Guideline-based survey of outpatient COPD management by pulmonary specialists in Germany

Risk Factors for Recurrent Exacerbations in the General-Practitioner-Based Swiss Chronic Obstructive Pulmonary Disease (COPD) Cohort

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often suffer from acute exacerbations. Our objective was to describe recurrent exacerbations in a GP-based Swiss COPD cohort and develop a statistical model for predicting exacerbation.

METHODS

COPD cohort demographic and medical data were recorded for 24 months, by means of a questionnaire-based COPD cohort. The data were split into training (75%) and validation (25%) datasets. A negative binomial regression model was developed using the training dataset to predict the exacerbation rate within 1 year. An exacerbation prediction model was developed, and its overall performance was validated. A nomogram was created to facilitate the clinical use of the model.

RESULTS

Of the 229 COPD patients analyzed, 77% of the patients did not experience exacerbation during the follow-up. The best subset in the training dataset revealed that lower forced expiratory volume, high scores on the MRC dyspnea scale, exacerbation history, and being on a combination therapy of LABA + ICS (long-acting beta-agonists + Inhaled Corticosteroids) or LAMA + LABA (Long-acting muscarinic receptor antagonists + long-acting beta-agonists) at baseline were associated with a higher rate of exacerbation. When validated, the area-under-curve (AUC) value was 0.75 for one or more exacerbations. The calibration was accurate (0.34 predicted exacerbations vs 0.28 observed exacerbations).

CONCLUSION

Nomograms built from these models can assist clinicians in the decision-making process of COPD care.

Are We Missing the Opportunity to Disseminate GOLD Recommendations Through AECOPD Discharge Letters?

Introduction

Acute exacerbations in chronic obstructive pulmonary disease (AECOPD) lead to poor outcomes and increased burden for patients and healthcare systems. The Global Initiative for COPD (GOLD) includes specific recommendations for AECOPD interventions, discharge criteria, and follow-up. Aligning the AECOPD discharge letters (DL) with GOLD guidelines could facilitate dissemination of recommendations among general practitioners (GPs).

Purpose

This study was conducted to assess the compliance of DL with the GOLD recommendations in Croatia.

Methods

Pre-pandemic DL of patients presenting for AECOPD to emergency room (ER) were analyzed and stratified by clinical decision to hospitalize (HDL) or discharge patients for outpatient treatment (ERDL). Experienced pulmonologists checked the information from DL against guidelines by using online study-specific questionnaires.

Results

In total, 225 HDL and 368 ERDL were analyzed. In most cases, the GOLD ABCD categories (85% HDL, 92% ERDL) or the spirometry-based degree of severity (90% HDL, 91% ERDL) were not included. The number of AEs in the previous year was recorded, but the specific frequent exacerbator phenotype not explicitly stated. The AE phenotype was included in two thirds of HDL and one third of ERDL. The blood eosinophil count was frequently available, but not considered decision-relevant information. Adjustments of previous maintenance therapy, mostly escalation, were recommended in 58.4% HDL and 27.9% ERDL, respectively. Education on proper use of inhalers was recommended only in 15.6% of HDL. Smoking cessation measures were advised in 23.1% HDL and 7.9% ERDL; pulmonary rehabilitation in 35.6% HDL and 0.8% ERDL. Early follow-up was frequently advised (>50%), but rarely appointed.

Conclusion

Significant deficiencies in compliance with the GOLD guidelines were identified, translating into a missed opportunity for GPs to become acquainted with GOLD recommendations. These findings emphasize the necessity to increase compliance with guidelines first at specialist level and consequent standardization of DL.

Quality Standard Position Statements for Health System Policy Changes in Diagnosis and Management of COPD: A Global Perspective

Introduction

Despite being a leading cause of death worldwide, chronic obstructive pulmonary disease (COPD) is underdiagnosed and underprioritized within healthcare systems. Existing healthcare policies should be revisited to include COPD prevention and management as a global priority. Here, we propose and describe health system quality standard position statements that should be implemented as a consistent standard of care for patients with COPD.

