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Zhang C, Song J, Wang J. Meta-analysis of peripheral blood eosinophils in clinical testing of chronic obstructive pulmonary disease patients. Postepy Dermatol Alergol 2024; 41:155-163. [PMID: 38784932 PMCID: PMC11110220 DOI: 10.5114/ada.2024.139124] [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: 11/18/2023] [Accepted: 12/11/2023] [Indexed: 05/25/2024] Open
Abstract
Introduction Meta-analysis was used to investigate the relationship between peripheral blood eosinophil (EOS) levels, clinical characteristics, and prognosis in chronic obstructive pulmonary disease (COPD)patients in previous literature. Aim To analyse the correlation between peripheral blood EOS levels and clinical characteristics and prognosis of patients with COPD using meta-analysis. Material and methods In databases such as PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wan Fang Data, literature related to the clinical characteristics or prognosis of COPD patients with high-level EOS published before July 2023 was searched for meta-analysis. Results Through computer search and screening, 29 articles were ultimately included. The meta-analysis results showed that compared to conventional EOS levels, COPD patients with high EOS levels had a lower proportion of GOLD III-IV grade patients (OR = 00.78, 95% CI (0.68, 0.88), p < 0.001), lower CAT scores (OR = -1.01, 95% CI (-1.75, -0.28), p = 0.007), shorter hospital stay (OR = -1.33, 95% CI (-1.52, -1.14), p < 0.001), and lower mortality rate (OR = 0.53, 95% CI (0.42, 0.66), p < 0.001). The readmission rate was low (OR = 0.40, 95% CI (0.33, 0.48), p < 0.001), and there was no statistically significant difference in FEV1%pred (OR = -0.55, 95% CI (-1.33, 0.23), p = 0.17), higher FEV1/FVC values (OR = -0.45, 95% CI (-1.08, 0.18), p = 0.160), and mechanical ventilation usage rate (OR = 0.89, 95% CI (0.65, 1.21), p = 0.450) among COPD patients with different EOS levels. Conclusions The levels of peripheral blood EOS in COPD patients are related to lung function, respiratory symptoms, etc.; Moreover, COPD patients with high-level EOS have shorter hospital stays, lower mortality and readmission rates. Therefore, ESO can be used as an auxiliary indicator for clinical symptom diagnosis of COPD patients and as an auxiliary indicator for predicting prognosis.
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Affiliation(s)
- Chunmei Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jie Song
- Department of Pulmonary and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jinxiang Wang
- Department of Pulmonary and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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Klitgaard A, Ibsen R, Lykkegaard J, Hilberg O, Løkke A. National Development in the Use of Inhaled Corticosteroid Treatment in Chronic Obstructive Pulmonary Disease: Repeated Cross-Sectional Studies from 1998 to 2018. Biomedicines 2024; 12:372. [PMID: 38397973 PMCID: PMC10886715 DOI: 10.3390/biomedicines12020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Recommendations for the treatment of chronic obstructive pulmonary disease (COPD) have shifted towards a more restrictive use of inhaled corticosteroids (ICS). We aimed to identify the nationwide development over time in the use of ICS treatment in COPD. We conducted a register-based repeated cross-sectional study using Danish nationwide registers. On a yearly basis from 1998 to 2018, we included all patients in Denmark ≥ 40 years of age with an ICD-10 diagnosis of COPD (J44). Accumulated ICS use was calculated for each year based on redeemed prescriptions. Patients were divided into the following groups: No ICS, low-dose ICS, medium-dose ICS, or high-dose ICS. From 1998 to 2018, the yearly proportion of patients without ICS treatment increased (from 50.6% to 57.6%), the proportion of patients on low-dose ICS treatment increased (from 11.3% to 14.9%), and the proportion of patients on high-dose ICS treatment decreased (from 17.0% to 9.4%). We demonstrated a national reduction in the use of ICS treatment in COPD from 1998 to 2018, with an increase in the proportion of patients without ICS and on low-dose ICS treatment and a decrease in the proportion of patients on high-dose ICS treatment.
