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Chen YF, Hou HH, Chien N, Lu KZ, Lin CH, Liao YC, Lor KL, Chien JY, Chen CM, Chen CY, Cheng SL, Wang HC, Hsueh PR, Yu CJ. The clinical impacts of lung microbiome in bronchiectasis with fixed airflow obstruction: a prospective cohort study. Respir Res 2024; 25:308. [PMID: 39143556 PMCID: PMC11325704 DOI: 10.1186/s12931-024-02931-x] [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: 01/20/2024] [Accepted: 07/31/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Airflow obstruction is a hallmark of disease severity and prognosis in bronchiectasis. The relationship between lung microbiota, airway inflammation, and outcomes in bronchiectasis with fixed airflow obstruction (FAO) remains unclear. This study explores these interactions in bronchiectasis patients, with and without FAO, and compares them to those diagnosed with chronic obstructive pulmonary disease (COPD). METHODS This prospective observational study in Taiwan enrolled patients with either bronchiectasis or COPD. To analyze the lung microbiome and assess inflammatory markers, bronchoalveolar lavage (BAL) samples were collected for 16S rRNA gene sequencing. The study cohort comprised 181 patients: 86 with COPD, 46 with bronchiectasis, and 49 with bronchiectasis and FAO, as confirmed by spirometry. RESULTS Patients with bronchiectasis, with or without FAO, had similar microbiome profiles characterized by reduced alpha diversity and a predominance of Proteobacteria, distinctly different from COPD patients who exhibited more Firmicutes, greater diversity, and more commensal taxa. Furthermore, compared to COPD and bronchiectasis without FAO, bronchiectasis with FAO showed more severe disease and a higher risk of exacerbations. A significant correlation was found between the presence of Pseudomonas aeruginosa and increased airway neutrophilic inflammation such as Interleukin [IL]-1β, IL-8, and tumor necrosis factor-alpha [TNF]-α, as well as with higher bronchiectasis severity, which might contribute to an increased risk of exacerbations. Moreover, in bronchiectasis patients with FAO, the ROSE (Radiology, Obstruction, Symptoms, and Exposure) criteria were employed to classify individuals as either ROSE (+) or ROSE (-), based on smoking history. This classification highlighted differences in clinical features, inflammatory profiles, and slight microbiome variations between ROSE (-) and ROSE (+) patients, suggesting diverse endotypes within the bronchiectasis with FAO group. CONCLUSION Bronchiectasis patients with FAO may exhibit two distinct endotypes, as defined by ROSE criteria, characterized by greater disease severity and a lung microbiome more similar to bronchiectasis without FAO than to COPD. The significant correlation between Pseudomonas aeruginosa colonization and increased airway neutrophilic inflammation, as well as disease severity, underscores the clinical relevance of microbial patterns. This finding reinforces the potential role of these patterns in the progression and exacerbations of bronchiectasis with FAO.
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Affiliation(s)
- Yen-Fu Chen
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yunlin County, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100, Taiwan (ROC)
- Thoracic Medicine Center, Department of Medicine and Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Hsin-Han Hou
- Graduate Institute of Oral Biology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ning Chien
- Department of Medical Imaging, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Kai-Zen Lu
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chieh-Hua Lin
- Big Data Center, China Medical University Hospital, Taichung, Taiwan
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli, 350, Taiwan
| | - Yu-Chieh Liao
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli, 350, Taiwan
| | - Kuo-Lung Lor
- Department of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Jung-Yien Chien
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100, Taiwan (ROC)
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chung-Ming Chen
- Department of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Chung-Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yunlin County, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100, Taiwan (ROC)
- Thoracic Medicine Center, Department of Medicine and Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Shih-Lung Cheng
- Division of Thoracic Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan City 320, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
- Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
- Ph.D Programme for Aging, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chong-Jen Yu
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, 7 Chung-Shan South Road, Taipei, 100, Taiwan (ROC).
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.
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2
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Kanwal H, Khan S, Eldesoky GE, Mushtaq S, Khan A. Management of COPD and Comorbidities in COPD patients by Dispensing Pharmaceutical Care following Global Initiative for chronic Obstructive Lung Disease-Guidelines (GOLD guidelines 2020): A study protocol for a Prospective Randomized Clinical Trial. Heliyon 2023; 9:e21539. [PMID: 37942165 PMCID: PMC10628705 DOI: 10.1016/j.heliyon.2023.e21539] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/14/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
COPD (chronic obstructive pulmonary disease) is a medical condition that encompasses several chronic, progressive, and severe respiratory illnesses, such as emphysema and chronic bronchitis. COPD is the 4th most deadly disease in the world and its prevalence is expected to increase. Despite the abundance of information on the disease's etiology, pathophysiology, and treatment possibilities, it has long been underdiagnosed and underreported for a long time, particularly in developing countries. The symptoms of COPD result in significant impairments and significant impact on quality of life. COPD is the third leading cause of death in Pakistan. According to the published literature, COPD has been found to be associated with a serious economic burden, either the direct cost to healthcare systems in the form of frequent hospital admissions or indirect costs to patients suffering from COPD. Despite the availability of excellent medication, COPD treatment goals are frequently not achieved resulting in poor management of COPD. The recent studies revealed that due to the missing role of Pharmacists in most of the public sector hospitals of Pakistan, the COPD disease management protocols are not being properly followed. Pharmacists can help the healthcare system by implementing these management protocols that focus on patient education about the disease, prescribed medications, and proper inhalation techniques. Furthermore, the pharmacists as an effective healthcare's team member properly educate the patients about the ongoing assessments and their willingness to follow treatment recommendations and quit smoking, while referring them to smoking cessation programs as needed, following the GOLD guidelines. This aim of this clinical trial is to evaluate the impact of implementing standard treatment guidelines and the role of pharmacists in implementing GOLD guidelines for COPD management.