Methods

A multidisciplinary group of clinicians with expertise in COPD management together with patient advocates from eight countries participated in a quality standards review meeting convened in April 2021. The principal objective was to achieve consensus on global health system priorities to ensure consistent standards of care for COPD. These quality standard position statements were either evidence-based or reflected the combined views of the panel.

Results

On the basis of discussions, the experts adopted five quality standard position statements, including the rationale for their inclusion, supporting clinical evidence, and essential criteria for quality metrics. These quality standard position statements emphasize the core elements of COPD care, including (1) diagnosis, (2) adequate patient and caregiver education, (3) access to medical and nonmedical treatments aligned with the latest evidence-based recommendations and appropriate management by a respiratory specialist when required, (4) appropriate management of acute COPD exacerbations, and (5) regular patient and caregiver follow-up for care plan reviews.

Conclusions

These practical quality standards may be applicable to and implemented at both local and national levels. While universally applicable to the core elements of appropriate COPD care, they can be adapted to consider differences in healthcare resources and priorities, organizational structure, and care delivery capabilities of individual healthcare systems. We encourage the adoption of these global quality standards by policymakers and healthcare practitioners alike to inform national and regional health system policy revisions to improve the quality and consistency of COPD care worldwide.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02137-x.

Educational interventions for health professionals managing chronic obstructive pulmonary disease in primary care

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable health condition. COPD is associated with substantial burden on morbidity, mortality and healthcare resources.

OBJECTIVES

To review existing evidence for educational interventions delivered to health professionals managing COPD in the primary care setting.

SEARCH METHODS

We searched the Cochrane Airways Trials Register from inception to May 2021. The Register includes records from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and PsycINFO. We also searched online trial registries and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs. Eligible studies tested educational interventions aimed at any health professionals involved in the management of COPD in primary care. Educational interventions were defined as interventions aimed at upskilling, improving or refreshing existing knowledge of health professionals in the diagnosis and management of COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data and assessed the risk of bias of included studies. We conducted meta-analyses where possible and used random-effects models to yield summary estimates of effect (mean differences (MDs) with 95% confidence intervals (CIs)). We performed narrative synthesis when meta-analysis was not possible. We assessed the overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were: 1) proportion of COPD diagnoses confirmed with spirometry; 2) proportion of patients with COPD referred to, participating in or completing pulmonary rehabilitation; and 3) proportion of patients with COPD prescribed respiratory medication consistent with guideline recommendations.

MAIN RESULTS

We identified 38 studies(22 cluster-RCTs and 16 RCTs) involving 4936 health professionals (reported in 19/38 studies) and 71,085 patient participants (reported in 25/38 studies). Thirty-six included studies evaluated interventions versus usual care; seven studies also reported a comparison between two or more interventions as part of a three- to five-arm RCT design. A range of simple to complex interventions were used across the studies, with common intervention features including education provided to health professionals via training sessions, workshops or online modules (31 studies), provision of practice support tools, tool kits and/or algorithms (10 studies), provision of guidelines (nine studies) and training on spirometry (five studies). Health professionals targeted by the interventions were most commonly general practitioners alone (20 studies) or in combination with nurses or allied health professionals (eight studies), and the majority of studies were conducted in general practice clinics. We identified performance bias as high risk for 33 studies. We also noted risk of selection, detection, attrition and reporting biases, although to a varying extent across studies. The evidence of efficacy was equivocal for all the three primary endpoints evaluated: 1) proportion of COPD diagnoses confirmed with spirometry (of the four studies that reported this outcome, two supported the intervention); 2) proportion of patients with COPD who are referred to, participate in or complete pulmonary rehabilitation (of the four studies that reported this outcome, two supported the intervention); and 3) proportion of patients with COPD prescribed respiratory medications consistent with guideline recommendations (12 studies reported this outcome, the majority evaluated multiple drug classes and reported a mixed effect). Additionally, the low quality of evidence and potential risk of bias make the interpretation more difficult. Moderate-quality evidence (downgraded due to risk of bias concerns) suggests that educational interventions for health professionals probably improve the proportion of patients with COPD vaccinated against influenza (three studies) and probably have little impact on the proportion of patients vaccinated against pneumococcal infection (two studies). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on the frequency of COPD exacerbations (10 studies). There was a high degree of heterogeneity in the reporting of health-related quality of life (HRQoL). Low-quality evidence suggests that educational interventions for health professionals may have little or no impact on HRQoL overall, and when using the COPD-specific HRQoL instrument, the St George's Respiratory Questionnaire (at six months MD 0.87, 95% CI -2.51 to 4.26; 2 studies, 406 participants, and at 12 months MD -0.43, 95% CI -1.52 to 0.67, 4 studies, 1646 participants; reduction in score indicates better health). Moderate-quality evidence suggests that educational interventions for health professionals may improve patient satisfaction with care (one study). We identified no studies that reported adverse outcomes.