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Affiliation(s)
- Allan Klitgaard
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | | | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 6705 Esbjerg, Denmark;
| | - Ole Hilberg
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
| | - Anders Løkke
- Department of Regional Health Research, University of Southern Denmark, 5230 Odense, Denmark; (O.H.); (A.L.)
- Department of Internal Medicine Vejle, University Hospital of Southern Denmark, 7100 Vejle, Denmark
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Duan KI, Donovan LM, Spece LJ, Feemster LC, Bryant AD, Plumley R, Collins MP, Au DH. Trends and Rural-Urban Differences in the Initial Prescription of Low-Value Inhaled Corticosteroids among U.S. Veterans with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:668-676. [PMID: 36867427 PMCID: PMC10174122 DOI: 10.1513/annalsats.202205-458oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
Rationale: Guidelines recommend inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) and select indications, including asthma history, high exacerbation risk, or high serum eosinophils. ICS are commonly prescribed outside of these indications, despite evidence of harm. We defined a "low-value" ICS prescription as the receipt of an ICS without evidence of a guideline-recommended indication. ICS prescription patterns are not well characterized and could inform health system interventions to reduce low-value practices. Objectives: To evaluate the national trends in initial low-value ICS prescriptions in the U.S. Department of Veterans Affairs and to determine whether rural-urban differences in low-value ICS prescribing exist. Methods: We performed a cross-sectional study between January 4, 2010, and December 31, 2018, identifying veterans with COPD who were new users of inhaler therapy. We defined low-value ICS as prescriptions in patients with 1) no asthma, 2) low risk of future exacerbation (Global Initiative for Chronic Obstructive Lung Disease group A or B), and 3) serum eosinophils <300 cells/μl. We performed multivariable logistic regression to evaluate trends in low-value ICS prescription over time, adjusting for potential confounders. We performed fixed effects logistic regression to assess rural-urban prescribing patterns. Results: We identified a total of 131,009 veterans with COPD starting inhaler therapy, 57,472 (44%) of whom were prescribed low-value ICS as initial therapy. From 2010 to 2018, the probability of receiving low-value ICS as initial therapy increased by 0.42 percentage points per year (95% confidence interval, 0.31-0.53). Compared with urban residence, rural residence was associated with a 2.5-percentage-point (95% confidence interval, 1.9-3.1) higher probability of receiving low-value ICS as initial therapy. Conclusions: The prescription of low-value ICS as initial therapy is common and increasing slightly over time for both rural and urban veterans. Given the widespread and persistent nature of low-value ICS prescribing, health system leaders should consider system-wide approaches to address this low-value prescribing practice.
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Affiliation(s)
- Kevin I. Duan
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Lucas M. Donovan
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Laura J. Spece
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | - Laura C. Feemster
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
| | | | - Robert Plumley
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Margaret P. Collins
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - David H. Au
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington; and
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Flor-Escriche X, Sanz Bas A, Álvarez Álvarez S, Zamora Putin V, Monteagudo Zaragoza M. Riesgos, fenotipos y comparación de tratamiento de EPOC en atención primaria según guías GOLD y GesEPOC. Semergen 2022; 48:101839. [DOI: 10.1016/j.semerg.2022.101839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/22/2022] [Accepted: 09/02/2022] [Indexed: 11/22/2022]
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Sethi S, Wright A, Hartgers-Gubbels ES, Hechtner M, Clark B, Wright C, Langham S, Buhl R. Costs and Clinical Consequences of Compliance with COPD GOLD Recommendations or National Guidelines Compared with Current Clinical Practice in Belgium, Germany, Sweden, and the United States. Int J Chron Obstruct Pulmon Dis 2022; 17:2149-2160. [PMID: 36101790 PMCID: PMC9464634 DOI: 10.2147/copd.s371440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose The objective of this study was to assess the clinical and cost benefits of treating patients with chronic obstructive pulmonary disease (COPD) according to global and national guidelines compared to real-life clinical practice in the United States and three European countries (Belgium, Germany, Sweden). Patients and Methods A cost-consequence model was developed to compare current prescribing patterns with two alternative scenarios, the first aligned with the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2022) recommendations and the second with national guidelines. Costs and clinical outcomes were modeled for these alternative scenarios over a time horizon of one year, based on real-world evidence and health insurance data. Results Current clinical practice in each of the countries was inconsistent with published recommendations. A redistribution to prescribing patterns according to global and national recommendations led to a substantial decrease in the use of inhaled corticosteroid (ICS) containing therapies of more than 80% and 44%, respectively. There was a reduced incidence of up to 16% of mild-to-moderate pneumonia and up to 29% of severe pneumonia. Exacerbations decreased across all countries apart from Sweden, where a small increase in the rate of exacerbations was due to the redistribution of some patients currently undergoing inhaled triple therapy to non-ICS-containing therapies. Adapting treatment to recommendations could provide potential cost savings of up to 13% in estimated annual direct costs, resulting predominantly from the reduction in cost of healthcare resource use, including hospitalization associated with treating incident pneumonia, particularly severe pneumonia. Cost savings for prevalent adult patients with COPD on long-acting inhaler therapy ranged from €31 to €675 per patient per year. Conclusion Redistribution of COPD patients from current clinical practice to treatment according to published recommendations would provide clinical benefits and substantial cost savings.