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Affiliation(s)
- Hafsa Kanwal
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Shahzeb Khan
- Centre for Pharmaceutical Engineering, Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, West Yorkshire, BD7, 1DP, UK
| | - Gaber E. Eldesoky
- Department of Chemistry, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Saima Mushtaq
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences (ASAB), National University of Sciences and Technology (NUST), Islamabad, Pakistan
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
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Mangold V, Boesing M, Berset C, Bridevaux PO, Geiser T, Joos Zellweger L, Kohler M, Lüthi-Corridori G, Maier S, Miedinger D, Thurnheer R, von Garnier C, Leuppi JD. Adherence to the GOLD Guidelines in Primary Care: Data from the Swiss COPD Cohort. J Clin Med 2023; 12:6636. [PMID: 37892775 PMCID: PMC10607923 DOI: 10.3390/jcm12206636] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/11/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Introduction: Chronic obstructive pulmonary disease (COPD) and its associated morbidity and mortality are a global burden on both affected patients and healthcare systems. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) issues guidelines with the aim of improving COPD management. Previous studies reported significant variability in adherence to these recommendations. The objective of this study was to evaluate Swiss primary practitioners' adherence to the GOLD guidelines for the pharmacological treatment of stable COPD. (2) Methods: We studied patients who were included in the Swiss COPD cohort study, an ongoing prospective study in a primary care setting, between 2015 and 2022. The key inclusion criteria are age ≥ 40 years, FEV1/FVC ratio < 70%, and a smoking history of at least 20 pack-years. Adherence to the GOLD guidelines was assessed per visit and over time. (3) Results: The data of 225 COPD patients (mean age 67 ± 9 years, 64% male) and their respective 1163 visits were analyzed. In 65% of visits (726/1121), treatment was prescribed according to the GOLD guidelines. Non-adherence was most common in GOLD groups A and B (64% and 33%) and mainly consisted of over-treatment (two long-acting bronchodilators in group A (98/195, 50%) and ICS in groups A (21/195, 11%) and B (198/808, 25%)). In group D, the prescriptions conformed with the guidelines in 99% of cases (109/108). Guideline adherence was associated with high symptom load (COPD Assessment Test) (OR 1.04, p = 0.002), high number of exacerbations (OR = 2.07, p < 0.001), asthma overlap (OR 3.36, p = 0.049), and diabetes mellitus (OR 2.82, p = 0.045). (4) Conclusion: These results confirm a conflict between the GOLD recommendations and primary practice, mainly concerning over-treatment in GOLD groups A and B. Patients with high symptom load, high exacerbation risk, asthma overlap, and diabetes mellitus are more likely to be treated in conformity with the guidelines. Further research is needed to uncover the reasons for the discrepancies and to design strategies for improvement.
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Affiliation(s)
- Veronika Mangold
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Maria Boesing
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Camille Berset
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | | | - Thomas Geiser
- Department of Pulmonary Medicine and Allergology, University Hospital, University of Bern, 3010 Bern, Switzerland
| | | | - Malcolm Kohler
- Department of Pneumology, University Hospital Zürich, 8091 Zürich, Switzerland
| | - Giorgia Lüthi-Corridori
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Sabrina Maier
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
| | - David Miedinger
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Robert Thurnheer
- Clinic of Medicine, Department of Pneumology, Cantonal Hospital Münsterlingen, 8596 Münsterlingen, Switzerland
| | - Christophe von Garnier
- Division of Pulmonology, Department of Medicine, University Hospital Lausanne, CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| | - Jörg Daniel Leuppi
- University Center of Internal Medicine, Cantonal Hospital Baselland, 4410 Liestal, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
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Nguyen-Nhu V, Nguyen LP, Duong-Quy S, Le An P, Bui-Minh T. Classification of COPD as ABCD according to GOLD 2011 and 2017 versions in COPD patients at University Medical Center in Ho Chi Minh City, Vietnam. Monaldi Arch Chest Dis 2023. [PMID: 37522870 DOI: 10.4081/monaldi.2023.2619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/21/2023] [Indexed: 08/01/2023] Open
Abstract
In 2017, Global Initiative for Chronic Lung Disease (GOLD) made substantial changes to its ABCD group categorization. Although several studies had been conducted to assess the impact of the new GOLD category, there was no research on the change of the GOLD classification in Vietnam. This retrospective analysis was conducted at Asthma and COPD clinic at the University Medical Center in Ho Chi Minh City, Vietnam. Our study population comprised patients visiting Medical Center from January 2018 to January 2020. We categorized patients' demographic, clinical characteristics and pharmacotherapy based on GOLD 2011 and 2017 guidelines. A comparison between the two versions was also determined. A total of 457 patients were included in this study. The percentage of groups A, B, C and D according to GOLD 2011 was 5%, 20.8%, 13.1% and 61.1%; and according to GOLD 2017 was 6.1%, 34.1%, 12% and 47.8%, respectively. In terms of gender, male patients constituted nearly 95% of the study's population (433/457 patients). Regarding pharmacotherapy, approximately 20% of the low-risk group (group A-B) was overtreated with ICS components: LABA+ICS (15.8%) and LAMA+LABA+ICS (3.8%). There were 13.3% and 1.1% of patients transferred from D to B and from C to A, respectively. All of them had lower FVC% pred, FEV1% pred and FEV1/FVC than the patients remained in group B or A (p<0.005). This is the first research in Vietnam to show the distribution of COPD patients using both the GOLD 2011 and GOLD 2017 criteria. There was 14% of patients reclassified from high-risk groups to low-risk groups when changing from 2011 to 2017 version and discordance of medications between guidelines and real-life practice. Therefore, clinicians should use their clinical competence to consider patients' conditions before deciding the appropriate therapeutic approach. Consequently, further studies were required to evaluate the effect of the change in GOLD classification.
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Affiliation(s)
- Vinh Nguyen-Nhu
- Faculty of Medicine, University of Medicine and Pharmacy, Ho Chi Minh City; Department of Respiratory Functional Exploration, University Medical Center, Ho Chi Minh City.
| | - Lam-Phuoc Nguyen
- Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City.
| | - Sy Duong-Quy
- Bio-Medical Research Centre, Lam Dong Medical College, Da Lat.
| | - Pham Le An
- Faculty of Medicine and Grant Innovation Center, University of Medicine and Pharmacy, Ho Chi Minh City.
| | - Tri Bui-Minh
- Grant Innovation Center, University of Medicine and Pharmacy, Ho Chi Minh City.