AUTHORS' CONCLUSIONS

The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.

Association of Patient and Primary Care Provider Factors with Outpatient COPD Care Quality

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.

The Need for Expanding Pulmonary Rehabilitation Services

Pulmonary rehabilitation is a strongly recommended and effective treatment for people with chronic lung disease. However, access to pulmonary rehabilitation is poor. Globally, pulmonary rehabilitation is accessed by less than 3% of people with chronic lung disease. Barriers to referral, uptake and completion of pulmonary rehabilitation are well documented and linked with organizational, practitioner and patient-related factors. Enhancing the knowledge of health care professionals, family carers, and people with chronic lung disease about the program and its benefits produces modest increases in referral and uptake rates, but evidence of the sustainability of such approaches is limited. Additionally, initiatives focusing on addressing organizational barriers to access, such as expanding services and implementing alternative models to the conventional center-based setting, are not yet widely used in clinical practice. The COVID-19 pandemic has highlighted the urgent need for health care systems to deliver pulmonary rehabilitation programs remotely, safely, and efficiently. This paper will discuss the pressing need to address the issue of the low accessibility of pulmonary rehabilitation. It will also highlight the distinctive challenges to pulmonary rehabilitation delivery in rural and remote regions, as well as low-income countries.

[Pulmonary Rehabilitation in Patients with Chronic Obstructive Airway Diseases]

Pulmonary rehabilitation of asthma and COPD patients can improve their physical performance and quality of life, maintain participation in social and professional life and actively promote self-help. In addition, the resources for acute medical treatment can be spared. In case of COPD, rehabilitation directly after exacerbation can also improve the poor survival prognosis and reduce the risk of emergency hospital readmission. Therefore, pulmonary rehabilitation is an essential component of evidence-based long-term management of both bronchial asthma and, in particular, COPD. In the German healthcare system, however, pneumological rehabilitation is offered only for a small fraction of patients. Despite a very good evidence of pulmonary rehabilitation, especially in COPD patients, their share in all rehabilitation services is remarkably low. It does not even amount to 3 % of all medical rehabilitation measures approved by the German Pension Insurance.

Physician's attitude against COPD guidelines and the choice of first-line treatment for COPD

AIM

Our aim was to evaluate changes in attitudes of pulmonologists in Turkey towards COPD guidelines and their choice of first-line treatments for COPD patients.

MATERIAL-METHOD

333 physicians who completed the questionnaire were included in this cross-sectional questionnaire study. The questionnaire contained demographic data, professional information, extent of guideline use, rationales behind using or not using a guideline. The data was compared with the same survey conducted previously in 2011 and was analyzed by appropriate statistical methods.

