Centre (Gershon); Institute of Health Policy, Management and Evaluation (Gershon, Stanbrook) and Dalla Lana School of Public Health (To), University of Toronto; The Hospital for Sick Children (To); University Health Network (Stanbrook), Toronto, Ont.; Ottawa Hospital Research Institute (Aaron), University of Ottawa, Ottawa, Ont.
| | - Graham Mecredy
- Institute for Clinical Evaluative Sciences (Gershon, Mecredy, Croxford, To, Stanbrook); Sunnybrook Health Sciences Centre (Gershon); Institute of Health Policy, Management and Evaluation (Gershon, Stanbrook) and Dalla Lana School of Public Health (To), University of Toronto; The Hospital for Sick Children (To); University Health Network (Stanbrook), Toronto, Ont.; Ottawa Hospital Research Institute (Aaron), University of Ottawa, Ottawa, Ont
| | - Ruth Croxford
- Institute for Clinical Evaluative Sciences (Gershon, Mecredy, Croxford, To, Stanbrook); Sunnybrook Health Sciences Centre (Gershon); Institute of Health Policy, Management and Evaluation (Gershon, Stanbrook) and Dalla Lana School of Public Health (To), University of Toronto; The Hospital for Sick Children (To); University Health Network (Stanbrook), Toronto, Ont.; Ottawa Hospital Research Institute (Aaron), University of Ottawa, Ottawa, Ont
| | - Teresa To
- Institute for Clinical Evaluative Sciences (Gershon, Mecredy, Croxford, To, Stanbrook); Sunnybrook Health Sciences Centre (Gershon); Institute of Health Policy, Management and Evaluation (Gershon, Stanbrook) and Dalla Lana School of Public Health (To), University of Toronto; The Hospital for Sick Children (To); University Health Network (Stanbrook), Toronto, Ont.; Ottawa Hospital Research Institute (Aaron), University of Ottawa, Ottawa, Ont
| | - Matthew B Stanbrook
- Institute for Clinical Evaluative Sciences (Gershon, Mecredy, Croxford, To, Stanbrook); Sunnybrook Health Sciences Centre (Gershon); Institute of Health Policy, Management and Evaluation (Gershon, Stanbrook) and Dalla Lana School of Public Health (To), University of Toronto; The Hospital for Sick Children (To); University Health Network (Stanbrook), Toronto, Ont.; Ottawa Hospital Research Institute (Aaron), University of Ottawa, Ottawa, Ont
| | - Shawn D Aaron
- Institute for Clinical Evaluative Sciences (Gershon, Mecredy, Croxford, To, Stanbrook); Sunnybrook Health Sciences Centre (Gershon); Institute of Health Policy, Management and Evaluation (Gershon, Stanbrook) and Dalla Lana School of Public Health (To), University of Toronto; The Hospital for Sick Children (To); University Health Network (Stanbrook), Toronto, Ont.; Ottawa Hospital Research Institute (Aaron), University of Ottawa, Ottawa, Ont
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20
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Prevalence of airflow obstruction in patients with stable systolic heart failure. BMC Pulm Med 2017; 17:6. [PMID: 28061834 PMCID: PMC5219786 DOI: 10.1186/s12890-016-0351-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/14/2016] [Indexed: 11/25/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is an important differential diagnosis in heart failure (HF). However, routine use of spirometry in outpatient HF clinics is not implemented. The aim of the present study was to determine the prevalence of both airflow obstruction and non obstructive lung function impairment in patients with HF and to examine the effect of optimal medical treatment for HF on lung function parameters. Methods Consecutive patients with HF (ejection fraction (EF) < 45%) and New York Heart Association (NYHA) functional class II-IV at 10 different outpatient heart failure clinics were examined with spirometry at their first visit and after optimal medical treatment for HF was achieved. airflow obstruction was classified and graded according to the GOLD 2011 revision. Results Baseline spirometry was performed in 593 included patients and 71 (12%) had a clinical diagnosis of COPD. Mean age was 69 ± 11 years and mean EF was 30 ± 9%. Thirty-two % of the patients were active smokers and 53% were previous smokers. Mean FEV1 and FVC was 77.9 ± 1.7% and 85.4 ± 1.5% of predicted respectively. Obstructive pattern was observed in 233 (39%) of the patients. Of these, 53 patients (9%) had mild disease (GOLD I) and 180 (30%) patients had moderate to very severe disease (GOLD II-IV). No difference in spirometric variables was observed following up titration of medication. Conclusion In stable patients with HF airflow obstruction is frequent and severely underdiagnosed. Spirometry should be considered in all patients with HF in order to improve diagnosis and treatment for concomitant pulmonary disease.
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Sogbetun F, Eschenbacher WL, Welge JA, Panos RJ. Veterans Airflow Obstruction Screening Questionnaire: A Survey to Identify Veterans with Airflow Obstruction. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 3:705-715. [PMID: 28848897 DOI: 10.15326/jcopdf.3.4.2016.0128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality within the Veterans Healthcare Administration (VHA) and is frequently under-diagnosed. We developed the Veterans Airflow Screening Questionnaire (VAFOSQ) to improve the identification of Veterans with airflow obstruction (AFO), the most commonly used criterion for the diagnosis of COPD.We created an initial survey with 78 variables that have been associated with AFO. A total of 825 patients in 3 primary care clinics performed spirometry after bronchodilator administration and completed the initial survey. Best sets regression was used to build a model that predicted AFO optimally. A total of 195 of 825 (23.3%) patients had AFO and 7 items positively predicted AFO. When the questionnaire score was greater than 25, the VAFOSQ accurately identified AFO with an area under the receiver operating curve of 0.72. In a prospective validation cohort of 376 participants, the positive predictive value was 32% and negative predictive value 81%. The VAFOSQ is a reliable and valid instrument for the identification of veterans at risk for AFO who would benefit from further evaluation with spirometry and assessment for COPD. The VAFOSQ is straightforward to use and can be easily self-administered and self-scored enabling widespread application within the VHA.