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Czira A, Purushotham S, Iheanacho I, Rothnie KJ, Compton C, Ismaila AS. Burden of Disease in Patients with Mild or Mild-to-Moderate Chronic Obstructive Pulmonary Disease (Global Initiative for Chronic Obstructive Lung Disease Group A or B): A Systematic Literature Review. Int J Chron Obstruct Pulmon Dis 2023; 18:719-731. [PMID: 37151760 PMCID: PMC10155715 DOI: 10.2147/copd.s394325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/06/2023] [Indexed: 05/09/2023] Open
Abstract
Background Patients with mild or mild-to-moderate chronic obstructive pulmonary disease (COPD), defined as Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A/B, are regarded as having a lower risk of experiencing multiple or severe exacerbations compared with patients classified as GOLD group C/D. Current guidelines suggest that patients in GOLD A/B should commence treatment with a bronchodilator; however, some patients within this population who have a higher disease burden may benefit from earlier introduction of dual bronchodilator or inhaled corticosteroid-containing therapies. This study aimed to provide research-based insights into the burden of disease experienced by patients classified as GOLD A/B, and to identify characteristics associated with poorer outcomes. Methods A systematic literature review (SLR) was conducted to identify evidence (burden of disease and prevalence data) relating to the population of interest (patients with COPD classified as GOLD A/B). Results A total of 79 full-text publications and four conference abstracts were included. In general, the rates of moderate and severe exacerbations were higher among patients in GOLD group B than among those in group A. Among patients classified as GOLD A/B, the risk of exacerbation was higher in those with more symptoms (modified Medical Research Council or COPD Assessment Test scales) and more severe airflow limitation (forced expiratory volume in 1 second % predicted). Conclusion Data from this SLR provide clear evidence of a heavier burden of disease for patients in GOLD B, compared with those in GOLD A, and highlight factors associated with worse outcomes for patients in GOLD A/B.
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Affiliation(s)
- Alexandrosz Czira
- Value Evidence and Outcomes, R&D Global Medical, GSK, Brentford, UK
- Correspondence: Alexandrosz Czira, Value Evidence and Outcomes, R&D Global Medical, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS, UK, Tel +44 7788 351610, Email
| | | | | | - Kieran J Rothnie
- Value Evidence and Outcomes, R&D Global Medical, GSK, Brentford, UK
| | | | - Afisi S Ismaila
- Value Evidence and Outcomes, GSK, Collegeville, PA, USA
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Chin PQ, Sheu CC, Tsai JR, Chang HL, Lee LY, Chen CY. Establishing Quality of Life in Southern Taiwan COPD Patients Using Long-Acting Bronchodilator. Patient Prefer Adherence 2022; 16:875-886. [PMID: 35411135 PMCID: PMC8994661 DOI: 10.2147/ppa.s355023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/19/2022] [Indexed: 12/13/2022] Open
Abstract
Background To assess the health-related quality of life (HRQoL) of Taiwan patients with different stages of chronic obstructive pulmonary disease (COPD) and using different combination therapies and to explore the factors affecting HRQoL in these patients. Methods This cross-sectional study included outpatient participants aged 35 years old and older who were receiving long-acting bronchodilator treatment in one of two hospitals in Southern Taiwan. Participants were categorized according to their Global Initiative for Obstructive Lung Disease (GOLD) classification as either their COPD group, based on symptoms and exacerbation risk, or their COPD stage, based on spirometry results. Patients' HRQoL was assessed using the St. George's Respiratory Questionnaire score (SGRQ), World Health Organization Quality of Life Quality of Life-BREF (WHOQOL-BREF), and EQ-5D-5L. The total scores of the SGRQ, WHOQOL-BREF, EQ-5D utility index, and EQ-VAS were presented as mean ± standard deviation (SD) among different combination treatments. Univariate and multivariate analyses were used to explore the association of patients' baseline characteristics and environmental factors with HRQoL. Results A total of 218 patients were enrolled in the study. The distribution of patients using GOLD group classification were as follows: 73.39% in group A, 20.19% group B, 1.83% group C and 4.59% group D. Triple therapy patients mostly showed a lower quality of life than other combination therapies, regardless of the GOLD classification system. However, only the SGRQ scores of GOLD groups A and B were significantly different when using different drug combinations (p-value = 0.0072 and 0.0430, respectively). The COPD assessment test (CAT) score, a questionnaire to assess impact of COPD on health status, was found to be associated with all the questionnaires. Conclusion The HRQoL is impaired in patients with COPD, and it deteriorates with an increase of severity. The CAT was the strongest predictor of HRQoL.
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Affiliation(s)
- Pik-Qi Chin
- Master Program in Clinical Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jong-Rung Tsai
- Division of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Cijin Hospital, Kaohsiung, Taiwan
| | - Hsu-Liang Chang
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital; Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Yao Lee
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chung-Yu Chen
- Master Program in Clinical Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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7
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Development of primary care quality indicators for chronic obstructive pulmonary disease using a Delphi-derived method. NPJ Prim Care Respir Med 2022; 32:12. [PMID: 35304476 PMCID: PMC8933430 DOI: 10.1038/s41533-022-00276-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/17/2022] [Indexed: 11/08/2022] Open
Abstract
High-quality care for patients with COPD is necessary. To achieve quality improvement in primary care, the general practitioner and the electronic health record (EHR) play an important role. The aim of this study was to develop a set of evidence-based and EHR extractable quality indicators (QIs) to measure and improve the quality of COPD primary care. We composed a multidisciplinary expert panel of 12 members, including patients, and used a RAND-modified Delphi method. The SMART principle was applied to select recommendations and QIs from international guidelines as well as existing sets of QIs, and these recommendations and QIs were added to an individual written questionnaire. Based on the median score, prioritization and degree of agreement, the recommendations and QIs were rated as having a high, uncertain or low potential to measure the quality of COPD primary care and were then discussed in an online consensus meeting for inclusion or exclusion. After a final validation, a core set of recommendations was translated into QIs. From 37 recommendations, obtained out of 10 international guidelines, and 5 existing indicators, a core set of 18 recommendations and 2 QIs was derived after the rating procedure. The expert panel added one new recommendation. Together, the recommendations and QIs were translated and merged into a final set of 21 QIs. Our study developed a set of 21 evidence-based and EHR-extractable QIs for COPD in primary care. These indicators can be used in an automated quality assessment to measure and improve the quality of COPD primary care.