RESULTS

80 physicians were resident pulmonologists (24%), 250 physicians were specialists (75.1%). 298 (89.5%) physicians reported that they follow at least one guideline for selection of the appropriate treatment in COPD. The current application of guidelines when compared with the first survey in 2011, was found to be decreased, 91.2% and 89.5%, respectively (p = 0.07). 46.8% (n = 156) of participants thought that guidelines provided the physicians more legal protection (p < 0.001). The number of physicians who didn't follow the guidelines due to workload increased over this period of time (36.8% in 2011, 85.3% in 2018, p < 0.001). The number of physicians using inhaler steroid combinations as their first choice of treatment was found to be similar with the previous survey (p = 0.909).

CONCLUSION

According to the results of previous questionnaire, the application of COPD guidelines has decreased. The number of pulmonologists who declared they have no time for following or applying guidelines has profoundly increased since 2011. Despite the warnings of these guidelines, the use of inhaler steroid combination as a first treatment option in COPD is still common.

Utilization and determinants of use of non-pharmacological interventions in COPD: Results of the COSYCONET cohort

BACKGROUND

Guidelines for chronic obstructive pulmonary disease (COPD) recommend supplementing pharmacotherapy with non-pharmacological interventions. Little is known about the use of such interventions by patients. We analyzed the utilization of a number of non-pharmacological interventions and identified potential determinants of use.

METHODS

Based on self-reports, use of interventions (smoking cessation, influenza vaccination, physiotherapy, sports program, patient education, pulmonary rehabilitation) and recommendation to use were assessed in 1410 patients with COPD. The utilization was analyzed according to sex and severity of disease. Potential determinants of utilization included demographic variables and disease characteristics and were analyzed using logistic regression models.

RESULTS

Influenza vaccination in the previous autumn/winter was reported by 73% of patients. About 19% were currently participating in a reimbursed sports program, 10% received physiotherapy, 38% were ever enrolled in an educational program, and 34% had ever participated in an outpatient or inpatient pulmonary rehabilitation program. Out of 553 current or former smokers, 24% had participated in a smoking cessation program. While reports of having received a recommendation to use mainly did not differ according to sex, women showed significantly (p < 0.05) higher utilization rates than men for all interventions except influenza vaccination. Smoking was a predictor for not having received a recommendation for utilization and also significantly associated with a reduced odds of utilization. We found a correlation between recommendation to use and utilization.

CONCLUSIONS

Utilization of non-pharmacological interventions was lower in men and smokers. A recommendation or offer to use by the physician could help to increase uptake.

Clinical and Functional Characteristics of COPD Patients Across GOLD Classifications: Results of a Multicenter Observational Study

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease. The severity grading systems proposed by the Global initiative for Chronic Obstructive Lung Disease (GOLD) have changed over time. The aim of the study was to evaluate if the different GOLD classifications can capture the complexity of the disease by investigating the distribution of lung function and clinical parameters across the GOLD classification systems. This was an observational, retrospective, multicentre study. COPD patients were stratified according to the GOLD severity grading proposed in the 2007, and to the ABCD assessment tool present in the 2011, and 2017 versions of the initiative. Data from body plethysmography, DLCO, comorbidities, exacerbation history, pharmacological therapy and eosinophil counts were collected. A total of 1360 patients (73.4% males) were included in the analysis. Overall, 37% of the patients were severe-very severe according to GOLD 2007. Compared with GOLD 2011, applying the GOLD 2017 criteria, the proportion of the at risk categories (C and D) was reduced by ∼23%. Impairment in inspiratory capacity, DLCO and the prevalence of emphysema paralleled the GOLD 2007 classification only. The proportion of patients with ≥ 200 eosinophils/µL was higher in GOLD 2007 stages 3-4 compared with stages 1-2 (P = 0.008). Eosinophil levels were similar across risk classes in GOLD 2011 and 2017. Overall, 41.8% and 52.4% of the patients in the low risk groups according to GOLD 2011 and 2017 were exposed to inhaled corticosteroids. The GOLD 2011 and 2017 classifications, despite exploring symptoms and exacerbations, might miss other relevant patients' clinical characteristics such as lung function and phenotypes, which have a significant impact on outcomes and disease severity.