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Affiliation(s)
- Sanjay Sethi
- Pulmonary/Critical Care/Sleep Medicine, University at Buffalo, State University of New York, Buffalo, NY, USA
| | | | | | | | - Brendan Clark
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | | | - Sue Langham
- Maverex Ltd., Newcastle Upon Tyne, NE6 2HL, UK
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
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Sulku J, Janson C, Melhus H, Ställberg B, Bröms K, Högman M, Lisspers K, Malinovschi A, Nielsen EI. Changes in critical inhaler technique errors in inhaled COPD treatment – A one-year follow-up study in Sweden. Respir Med 2022; 197:106849. [DOI: 10.1016/j.rmed.2022.106849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/28/2022] [Accepted: 04/06/2022] [Indexed: 12/01/2022]
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Larsson K, Ekberg-Jansson A, Stridsman C, Hanno M, Vanfleteren LEGW. Adherence to Treatment Recommendations for Chronic Obstructive Pulmonary Disease - Results from the Swedish National Airway Register. Int J Chron Obstruct Pulmon Dis 2021; 16:909-918. [PMID: 33854309 PMCID: PMC8039432 DOI: 10.2147/copd.s300299] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Swedish guidelines adhere to the international GOLD document regarding management of chronic obstructive pulmonary disease (COPD). Based on data from the Swedish National Airway Register (SNAR) the aim was to evaluate adherence to guidelines of pharmacological treatment of COPD in Swedish primary and secondary care. METHODS During a period of 18 months, data on symptoms (CAT, mMRC), lung function, exacerbation history and pharmacological treatment from 15,595 COPD patients from 853 primary care and 125 secondary care clinics were collected from SNAR. Patients with a co-diagnosis of asthma were excluded. Patients were divided into four treatment groups: no pharmacological treatment, short-acting bronchodilators alone, long-acting bronchodilators alone and ICS alone or in combination with bronchodilators. RESULTS Of the patients, 29% were in GOLD group A, 58% in group B, 2% in group C and 11% in group D. CAT score was ≥10 and mMRC score was below 2 in 30.9% of the patients and mMRC score was ≥2 and CAT score <10 in 4.2% of the patients. In 61.4% of the patients, no exacerbation was registered during the last year. Long-acting bronchodilators were prescribed for 78% and ICS for 46% of all patients. In groups A, B, C and D, respectively, 21%, 11%, 11% and 5% did not receive any inhaler therapy; 67%, 81%, 81% and 90% received long-acting bronchodilators; 33%, 46%, 55% and 71% received any ICS containing therapy and 19%, 34%, 39% and 61% received triple therapy. DISCUSSION Data from the SNAR indicate that only a minority of COPD patients were untreated. There was a liberal use of ICS containing drug combinations in subjects who do not have an indication for ICS. A considerable proportion of subjects at high risk of exacerbations did not receive ICS treatment.