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Keller TL, Wright J, Donovan LM, Spece LJ, Duan K, Sulayman N, Dominitz A, Curtis JR, Au DH, Feemster LC. Association of Patient and Primary Care Provider Factors with Outpatient COPD Care Quality. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2022; 9:55-67. [PMID: 34915603 PMCID: PMC8893974 DOI: 10.15326/jcopdf.2021.0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
RATIONALE Large gaps exist between guideline-recommended outpatient chronic obstructive pulmonary disease (COPD) care and clinical practice. Seeking to design effective interventions, we identified patient and primary care provider (PCP) characteristics associated with receiving evidence-based COPD care. METHODS We performed an observational study of adults aged ≥ 40 years with clinically diagnosed COPD who received care at 2 University of Washington-affiliated primary care clinics between June 1, 2011, and June 1, 2013. Our primary outcome was the proportion of evidence-based outpatient COPD quality measures received through primary or pulmonary care. Among all patients, we assessed spirometry completion, respiratory symptom identification, smoking status ascertainment, oxygen saturation measurement, and guideline-concordant inhaled therapy prescription. We also determined confirmation of airflow obstruction, oxygen prescription, smoking cessation intervention, and pulmonary rehabilitation referral if eligible. We used multivariable mixed effects linear regression to estimate the association of patient and PCP characteristics with the primary outcome. RESULTS Among 641 patients, 382 were male (59.6%) with mean age 63.6 (standard deviation [SD] 10.6) years. Most patients currently smoked (N=386, 60.2%). Patients saw 150 unique PCPs during 5.3 (SD 3.2) PCP visits, with 107 completing pulmonary referrals (16.7%). Patients received 67.5% (SD 18.4%) of eligible (median 7 [interquartile range 6-7]) evidence-based quality measures. After adjustment, pulmonary referral was associated with a higher receipt of outpatient quality measures (ß117.7%, 95% confidence interval: 12.6%, 22.7%). Patient demographics, comorbidities, and PCP identity/characteristics were not associated with outpatient care quality. CONCLUSIONS The quality of outpatient COPD care was suboptimal. Future studies should investigate if engaging pulmonologists in COPD management improves care quality.
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Affiliation(s)
- Thomas L Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Jennifer Wright
- Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Lucas M Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Laura J Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Kevin Duan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Nadiyah Sulayman
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Alexandria Dominitz
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, United States
| | - David H Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, Washington, United States
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Issac H, Moloney C, Taylor M, Lea J. Mapping of Modifiable Factors with Interdisciplinary Chronic Obstructive Pulmonary Disease (COPD) Guidelines Adherence to the Theoretical Domains Framework: A Systematic Review. J Multidiscip Healthc 2022; 15:47-79. [PMID: 35046662 PMCID: PMC8759995 DOI: 10.2147/jmdh.s343277] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/16/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND COPD guidelines non-concordance is a challenge frequently highlighted by respiratory experts. Despite the provision of comprehensive evidence-based national and international guidelines, the COPD burden to frontline healthcare services has increased in the last decade. Suboptimal guidelines concordance can be disruptive to health-related quality of life (HRQoL), hastening pulmonary function decline and surging overall morbidity and mortality. A lack of concordance with guidelines has created an escalating economic burden on health-care systems. Identifying interdisciplinary interventions to facilitate improved adherence to guidelines may significantly reduce re-admissions, enhance HRQoL amongst patients and their families, and facilitate economic efficiency. MATERIALS AND METHODS This review adhered to the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews and the PRISMA ScR reporting guidelines. Two independent reviewers screened abstracts and full text articles in consonance with inclusion criteria. The convergent integrative JBI method collated quantitative, qualitative and mixed methods studies from nine databases. JBI critical appraisal tools were utilised to assess the quality of research papers. The theoretical domains framework (TDF) along with a specifically developed COPD data extraction tool were adopted as a priori to collect and collate data. Identified barriers and corresponding clinical behavioural change solutions were categorised using TDF domains and behavior change wheel (BCW) to provide future research and implementation recommendations. RESULTS Searches returned 1068 studies from which 37 studies were included (see Figure 1). COPD recommendations identified to be discordant with clinical practice included initiating non-invasive ventilation, over- or under-prescription of corticosteroids and antibiotics, and a lack of discharging patients with a smoking cessation plan or pulmonary rehabilitation. TDF domains with highest frequency scores were knowledge, environmental resources, and clinical behaviour regulation. Electronic order sets/digital proforma with guideline resources at point of care and easily accessible digital community referrals to target both pharmacological and non-pharmacological management appear to be a solution to improve concordance. CONCLUSION Implementation of consistent quality improvement intervention within hospitals for patients with COPD may exclude any implementation gap and prevent readmissions. Electronic proformas with digital referrals will assist with future evaluation audits to prioritise and target interventions to improve guidelines concordance. ETHICS AND DISSEMINATION Ethical approval is not required, and results dissemination will occur through peer-reviewed publication. PROSPERO REGISTRATION NUMBER CRD42020156267.
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Affiliation(s)
- Hancy Issac
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
| | - Clint Moloney
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- College of Health and Biomedicine, Nursing and Midwifery, Victoria University, Melbourne, Australia
- Clinical Community Health and Wellbeing, Research Institute for Health and Sport, Victoria University, Melbourne, Australia
| | - Melissa Taylor
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
| | - Jackie Lea
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, Australia
- Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
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10
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Jian W, Zeng H, Zhang X, Yun C, Xu Z, Chen Y, Shi G, Wang Y, Li Y, Zheng J. Clinical characteristics of patients with chronic obstructive pulmonary disease assessed using GOLD 2016 and GOLD 2018 classifications: a cross-sectional study in China. J Thorac Dis 2021; 13:5701-5716. [PMID: 34795920 PMCID: PMC8575805 DOI: 10.21037/jtd-21-255] [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: 02/08/2021] [Accepted: 07/19/2021] [Indexed: 11/06/2022]
Abstract
Background In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) removed spirometry as a criterion for classifying GOLD risk groups (A–D, low–high risk). Methods In this cross-sectional observational study in China, we used the GOLD 2016 (spirometry included) and 2018 (spirometry eliminated) criteria for classifying GOLD risk groups to describe: the proportion of patients with chronic obstructive pulmonary disease (COPD) in each GOLD risk group; disease severity; demographics and comorbidities. Patients aged ≥40 years with a clinical COPD diagnosis for ≥1 year were included. During a single study visit, patients completed the COPD assessment test, modified Medical Research Council (mMRC) dyspnea scale assessment, and spirometry tests. Demographics, medical history, and treatment data were recorded. Results In total, 838 patients were included. Most patients were male (86.4%), ≥65 years old (58.6%), and current or former smokers (78.5%). By GOLD 2016, the highest proportion of patients were Group D (42.8%), followed by B (28.2%). By GOLD 2018, the highest proportion of patients were Group B (57.3%), followed by A (25.5%). A total of 296 patients (35.3%) were reclassified, either from Group C to Group A or from Group D to Group B. Overall, 36.2% of patients were receiving treatment concordant with GOLD 2016 recommendations; 34.1% were not receiving any inhaled medication. Conclusions The distribution of COPD severity shifted from a high-risk category (by GOLD 2016) to a low-risk category (by GOLD 2018). The high proportion of patients not receiving maintenance medication reflects a high level of under-treatment of the disease.