¿Por qué la rehabilitación respiratoria no llega a todos los pacientes de enfermedad pulmonar obstructiva crónica que lo necesitan? Revisión de la literatura

Introducción. La rehabilitación respiratoria (RR) es un tratamiento clave en la enfermedad pulmonar obstructiva crónica, pero aun estando disponible, los pacientes no siempre acceden a ella.Objetivo. Identificar los factores que pueden limitar el acceso a la RR y que se relacionan con los pacientes, los médicos y los fisioterapeutas.Materiales y métodos. Se realizó una revisión de artículos publicados en inglés y español entre 2006 y 2018. Se usaron los términos “COPD”, “chronic obstructive pulmonary disease”, “COLD”, “chronic obstructive lung disease”, “physical therapy modalities”, “rehabilitation”, “health services accessibility” y “patient” en las bases de datos PubMed, PEDro, Scielo e IBECS.Resultados. Se seleccionaron 11 publicaciones. Entre las barreras que afectan a los pacientes destacan el transporte, la condición ambiental, las situaciones personales y algunos factores sociales y contextuales. El conocimiento de los profesionales, sus condiciones de trabajo y sus expectativas sobre beneficio de los protocolos de RR también son factores que condicionan el acceso de los pacientes.Conclusiones. La formación interprofesional de médicos y fisioterapeutas, la implantación de protocolos flexibles a las condiciones de los pacientes y las medidas organizativas e intersectoriales del sistema sanitario pueden facilitar la accesibilidad a la RR de los pacientes.

COPD: Rethinking Patient Management - How to Approach a Challenging Patient Group Successfully

In comparison to other chronically ill people, patients suffering from chronic obstructive pulmonary disease (COPD) have many additional difficulties to face and conquer. Due to the contribution of avoidable causes of their illness ("smokers' lung"), society holds people with COPD responsible for their disease, which in return often leads to stigmatization and social isolation. In addition, COPD patients commonly belong to a less privileged social class, own a low socioeconomic status, and lower education. Their physical symptoms are easily observable and - by employing moderate adherence - treatable. Nonetheless, the influence of COPD on a patient's psyche often plays an overly prominent role during therapy. "There is only half a patient laying on the examination table," a revelation that sums up the current state of COPD research and the result of the expert meeting "Luftschlösser" ("castles in the clouds"), which took place in spring 2018. Within the limits of the meeting, participants identified practically applicable approaches aiming to enhance the patient management of this challenging patient group. These considerations are supposed to support healthcare professionals in their daily work and aim to improve the therapy as well as the outcome for COPD patients.

Administrative databases and clinical governance: The case of COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. However, COPD is still underdiagnosed, undertreated, and not sufficiently prevented. Health administrative databases provide a powerful way of studying COPD in the population.

METHODS

This retrospective study used administrative data, collected during 2011 and 2012, retrieved from 3 Italian local health authorities (LHAs).

RESULTS

The analysis through administrative databases allowed firstly to identify patients with COPD receiving services by the 3 LHAs: The estimated average is ~3% of the population aged ≥40 years. Furthermore, it was also possible to stratify patients by investigating the health consumption in hospitalization for COPD and use of respiratory drugs. In all 3 LHA patients with moderate COPD were the majority of the population with COPD. Finally, it was possible to distinguish patients who made an appropriate use of SABA (76% of the total), patients who had a potentially inappropriate use (20%), and those with an overuse of SABA (4%).

CONCLUSION

The use of SABA consumption patterns can be a reliable proxy variable to detect subgroups who may necessitate therapy revision. Health administrative databases seem beneficial for planning health care interventions, including the COPD field. They are robust information systems subjected to regular data quality controls remaining the prevalent data source, reliable because of the amount of data and the population coverage, especially in countries with a National Health Service System.