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Affiliation(s)
- Kjell Larsson
- Integrative Toxicology, National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ann Ekberg-Jansson
- Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Caroline Stridsman
- Department of Public Health and Clinical Medicine, Division of Medicine, Umeå University, Umeå, Sweden
| | | | - Lowie E G W Vanfleteren
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, 413 45, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 413 45, Sweden
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Larsson K, Janson C, Lisspers K, Ställberg B, Johansson G, Gutzwiller FS, Mezzi K, Bjerregaard BK, Jorgensen L. The Impact of Exacerbation Frequency on Clinical and Economic Outcomes in Swedish COPD Patients: The ARCTIC Study. Int J Chron Obstruct Pulmon Dis 2021; 16:701-713. [PMID: 33776429 PMCID: PMC7987259 DOI: 10.2147/copd.s297943] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/04/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The aim of this study was to assess the association between exacerbation frequency and clinical and economic outcomes in patients with COPD. PATIENTS AND METHODS Electronic medical record data linked to National Health Registries were collected from COPD patients at 52 Swedish primary care centers (2000-2014). The outcomes analyzed were exacerbation rate, mortality, COPD treatments, lung function and healthcare costs during the follow-up period. Based on the exacerbation rate two years before index date, the patients were initially classified into three groups, either 0, 1 or ≥2 exacerbations per year. After the index date, the classification into exacerbation groups was updated each year based on the exacerbation rate during the last year of follow-up. A sensitivity analysis was conducted excluding patients with asthma diagnosis from the analysis. RESULTS In total 18,586 COPD patients were analyzed. A majority of the patients (60-70%) who either have had no exacerbation or frequent exacerbations (≥2/year) during the pre-index period remained in their group (ie, with 0 or ≥2 annual exacerbations) during up to 11 years of follow-up. Compared with having no exacerbation, mortality was higher in patients having 1 (HR; 2.06 [1.93-2.20]) and ≥2 (4.58 [4.33-4.84]) exacerbations at any time during the follow-up. Lung function decline was more rapid in patients with frequent exacerbations and there was an almost linear relationship between exacerbations frequency and mortality. Total healthcare costs were higher in the frequent exacerbation group (≥2/year) than in patients with no or one exacerbation annually (p<0.0001 for both). The results did not differ from the main analysis after exclusion of patients with a concurrent asthma diagnosis. CONCLUSION In addition to faster lung function decline and increased mortality, frequent exacerbations in COPD patients imply a significant economic burden.
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Affiliation(s)
- Kjell Larsson
- Integrative Toxicology, The National Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Gunnar Johansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Karen Mezzi
- Novartis Pharma AG, Global Patient Access, Basel, Switzerland
| | | | - Leif Jorgensen
- IQVIA Solutions, Real World Evidence Solutions, Copenhagen, Denmark
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Sulku J, Bröms K, Högman M, Janson C, Lisspers K, Malinovschi A, Melhus H, Ställberg B, Nielsen EI. Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations. NPJ Prim Care Respir Med 2021; 31:5. [PMID: 33563979 PMCID: PMC7873256 DOI: 10.1038/s41533-021-00218-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
A correct use of inhaler devices is essential in chronic obstructive pulmonary disease (COPD) treatment. Critical errors were studied by analysing 659 video-recorded demonstrations of inhaler technique from 364 COPD patients using six different inhaler device models. The majority of the included patients used two (55%) or more (20%) device models. Overall, 66% of the patients made ≥1 critical error with at least one device model. The corresponding numbers for patients using 1, 2 and ≥3 device models were 43%, 70% and 86%, respectively. The only factor associated with making ≥1 critical error was simultaneous use of two (adjusted odds ratios (aOR) 3.17, 95% confidence interval (95% CI) 1.81, 5.64) or three or more (aOR 8.97, 95% CI 3.93, 22.1) device models. In conclusion, the proportion of patients making critical errors in inhaler technique was substantial, particularly in those using several different device models. To obtain optimal COPD treatment, it is important to assess a patient's inhaler technique and to minimise the number of inhaler device models.