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Affiliation(s)
- Wenhua Jian
- State Key Laboratory of Respiratory Disease, National Clinical Research Centre for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Huiqing Zeng
- Department of Respiratory Medicine, Zhongshan Hospital Xiamen University, Xiamen, China
| | - Xiaoju Zhang
- Department of Pulmonary and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou, China
| | - Chunmei Yun
- Department of Pulmonary and Critical Care Medicine, Inner Mongolia Autonomous Region People's Hospital, Hohhot, China
| | - Zuojun Xu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Chen
- Department of Respiratory and Critical Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Guochao Shi
- Department of Pulmonary and Critical Care Medicine, Shanghai Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | | | - Yun Li
- GlaxoSmithKline, Shanghai, China
| | - Jinping Zheng
- State Key Laboratory of Respiratory Disease, National Clinical Research Centre for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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11
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Cheng SL, Li YR, Huang N, Yu CJ, Wang HC, Lin MC, Chiu KC, Hsu WH, Chen CZ, Sheu CC, Perng DW, Lin SH, Yang TM, Lin CB, Kor CT, Lin CH. Effectiveness of Nationwide COPD Pay-for-Performance Program on COPD Exacerbations in Taiwan. Int J Chron Obstruct Pulmon Dis 2021; 16:2869-2881. [PMID: 34703221 PMCID: PMC8539057 DOI: 10.2147/copd.s329454] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/05/2021] [Indexed: 12/17/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It has also imposed a substantial economic and social burden on the health care system. In Taiwan, a nationwide COPD pay-for-performance (P4P) program was designed to improve the quality of COPD-related care by introducing financial incentives for health care providers and employing a multidisciplinary team to deliver guideline-based, integrated care for patients with COPD, reducing adverse outcomes, especially COPD exacerbation. However, the results of a survey of the effectiveness of the pay-for-performance program in COPD management were inconclusive. To address this knowledge gap, this study evaluated the effectiveness of the COPD P4P program in Taiwan. Methods This retrospective cohort study used data from Taiwan’s National Health Insurance claims database and nationwide COPD P4P enrollment program records from June 2016 to December 2018. Patients with COPD were classified into P4P and non-P4P groups. Patients in the P4P group were matched at a ratio of 1:1 based on age, gender, region, accreditation level, Charlson Comorbidity Index (CCI), and inhaled medication prescription type to create the non-P4P group. A difference-in-difference analysis was used to evaluate the influence of the P4P program on the likelihood of COPD exacerbation, namely COPD-related emergency department (ED) visit, intensive care unit (ICU) admission, or hospitalization. Results The final sample of 14,288 patients comprised 7144 in each of the P4P and non-P4P groups. The prevalence of COPD-related ED visits, ICU admissions, and hospitalizations was higher in the P4P group than in the non-P4P group 1 year before enrollment. After enrollment, the P4P group exhibited a greater decrease in the prevalence of COPD-related ED visits and hospitalizations than the non-P4P group (ED visit: −2.98%, p<0.05, 95% confidence interval [CI]: −0.277 to −0.086; hospitalization: −1.62%, p<0.05, 95% CI: −0.232 to −0.020), whereas no significant difference was observed between the groups in terms of the changes in the prevalence of COPD-related ICU admissions. Conclusion The COPD P4P program exerted a positive net effect on reducing the likelihood of COPD exacerbation, namely COPD-related ED visits and hospitalizations. Future studies should examine the long-term cost-effectiveness of the COPD P4P program.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, 220, Taiwan.,Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli, Taoyuan, 320, Taiwan
| | - Yi-Rong Li
- Changhua Christian Hospital, Thoracic Medicine Research Center, Changhua, 500, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, 833, Taiwan
| | - Kuo-Chin Chiu
- Division of Chest, Department of Internal Medicine, Poh-Ai Hospital, Luodong, 265, Taiwan
| | - Wu-Huei Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, 404, Taiwan
| | - Chiung-Zuei Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, 701, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, 807, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan
| | - Sheng-Hao Lin
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Tsung-Ming Yang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi Branch, 613, Taiwan
| | - Chih-Bin Lin
- Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, 970, Taiwan
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Ching-Hsiung Lin
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan.,Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, 402, Taiwan.,Department of Recreation and Holistic Wellness, MingDao University, Changhua, 523, Taiwan
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12
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Determinants of Longitudinal Change of Lung Function in Different Gender in a Large Taiwanese Population Follow-Up Study Categories: Original Investigation. J Pers Med 2021; 11:jpm11101033. [PMID: 34683172 PMCID: PMC8537043 DOI: 10.3390/jpm11101033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/09/2021] [Accepted: 10/12/2021] [Indexed: 01/21/2023] Open
Abstract
Chronic lung disease is associated with tremendous social and economic burden worldwide. The aim of this study was to investigate the sex-specific risk factors for changes in lung function in a large longitudinal study. We included 9059 participants from the Taiwan Biobank. None of the participants had a history of smoking, asthma, emphysema or bronchitis. Lung function was assessed using spirometry measurements of forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1). Change in the FEV1/FVC (ΔFEV1/FVC) was calculated as a follow-up FEV1/FVC minus baseline FEV1/FVC. Linear regression analysis was used to identify associations between variables and ΔFEV1/FVC in the male and female participants. After multivariable adjustments, the male participants (vs. females; p = 0.021) were significantly associated with a low ΔFEV1/FVC. In addition, the male participants with low aspartate aminotransferase (AST) (p = 0.003), high alanine aminotransferase (ALT) (p = 0.006) and a low estimated glomerular filtration rate (eGFR) (p = 0.003) were significantly associated with a low ΔFEV1/FVC. For the female participants, low systolic blood pressure (p = 0.005), low diastolic blood pressure (p = 0.031), low AST (p < 0.001), high ALT (p < 0.001) and a low eGFR (p = 0.001) were significantly associated with a low ΔFEV1/FVC. In this large follow-up study, we found that the male participants had a faster decrease in the FEV1/FVC than the female participants. In addition, liver and renal functions were correlated with changes in lung function in both the male and female participants. Our findings provide useful information on sex-specific changes in lung function.