COPD Care in the 21st Century: A Public Health Priority

COPD is an underdiagnosed, undertreated, and yet largely preventable disease. COPD affects millions of Americans on a daily basis, accounts for tens of thousands of deaths per year, and costs billions to the United States health-care system annually. Further, it impacts the quality of life for patients living with the disease. COPD care is fragmented in the United States, with a high level of responsibility placed on patients and their primary care physicians. Pulmonary specialists care for a minority of patients with COPD in the United States. Unfortunately, tobacco dependence, which is the leading cause of COPD, remains prevalent. Further, women and those with low socioeconomic status continue to share a relatively greater burden of disease. Exacerbations are experienced frequently by patients and contribute to high rates of emergency department visits and in-patient admissions and readmissions as well as high medical costs to the United States economy. Numerous strategies have been proposed to combat these high rates, including the use of discharge bundles, hospital at-home programs, telemedicine, and tele-rehabilitation, but no single best strategy has emerged. The COPD National Action Plan was introduced in 2017 as part of a multi-stakeholder endeavor to encourage collaboration among various patients, caregivers, physicians, researchers, and policymakers to optimize awareness, diagnosis, and treatment of this disease. It is time to make COPD care a public health priority.

Missed diagnosis and overtreatment of COPD among smoking primary care population in Central Greece: old problems persist

Background

The diagnosis of COPD is not always consistent with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy in daily clinical practice, especially in primary care. This study aimed to estimate the overall COPD prevalence and severity, to identify differences between newly and previously diagnosed patients, and to evaluate the potential COPD overtreatment in a smoking population attending a primary care spirometry surveillance program.

Methods

A study was conducted in 10 primary health care centers of Central Greece during a 7-month period. Eligible participants were aged ≥40 years and were either current smokers or exsmokers.

Results

A total of 186 subjects were included (68% males, mean age 62.3±12.6 years, mean life-time tobacco exposure 50 pack-years). COPD prevalence was 17.8%, identified to be higher in elderly males. Forty-two percent of the COPD group were newly diagnosed patients, who were of younger age, current smokers, presented with less dyspnea and better health status, and mainly appeared with mild-to-moderate disease. Interestingly, 61.4% of non-COPD and 85.7% of newly diagnosed COPD individuals had been using inhaled medication under primary care provider's prescription without ever undergoing spirometry or further evaluation by a pulmonologist; thus, the phenomena of COPD overdiagnosis and missed diagnosis came into the spotlight. Moreover, only 26.3% of known COPD patients were properly medicated according to GOLD guidelines, while half of them were inappropriately treated with triple inhaled therapy.

Conclusion

We reported a significant prevalence of COPD in smoking population attending this spirometry program. A remarkable proportion of COPD patients were undiagnosed and made case finding worthwhile. Underutilization of spirometry in the diagnosis and management of COPD as well as general practitioners' nonadherence to the GOLD treatment guidelines was confirmed by our data. These findings highlight the need for a major overhaul and culture change in primary care settings of Central Greece.

Use of ICS in COPD: From Blockbuster Medicine to Precision Medicine

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality worldwide, whose burden is expected to increase in the next decades, because of numerous risk factors, including the aging of the population. COPD is both preventable and treatable by an effective management including risk factor reduction, prevention, assessment, and treatment of acute exacerbations and co-morbidities. The available agents approved for COPD treatment are long-acting or ultra-long-acting β2-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) bronchodilators, as well as inhaled corticosteroids (ICS) in combination with LABAs. ICS use has been restricted only to selected COPD patients by the most recent documents, mainly based on the risk of exacerbations. However, several observational studies showed a high rate of prescription of ICS in COPD, irrespective of clinical recommendations, questioning the efficacy of these compounds in unselected patients with COPD and leading to possible increase risk of side effects related to ICS use. After examining the low levels of adherence in primary care and in the clinical settings to national and international recommendations for the treatment of COPD in different countries, the most common drivers of the prevailing use of ICS are critically reviewed here by examining their pros and cons, aimed at identifying evidence-based drivers for a proper selection of patients who may benefit from the proper use of ICS.