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Grants
- Uppsala-Örebro Regional Research Council, Centre for Research & Development, Uppsala university/Region Gävleborg, Bror Hjerpstedt Foundation, Uppsala County Association Against Heart and Lung Diseases
- Uppsala-Örebro Regional Research Council; Centre for Research & Development, Uppsala University/Region Gävleborg
- Uppsala-Örebro Regional Research Council; Centre for Research & Development, Uppsala University/Region Gävleborg; Swedish Heart-Lung Foundation
- Uppsala-Örebro Regional Research Council, County Council Dalarna
- Uppsala-Örebro Regional Research Council, Centre for Clinical Research, Uppsala University, the Swedish Heart-Lung Foundation, the Swedish Heart and Lung Association
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Affiliation(s)
- Johanna Sulku
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.
- Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.
| | - Kristina Bröms
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Marieann Högman
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Clinical Pharmacogenomics and Osteoporosis, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
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Cabrera López C, Mascarós E, Azpeitia A, Villarrubia E. A Simplified Algorithm for the Diagnosis, Treatment, and Management of COPD in Routine Primary Care Practice. Int J Chron Obstruct Pulmon Dis 2020; 15:3347-3355. [PMID: 33364753 PMCID: PMC7751579 DOI: 10.2147/copd.s281422] [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: 09/10/2020] [Accepted: 11/16/2020] [Indexed: 11/23/2022] Open
Abstract
Background Diagnostic and treatment strategies for chronic obstructive pulmonary disease (COPD) vary greatly. Despite international efforts to standardize the management of COPD, two-thirds of primary care patients are not diagnosed, treated, or managed according to current evidence-based guidelines, probably because of the difficulty of applying these in routine practice. The aim of this study was to develop a simplified algorithm for diagnosing, treating, and managing COPD in primary care whose consistency, scientific relevance, and applicability to routine clinical practice met approval bct 3y family doctors (FDs) and pulmonologists. Methods The algorithm was developed in a series of sequential phases, consisting of a preliminary meeting among group coordinators to design the initial structure, an input meeting with FDs and pulmonologists to refine and validate the proposal, an algorithm design stage, and a Delphi survey in which FDs and pulmonologists evaluated and approved the final version. A target of 75% or more was established for each of the 20 items in the Delphi survey in the FDs group as well as the pulmonologists group. It was estimated that at least two Delphi rounds would be needed to reach consensus. Results In total, 118 physicians (75 FDs and 43 pulmonologists) participated in the Delphi process. Fourteen of the 20 items (70%) were approved in the first round. In the second round (in which 74 FDs and 42 pulmonologists participated), the remaining six items, which had been reformulated based on feedback from the first round, were approved, together with an additional question on the face validity of the algorithm as a whole. Dyspnea was positioned as the main determinant of treatment decisions in the new algorithm. Conclusion According to the experts consulted, this new simplified algorithm for the diagnosis, treatment, and management of COPD in primary care is a clear, functional, and useful tool for routine practice and meets the requirements for the correct management of this condition.
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Affiliation(s)
- Carlos Cabrera López
- Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | - Elena Villarrubia
- Health Outcomes Research Department, Advanced Outcomes Research, SL. Barcelona, Spain
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Baron AJ, Flokstra-de Blok BMJ, van Heijst E, Riemersma RA, Sonnenschein-van der Voort AMM, Metting EI, Kocks JWH. Prevalence of Asthma Characteristics in COPD Patients in a Dutch Well-Established Asthma/COPD Service for Primary Care. Int J Chron Obstruct Pulmon Dis 2020; 15:1601-1611. [PMID: 32753860 PMCID: PMC7351624 DOI: 10.2147/copd.s247819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/24/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Primary care COPD guidelines indicate that COPD patients with asthma characteristics should be treated as having asthma. This study aims to describe the prevalence of asthma characteristics in patients with a pulmonologist-confirmed working diagnosis of COPD or ACO. Patients and Methods This retrospective cross-sectional study used real-life data (collected between 2007 and 2017) from a Dutch asthma/COPD-service, a structured web-based system in which pulmonologists support general practitioners in their diagnosis of patients with suspicion of obstructive lung disease. The prevalence of asthma characteristics (history of asthma, atopy, symptoms, and reversibility) and blood eosinophil (Eos) counts were assessed in patients with a working diagnosis of COPD or ACO. Results Of the 14,141 patients, ≥40 years in the dataset, 4475 (31.6%) were diagnosed with asthma, 3532 (25.0%) with COPD, and 1276 (9.0%) with ACO. Asthma characteristics were present in 65.6% (n=1956) of the COPD and 90.9% (n=1059) of the ACO patients. Eos counts of ≥ 300 cells per μL were found in 35.7% (n=924) of the COPD patients and 35.3% (n=341) of the ACO patients. Conclusion In this group of COPD and ACO patients remotely diagnosed by pulmonologists, a substantial proportion would be considered to have asthma characteristics according to the guidelines. This may explain the high number of inhaled corticosteroid (ICS) prescriptions found in primary care COPD patients. Prospective studies are necessary to identify patients who may or may not benefit from ICS containing treatment. Hence, personalized care in primary care can be optimized.