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13
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Total Sleep Time in the Taiwan Obstructive Lung Disease Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137080. [PMID: 34281018 PMCID: PMC8296961 DOI: 10.3390/ijerph18137080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 11/24/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) have been reported to have poor sleep quality. However, total sleep time has not been evaluated in detail among patients with COPD. This retrospective, observational, multicenter research study was performed across six participating hospitals in Taiwan, with a total of 421 adult patients enrolled. Pulmonary function, the Modified British Medical Research Council Dyspnea Scale, the COPD Assessment Test and basic clinical data were assessed. The Pittsburgh Sleep Quality Index was also administered to patients, and the total sleep time was extracted for further analysis. The patients whose total sleep time was between 6 and 7 h had better pulmonary function, and the patients who slept less than 5 h had worse comorbidities. There was a significant higher total sleep time in Global Initiatives for Chronic Obstructive Lung Disease (GOLD) group B compared to GOLD group A. COPD patients who sleep between 5 and 6 h used fewer oral steroids and were less likely to use triple therapy (long-acting beta-agonist, long-acting muscarinic antagonist, inhaled cortical steroid). COPD patients sleeping from 5 to 7 h had better clinical features than those sleeping less than 5 h in terms of pulmonary function, comorbidities and medication usage.
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14
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Twenty years of changes in the disease assessment method of the Global Initiative for Chronic Obstructive Lung Disease. Chin Med J (Engl) 2021; 133:2098-2103. [PMID: 32769487 PMCID: PMC7478485 DOI: 10.1097/cm9.0000000000000920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has been changing for nearly 20 years. GOLD has moved from single assessment using spirometry to a more comprehensive assessment of chronic obstructive pulmonary disease using spirometry, symptoms and exacerbation history. And subsequently, a new assessment system for chronic obstructive pulmonary disease separated spirometric grades from the old assessment system, and classified patients only according to their symptoms and history of exacerbation. The distribution, clinical characteristics, treatment, and prognosis of the new subgroups were different from the old ones. In this review, we will present a brief profile of changes made to the disease assessment method of GOLD, based on the relevant existing literature.
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15
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Martinez FJ, Thomashow B, Sapir T, Simone L, Carter J, Han M. Does Evaluation and Management of COPD Follow Therapeutic Strategy Recommendations? CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2021; 8:230-242. [PMID: 33610138 DOI: 10.15326/jcopdf.2020.0175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction Recommendations for chronic obstructive pulmonary disease (COPD) diagnosis and management requires symptom and exacerbation risk assessment. Adherence to these recommendations appears to be limited. We examined the impact of a COPD quality improvement (QI) program in the Southeastern United States. Methods From 2017 to 2018, nine pulmonary and 15 primary care physicians were included in our study and asked to identify 6 to 7 of their COPD patients using maintenance COPD medications with at least 2 office visits in the past year. A separate group of COPD patients (n=135 pulmonary and 165 primary care) from the same practices were evaluated. Physicians underwent focused, educational, peer-to-peer small group webinars. Data were collected from physicians and their patients using a systematic survey. Chart audits occurred at baseline and 6 months after the webinars. Results The majority of physicians (67%) saw ≥ 20 COPD patients/week. There were important discrepancies between the care clinicians thought they provided, and the care recalled by their patients. Clinicians felt that 33% of their patients experienced at least 2 exacerbations in the past year; 56% of their patients reported this frequency. There was discrepancy in the clinicians' interpretations and the patients' reasons for discontinuing their medications and in the use of referrals. Self-reported changes were noted by clinicians after educational webinars and improvements in patient care were noted in the year following intervention. Conclusion We identified notable discrepancies between the clinicians' impression of care provided and the components actually recalled by their patients. We also identified improvements in processes of care and outcomes following an educational intervention based on the principles of audit and feedback.
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Affiliation(s)
- Fernando J Martinez
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Byron Thomashow
- Columbia University, New York Presbyterian Hospital, New York, New York, United States
| | - Tamar Sapir
- PRIME Education, LLC, Fort Lauderdale, Florida, United States
| | - Laura Simone
- PRIME Education, LLC, Fort Lauderdale, Florida, United States
| | - Jeffrey Carter
- PRIME Education, LLC, Fort Lauderdale, Florida, United States
| | - MeiLan Han
- University of Michigan Health System, Ann Arbor, Michigan, United States
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16
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Correlation between TNF- α -308 and +489 Gene Polymorphism and Acute Exacerbation of Chronic Obstructive Pulmonary Diseases. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6661281. [PMID: 33748274 PMCID: PMC7943264 DOI: 10.1155/2021/6661281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 12/21/2022]
Abstract
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is becoming a common respiratory disease, leading to increased morbidity and mortality worldwide. Tumor necrosis factor-alpha (TNF-α) is a powerful proinflammatory cytokine involved in the pathogenesis of AECOPD. Therefore, we proposed a close correlation between the TNF-α polymorphism [-308G/A (rs1800629), +489G/A (rs1800610)] and the disease progress of patients with AECOPD. Comparison of the TNF-α genotypes between the 198 AECOPD diagnosed patients groups and 195 healthy peoples suggested their significant differences of the three genotypes (AA, GA, GG) distribution for TNF-α -308 (P < 0.05), but no differences of that for TNF-α +489. We found that patients with TNF-α -308 GA/AA genotypes showed smaller adjacent arterial diameter, thicker bronchial wall, higher bronchial artery ratio, higher bronchial wall grading, and higher frequency of acute exacerbations than those with TNF-α -308 GG genotype. Patients with TNF-α +489 GA/AA genotypes showed the same AECOPD properties as patients with TNF-α -308 except for the high frequency of acute exacerbations. Further experiment showed that the TNF-α -308 and+489 gene polymorphisms could affect the expression level of TNF-α in macrophages, suggesting the involvement of the macrophage population in disease regulation of AECOPD patients with TNF-α -308G/A and+489G/A genotype heterogeneity. In conclusion, the TNF-α -308 G/A genotype was related to AECOPD susceptibility and progress, while the TNF-α +489G/A genotype was related to AECOPD progress, but not AECOPD susceptibility.