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Affiliation(s)
- Folarin Sogbetun
- Division of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, Veterans Affairs Medical Center Cincinnati, Ohio
| | - Wlliam L Eschenbacher
- Division of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, Veterans Affairs Medical Center Cincinnati, Ohio.,Division of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey A Welge
- Department of Psychiatry and Behavioral Neuroscience, Department of Environmental Health (Division of Biostatistics and Bioinformatics), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph J Panos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, Veterans Affairs Medical Center Cincinnati, Ohio.,Division of Pulmonary, Critical Care, and Sleep Medicine, Cincinnati, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Gershon AS, Hwee J, Chapman KR, Aaron SD, O'Donnell DE, Stanbrook MB, Bourbeau J, Tan W, Su J, Victor JC, To T. Factors associated with undiagnosed and overdiagnosed COPD. Eur Respir J 2016; 48:561-4. [PMID: 27338199 DOI: 10.1183/13993003.00458-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 04/10/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Andrea S Gershon
- Dept of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada The Hospital for Sick Children, Toronto, ON, Canada
| | - Jeremiah Hwee
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Kenneth R Chapman
- Asthma and Airway Centre, Toronto Western Hospital, Toronto, ON, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Matthew B Stanbrook
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Asthma and Airway Centre, Toronto Western Hospital, Toronto, ON, Canada
| | - Jean Bourbeau
- McGill University, Respiratory Division, Royal Victoria Hospital, Montreal, QC, Canada
| | - Wan Tan
- University of British Columbia, The UBC James Hogg Research Centre, Institute for Heart and Lung Health, St Paul's Hospital, Vancouver, BC, Canada
| | - Jiandong Su
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - J Charles Victor
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Teresa To
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada The Hospital for Sick Children, Toronto, ON, Canada
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Dement J, Welch L, Ringen K, Quinn P, Chen A, Haas S. A case-control study of airways obstruction among construction workers. Am J Ind Med 2015; 58:1083-97. [PMID: 26123003 PMCID: PMC5034836 DOI: 10.1002/ajim.22495] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND While smoking is the major cause of chronic obstructive pulmonary disease (COPD), occupational exposures to vapors, gases, dusts, and fumes (VGDF) increase COPD risk. This case-control study estimated the risk of COPD attributable to occupational exposures among construction workers. METHODS The study population included 834 cases and 1243 controls participating in a national medical screening program for older construction workers between 1997 and 2013. Qualitative exposure indices were developed based on lifetime work and exposure histories. RESULTS Approximately 18% (95% CI = 2-24%) of COPD risk can be attributed to construction-related exposures, which are additive to the risk contributed by smoking. A measure of all VGDF exposures combined was a strong predictor of COPD risk. CONCLUSIONS Construction workers are at increased risk of COPD as a result of broad and complex effects of many exposures acting independently or interactively. Control methods should be implemented to prevent worker exposures, and smoking cessation should be promoted.
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Affiliation(s)
- John Dement
- Division of Occupational and Environmental Medicine, Duke University Medical Center, Durham, North Carolina
| | - Laura Welch
- The Center for Construction Research and Training, Silver Spring, Maryland
| | - Knut Ringen
- The Center for Construction Research and Training, Silver Spring, Maryland
- Stoneturn Consultants, Seattle, Washington
| | - Patricia Quinn
- The Center for Construction Research and Training, Silver Spring, Maryland
| | - Anna Chen
- Zenith American Solutions, Seattle, Washington
| | - Scott Haas
- Zenith American Solutions, Seattle, Washington
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24
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Martinez CH, Curtis JL. Implications of the GOLD COPD Classification and Guidelines. Fed Pract 2015; 32:14S-18S. [PMID: 30766095 PMCID: PMC6375483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines classification is based on the combination of patient risk and the severity of their symptoms.
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Affiliation(s)
- Carlos H Martinez
- and are affiliated with Pulmonary & Critical Care Medicine Section, Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan and Pulmonary & Critical Care Medicine Division, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
| | - Jeffrey L Curtis
- and are affiliated with Pulmonary & Critical Care Medicine Section, Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan and Pulmonary & Critical Care Medicine Division, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
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Putcha N, Drummond MB, Wise RA, Hansel NN. Comorbidities and Chronic Obstructive Pulmonary Disease: Prevalence, Influence on Outcomes, and Management. Semin Respir Crit Care Med 2015; 36:575-91. [PMID: 26238643 DOI: 10.1055/s-0035-1556063] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Comorbidities impact a large proportion of patients with chronic obstructive pulmonary disease (COPD), with over 80% of patients with COPD estimated to have at least one comorbid chronic condition. Guidelines for the treatment of COPD are just now incorporating comorbidities to their management recommendations of COPD, and it is becoming increasingly clear that multimorbidity as well as specific comorbidities have strong associations with mortality and clinical outcomes in COPD, including dyspnea, exercise capacity, quality of life, healthcare utilization, and exacerbation risk. Appropriately, there has been an increased focus upon describing the burden of comorbidity in the COPD population and incorporating this information into existing efforts to better understand the clinical and phenotypic heterogeneity of this group. In this article, we summarize existing knowledge about comorbidity burden and specific comorbidities in COPD, focusing on prevalence estimates, association with outcomes, and existing knowledge about treatment strategies.
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Affiliation(s)
- Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - M Bradley Drummond
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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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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Affiliation(s)
- David A Kaminsky
- Pulmonary Disease and Critical Care Medicine Division, College of Medicine, The University of Vermont.
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