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Affiliation(s)
- Anna Jetske Baron
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, Groningen, the Netherlands
| | - Bertine M J Flokstra-de Blok
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Department of Pediatric Pulmonology and Pediatric Allergology, University of Groningen, University Medical Center Groningen, Beatrix Children’s Hospital, Groningen, the Netherlands
| | - Ellen van Heijst
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Astma/COPD Dienst, CERTE Laboratories, Groningen, the Netherlands
| | - Roland A Riemersma
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Esther I Metting
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore
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Bloom CI, Douglas I, Usmani OS, Quint JK. Inhaled Corticosteroid Treatment Regimens and Health Outcomes in a UK COPD Population Study. Int J Chron Obstruct Pulmon Dis 2020; 15:701-710. [PMID: 32308379 PMCID: PMC7136662 DOI: 10.2147/copd.s241568] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/10/2020] [Indexed: 01/23/2023] Open
Abstract
Background Inhaled corticosteroids (ICS) are a prevailing treatment option for COPD patients but recent guidelines have relegated their use predominantly to patients with frequent exacerbations. Yet large numbers of patients worldwide are currently treated with ICS-containing regimens. We wished to determine in routine clinical practice how common ICS withdrawal is and the differences in health outcomes between patients managed on ICS-containing and non-ICS containing regimens. Patients and Methods COPD patients were identified from the UK primary care electronic healthcare records, between 2014 and 2018. Patients were grouped into three treatment regimens: long-acting beta-agonist (LABA) and inhaled corticosteroids (ICS), LABA and long-acting muscarinic antagonist (LAMA), and triple therapy (LABA, LAMA and ICS). Annual incidence of ICS withdrawal was measured. Multivariable logistic regression was used to identify patient factors associated with withdrawal. Multivariable Poisson regression was used to assess the association of exacerbations and hospitalised pneumonia between the ICS-containing regimens (LABA-ICS and triple therapy) and patients prescribed LABA-LAMA. Results Of 117,046 patients, around three-quarters were prescribed ICS-containing inhalers but ICS withdrawal occurred annually in only approximately 2–3% of patients. Exacerbations in the past year, but not a past history of pneumonia, were associated with ICS withdrawal. A total of 31,034 patients using three treatment regimens (LABA-ICS, LABA-LAMA or triple therapy) were assessed for their relative risk of exacerbations and pneumonia; the exacerbation risk was slightly lower in LABA-ICS users but the same in triple therapy users, as compared to LABA-LAMA users (LABA-ICS adjusted IRR=0.82 (95% CI 0.73–0.93), triple adjusted IRR=0.99 (95% CI 0.88–1.11)). There was no difference in the pneumonia risk (LABA-ICS adjusted IRR=0.96 (95% CI 0.71–1.31), triple adjusted IRR=1.16 (95% CI 0.87–1.57)). Conclusion Use of ICS-containing inhaled medication is prevalent across the UK while ICS withdrawal from established treatment was relatively uncommon. Exacerbations and pneumonia risk was similar between the ICS-containing and non-ICS containing treatment regimens.
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Affiliation(s)
- Chloe I Bloom
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
| | - Ian Douglas
- London School of Hygiene and Tropical Medicine, London, UK
| | - Omar S Usmani
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
| | - Jennifer K Quint
- National Heart Lung Institute, Imperial College London, London SW3 6LR, UK
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