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17
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Kang J, Lee JS, Lee SW, Lee JB, Oh YM. Dual versus monotherapy with bronchodilators in GOLD group B COPD patients according to baseline FEV 1 level: a patient-level pooled analysis of phase-3 randomized clinical trials. Respir Res 2021; 22:55. [PMID: 33579288 PMCID: PMC7881547 DOI: 10.1186/s12931-021-01648-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Which patients should receive dual therapy as initial treatment for chronic obstructive pulmonary disease (COPD) is only loosely defined. We evaluated if a lower forced expiratory volume in 1 s (FEV1) identifies a population more likely to benefit from dual therapy than monotherapy among group B COPD patients in whom Global initiative for Chronic Obstructive Pulmonary Disease (GOLD) recommends monotherapy as initial treatment. Methods This was a patient-level pooled analysis of phase-3 randomized controlled trials involving dual bronchodilators. Study patients were classified into two groups based on the FEV1 of 50% of the predicted value (GOLD I/II versus GOLD III/IV). We evaluated the efficacy of dual versus monotherapy (long-acting beta-2 agonist [LABA] or long-acting muscarinic antagonist [LAMA]) between these two groups in the following outcomes: changes in trough FEV1, the St. George’s Respiratory Questionnaire (SGRQ) score, the proportion of SGRQ responders, time to first exacerbation, and risk of adverse events. Results A total of 14,449 group B patients from 12 studies were divided into GOLD III/IV (n = 8043) or GOLD I/II group (n = 6406). In the GOLD III/IV group, dual therapy was significantly more effective in improving FEV1, reducing SGRQ scores, and achieving a higher proportion of SGRQ responders compared with either LABA or LAMA. Dual therapy also showed a significantly longer time to first exacerbation compared with LABA in the GOLD III/IV group. In contrast, in the GOLD I/II group, the benefits of dual therapy over monotherapy were less consistent. Although dual therapy resulted in significantly higher FEV1 than either LABA or LAMA, it did not show significant differences in the SGRQ score and proportion of SGRQ responders as compared with LABA. The time to first exacerbation was also not significantly different between dual therapy and either LABA or LAMA in the GOLD I/II group. Conclusions Dual therapy demonstrated benefits over monotherapy more consistently in patients with lower FEV1 than those with higher FEV1.
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Affiliation(s)
- Jieun Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Seoul, Republic of Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Seoul, Republic of Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, 88 Olympic-ro 43-gil, Seoul, Republic of Korea.
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Seoul, Republic of Korea.
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Pulmonologists Adherence to the Chronic Obstructive Pulmonary Disease GOLD Guidelines: A Goal to Improve. ACTA ACUST UNITED AC 2020; 56:medicina56090422. [PMID: 32825456 PMCID: PMC7558424 DOI: 10.3390/medicina56090422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/05/2020] [Accepted: 08/19/2020] [Indexed: 01/09/2023]
Abstract
Background and objectives: Data about pulmonologist adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines showed a great variability and cannot be extrapolated. The present study investigates the current pharmacological prescribing practices in the treatment of chronic obstructive pulmonary disease (COPD) according to the 2017 GOLD guidelines, to determine the level of pulmonologist adherence and to identify possible factors that influence physician adherence. Materials and methods: This retrospective study took place between 1 February and 30 April 2018 in Pneumophtysiology Clinical Hospital Cluj-Napoca. We included 348 stable COPD outpatients classified according to the 2017 GOLD strategy in the ABCD risk groups. Pulmonologist adherence was defined as appropriate if the recommended pharmacological therapy was the first- or alternative-choice drug according to the guidelines, and inappropriate (overtreatment, undertreatment) if it was not in line with these recommendations. Results: The most prescribed treatment was the combination long-acting beta agonist (LABA) + long-acting antimuscarinic agent (LAMA) (34.77%), followed by LAMA + LABA + inhaled corticosteroid (ICS). Overall, pneumologist adherence was 79.02%. The most inappropriate therapies were in Group B (33.57%), followed by 33.33% in Group A. Compared to Groups C and D (analyzed together), Groups A and B had a 4.65 times higher chance (p = 0.0000001) of receiving an inappropriate therapy. Patients with cardiovascular comorbidities had a 1.89 times higher risk of receiving an inappropriate therapy (p = 0.021). ICS overprescription was the most common type of inappropriateness (17.81%). Groups C and D had a 3.12 times higher chance of being prescribed ICS compared to Groups A and B (p = 0.0000004). Conclusions: Pulmonologist adherence to the GOLD guidelines is not optimal and needs to be improved. Among the factors that influence the inappropriateness of COPD treatments, cardiovascular comorbidities and low-risk Groups A and B are important. ICS represent the most prescribed overtreatment. Further multicentric studies are needed to evaluate all factors that might influence the adherence rate.
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Yazar EE, Yiğitbaş B, Niksarlıoğlu EY, Bayraktaroğlu M, Kul S. Is group C really needed as a separate group from D in COPD? A single-center cross-sectional study. Pulmonology 2020; 29:188-193. [PMID: 32753319 DOI: 10.1016/j.pulmoe.2020.06.012] [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: 04/16/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION GOLD 2017 report proposed that the combined COPD assessment should be done according only to symptom burden and exacerbation history in the previous year. OBJECTIVE This study aims to investigate the change in the COPD groups after the GOLD 2017 revision and also to discuss the evaluation of group C and D as a single group after the GOLD 2019 report. METHOD The study was designed as a cross-sectional. 251 stable COPD patients admitted to our out-patient clinic; aged ≥40 years, at least one-year diagnosis of COPD and ≥10 pack-year smoking history were consecutively recruited for the study. RESULTS In GOLD 2017, a significant difference was found between the distribution of all groups compared to GOLD 2011 (P = 0,001). 31 patients included in group C were reclassified into group A and 37 patients in group D were reclassified into group B. The FEV1 values of group A and B patients were significantly low and group C and D patients had had exacerbations in more frequently the previous year in GOLD 2017 compared to GOLD 2011. CONCLUSION After the GOLD 2017 revision, the rate of group C patients decreased even more compared to GOLD 2011 and the group C and D may be considered as a single group in terms of the treatment recommendations with the GOLD 2019 revision. We think that future prospective studies are needed to support this suggestion.
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Affiliation(s)
- E E Yazar
- İstanbul Aydın University, Faculty of Medicine, Department of Chest Diseases, Küçükçekmece, Istanbul, 34295, Turkey.
| | - B Yiğitbaş
- Yedikule Chest Disease and Thorasic Surgery Training and Research Hospital, Zeytinburnu, Istanbul, TR 34100, Turkey
| | - E Y Niksarlıoğlu
- Yedikule Chest Disease and Thorasic Surgery Training and Research Hospital, Zeytinburnu, Istanbul, TR 34100, Turkey
| | - M Bayraktaroğlu
- İstanbul Aydın University, Faculty of Medicine, Department of Chest Diseases, Küçükçekmece, Istanbul, 34295, Turkey
| | - S Kul
- Seval KUL, School of Medicine, University of Gaziantep, Gaziantep, TR 27310, Turkey
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Keller T, Spece LJ, Donovan LM, Udris E, Coggeshall SS, Griffith M, Bryant AD, Casaburi R, Cooper JA, Criner GJ, Diaz PT, Fuhlbrigge AL, Gay SE, Kanner RE, Martinez FJ, Panos RJ, Shade D, Sternberg A, Stibolt T, Stoller JK, Tonascia J, Wise R, Yusen RD, Au DH, Feemster LC. Association of Guideline-Recommended COPD Inhaler Regimens With Mortality, Respiratory Exacerbations, and Quality of Life: A Secondary Analysis of the Long-Term Oxygen Treatment Trial. Chest 2020; 158:529-538. [PMID: 32278779 DOI: 10.1016/j.chest.2020.02.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/04/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Although inhaled therapy reduces exacerbations among patients with COPD, the effectiveness of providing inhaled treatment per risk stratification models remains unclear. RESEARCH QUESTION Are inhaled regimens that align with the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy associated with clinically important outcomes? STUDY DESIGN AND METHODS We conducted secondary analyses of Long-term Oxygen Treatment Trial (LOTT) data. The trial enrolled patients with COPD with moderate resting or exertional hypoxemia between 2009 and 2015. Our exposure was the patient-reported inhaled regimen at enrollment, categorized as either aligning with, undertreating, or potentially overtreating per the 2017 GOLD strategy. Our primary composite outcome was time to death or first hospitalization for COPD. Additional outcomes included individual components of the composite outcome and time to first exacerbation. We generated multivariable Cox proportional hazard models across strata of GOLD-predicted exacerbation risk (high vs low) to estimate between-group hazard ratios for time to event outcomes. We adjusted models a priori for potential confounders, clustered by site. RESULTS The trial enrolled 738 patients (73.4% men; mean age, 68.8 years). Of the patients, 571 (77.4%) were low risk for future exacerbations. Of the patients, 233 (31.6%) reported regimens aligning with GOLD recommendations; most regimens (54.1%) potentially overtreated. During a 2.3-year median follow-up, 332 patients (44.9%) experienced the composite outcome. We found no difference in time to composite outcome or death among patients reporting regimens aligning with recommendations compared with undertreated patients. Among patients at low risk, potential overtreatment was associated with higher exacerbation risk (hazard ratio, 1.42; 95% CI, 1.09-1.87), whereas inhaled corticosteroid treatment was associated with 64% higher risk of pneumonia (incidence rate ratio, 1.64; 95% CI, 1.01-2.66). INTERPRETATION Among patients with COPD with moderate hypoxemia, we found no difference in clinical outcomes between inhaled regimens aligning with the 2017 GOLD strategy compared with those that were undertreated. These findings suggest the need to reevaluate the effectiveness of risk stratification model-based inhaled treatment strategies.
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Affiliation(s)
- Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Laura J Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Lucas M Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Edmunds Udris
- Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Scott S Coggeshall
- Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Matthew Griffith
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Alexander D Bryant
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Richard Casaburi
- Los Angeles Biomedical Research Institute at Harbor - UCLA Medical Center, Torrance, CA
| | - J Allen Cooper
- Birmingham VA Medical Center and the Lung Health Center, University of Alabama Birmingham, Birmingham, AL
| | | | - Philip T Diaz
- 201 Heart Lung Institute, Ohio State University School of Medicine, Columbus, OH
| | | | - Steven E Gay
- University of Michigan School of Medicine, Ann Arbor, MI
| | | | | | - Ralph J Panos
- Cincinnati VA Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Shade
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Alice Sternberg
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Thomas Stibolt
- Kaiser Permanente Center for Health Research, Portland, OR
| | | | - James Tonascia
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Robert Wise
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roger D Yusen
- Washington University School of Medicine, Saint Louis, MO
| | - David H Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Health Services Research & Development Center of Innovation for Veteran-centered and Value-driven Care, VA Puget Sound Healthcare System, Seattle, WA
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21
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Adherence of North-African Pulmonologists to the 2017-Global Initiative for Chronic Obstructive Lung Disease (GOLD) Pharmacological Treatment Guidelines (PTGs) of Stable Chronic Obstructive Pulmonary Disease (COPD). BIOMED RESEARCH INTERNATIONAL 2020; 2020:1031845. [PMID: 32190644 PMCID: PMC7066397 DOI: 10.1155/2020/1031845] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 02/07/2023]
Abstract
Background No previous study has investigated the adherence rate of North-African pulmonologists to the 2017-GOLD PTGs. Aims To investigate the adherence rate of Tunisian pulmonologists to the 2017-GOLD PTGs and to identify the barriers to their adherence. Methods This was a cohort study involving clinically stable COPD patients who presented to a pulmonology outpatient consultation. The patients were classified as having been appropriately and inappropriately (over- or undertreatment) treated for the GOLD group. Logistic regression was performed to determine the adherence barriers to the 2017-GOLD PTGs. Results A total of 296 patients were included (88.1% males, mean age: 68 ± 10 years; GOLD A (7.1%), B (36.1%), C (4.1%), and D (52.7%)). The pulmonologists' adherence rate to the 2017-GOLD PTGs was 29.7%. There was a significant statistical difference between the adherence rates among the four GOLD groups (A: 19.0%, B: 20.6%, C: 8.3%, and D: 39.1%; p = 0.001). Differences were statistically significant between the GOLD group D and groups B (p = 0.001). Differences were statistically significant between the GOLD group D and groups B (p = 0.001). Differences were statistically significant between the GOLD group D and groups B (. Conclusion The adherence rate of Tunisian pulmonologists to the 2017-GOLD PTGs is low. It seems that the patients' age, socioeconomic level, national health insurance coverage, and GOLD groups influenced their adherence.
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Rodrigues C, Alfaro T, Fernandes L, Ferreira P, Silva S, Costa JC, Fernandes V, Seixas E, Viana R. Does practice follow evidence-based guidelines? Adherence to GOLD guidelines in Portugal. Pulmonology 2019; 25:177-179. [PMID: 31000443 DOI: 10.1016/j.pulmoe.2019.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/08/2019] [Accepted: 02/24/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- C Rodrigues
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Coimbra, Portugal.
| | - T Alfaro
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra - Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - L Fernandes
- Pulmonology Department, Hospital Distrital da Figueira da Foz, Figueira da Foz, Portugal
| | - P Ferreira
- Pulmonology Department, Centro Hospitalar do Baixo Vouga - Hospital Infante D. Pedro, Aveiro, Portugal
| | - S Silva
- Pulmonology Department, Centro Hospitalar de Leiria - Hospital de Santo André, Leiria, Portugal
| | - J C Costa
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Coimbra, Portugal
| | - V Fernandes
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra - Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - E Seixas
- Pulmonology Department, Centro Hospitalar do Baixo Vouga - Hospital Infante D. Pedro, Aveiro, Portugal
| | - R Viana
- Pulmonology Department, Centro Hospitalar de Leiria - Hospital de Santo André, Leiria, Portugal
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