Interdisciplinary model of care (RADICALS) for early detection and management of chronic obstructive pulmonary disease (COPD) in Australian primary care: study protocol for a cluster randomised controlled trial

INTRODUCTION

Up to half of all smokers develop clinically significant chronic obstructive pulmonary disease (COPD). Gaps exist in the implementation and uptake of evidence-based guidelines for managing COPD in primary care. We describe the methodology of a cluster randomised controlled trial (cRCT) evaluating the efficacy and cost-effectiveness of an interdisciplinary model of care aimed at reducing the burden of smoking and COPD in Australian primary care settings.

METHODS AND ANALYSIS

A cRCT is being undertaken to evaluate an interdisciplinary model of care (RADICALS - Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers). General practice clinics across Melbourne, Australia, are identified and randomised to the intervention group (RADICALS) or usual care. Patients who are current or ex-smokers, of at least 10 pack years, including those with an existing diagnosis of COPD, are being recruited to identify 280 participants with a spirometry-confirmed diagnosis of COPD. Handheld lung function devices are being used to facilitate case-finding. RADICALS includes individualised smoking cessation support, home-based pulmonary rehabilitation and home medicines review. Patients at control group sites receive usual care and Quitline referral, as appropriate. Follow-ups occur at 6 and 12 months from baseline to assess changes in quality of life, abstinence rates, health resource utilisation, symptom severity and lung function. The primary outcome is change in St George's Respiratory Questionnaire score of patients with COPD at 6 months from baseline.

ETHICS AND DISSEMINATION

This project has been approved by the Monash University Human Research Ethics Committee and La Trobe University Human Ethics Committee (CF14/1018 - 2014000433). Results of the study will be disseminated in peer-reviewed journals and research conferences. If the intervention is successful, the RADICALS programme could potentially be integrated into general practices across Australia and sustained over time.

TRIAL REGISTRATION NUMBER

ACTRN12614001155684; Pre-results.

Factors facilitating and hindering the intention to promote pulmonary rehabilitation for patients with COPD among respiratory therapists

Purpose

Pulmonary rehabilitation (PR) is recognized as the chief non-pharmacologic management approach for patients with COPD, but is clinically under-utilized. In Taiwan, respiratory therapists (RTs) are one of the first-line health care providers who spend vast amounts of time with COPD patients in PR programs. To better enhance patients’ knowledge of and participation in PR, it is necessary to understand how PR is viewed by RTs, as well as how these views influence their behavioral intentions toward promoting PR. This study applied the Theory of Planned Behavior (TPB) to investigate both the behavioral intentions and the influential factors surrounding PR in RTs.

Patients and methods

This cross-sectional study used structured self-administered questionnaires at a national symposium for RTs to collect data on their knowledge, attitudes, subjective norms, perceived behavioral controls, and behavioral intentions with regard to promoting PR. Multiple linear regression analysis was used to identify significant factors affecting the intended promotion of PR by RTs.

Results

The response rate after excluding respondents with incomplete data was 88.1% (n=379). A majority of the participants were college graduates, aged over 30 years, and women. The respective percentage scores derived from questionnaires gauging the knowledge, attitudes, subjective norms, self-efficacy, and behavioral intentions components of total PR scores were 63.12%, 71.33%, 68.96%, 66.46%, and 80.29%. The factors significantly affecting RTs’ intentions to suggest PR participation to COPD patients or encourage it were attitudes, subjective norms, and self-efficacy. The total model explained 22.5% of the variance in behavioral intentions.

Conclusion

The results of the study suggest that RTs strongly intend to promote PR, but are hindered by insufficient knowledge, attitudes, and self-efficacy with regard to it. Applying TPB provided insight into which factors can be addressed, and by whom. For example, enhancing RTs’ self-efficacy can be achieved through PR training via school curricula, further regular continuing education and/or courses, and practical experience.

Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework

QUESTION

What are the barriers and enablers of referral, uptake, attendance and completion of pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD)?

DESIGN

Systematic review of qualitative or quantitative studies reporting data relating to referral, uptake, attendance and/or completion in pulmonary rehabilitation.

PARTICIPANTS

People aged >18years with a diagnosis of COPD and/or their healthcare professionals.

DATA EXTRACTION AND ANALYSIS

Data were extracted regarding the nature of barriers and enablers of pulmonary rehabilitation referral and participation. Extracted data items were mapped to the Theoretical Domains Framework (TDF).

RESULTS

A total of 6969 references were screened, with 48 studies included and 369 relevant items mapped to the TDF. The most frequently represented domain was 'Environment' (33/48 included studies, 37% of mapped items), which included items such as waiting time, burden of illness, travel, transport and health system resources. Other frequently represented domains were 'Knowledge' (18/48 studies, including items such as clinician knowledge of referral processes, patient understanding of rehabilitation content) and 'Beliefs about consequences' (15/48 studies, including items such as beliefs regarding role and safety of exercise, expectations of rehabilitation outcomes). Barriers to referral, uptake, attendance or completion represented 71% (n=183) of items mapped to the TDF. All domains of the TDF were represented; however, items were least frequently coded to the domains of 'Optimism' and 'Memory'. The methodological quality of included studies was fair (mean quality score 9/12, SD 2).

CONCLUSION

Many factors - particularly those related to environment, knowledge, attitudes and behaviours - interact to influence referral, uptake, attendance and completion of pulmonary rehabilitation. Overcoming the challenges associated with the personal and/or healthcare system environment will be imperative to improving access and uptake of pulmonary rehabilitation.

TRIAL REGISTRATION

PROSPERO CRD42015015976. [Cox NS, Oliveira CC, Lahham A, Holland AE (2017) Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework. Journal of Physiotherapy 63: 84-93].

Characterization of secondary care for COPD in Sweden

Introduction: Only a selected proportion of chronic obstructive pulmonary disease (COPD) patients are managed in secondary care. The aim of this study was to characterize disease severity, treatment and structure of secondary care for COPD in Sweden. Methods: Information was collected from 29 of 33 existing secondary care units of respiratory medicine in Sweden, using both individual data from 373 consecutively enrolled COPD patients with Global initiative on Obstructive Lung Disease (GOLD) stage III-IV and a structural questionnaire about available resources at the units. Patient data included exacerbations, health status assessed by COPD Assessment Test (CAT), lung function, comorbid conditions, pharmacological treatment and vaccinations. Structural data included available smoking cessation support, multidisciplinary rehabilitation, physical training, patient education and routine follow-up after exacerbations at the respective unit. All patients were reclassified according to the GOLD 2014 group A-D classification. Multiple linear regression investigated associations of available resources with number of exacerbations and CAT score. Results: According to GOLD 2014, 87% of the population were GOLD D and 13% were GOLD C. Triple inhaled therapy were prescribed in 88% of the patients. Over 75% of the units had resources for smoking cessation, multidisciplinary rehabilitation, physical training and patient education. Routine follow-up after exacerbations was available in 35% of the units. Being managed at units with access to structured patient education was associated with statistically significantly fewer exacerbations (adjusted regression coefficient (95% confidence interval) -0.79 (-1.39 to -0.19), p = 0.010). Conclusion: Most stage III-IV COPD patients managed at secondary care respiratory units in Sweden have maximized inhaled therapy and high risk disease even when reclassified according to GOLD 2014. Most units have access to smoking cessation, rehabilitation and patient education. Patients managed at units with structured patient education have a lower exacerbation risk.

Validity and Usability of Physical Activity Monitoring in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Background

A large proportion of COPD patients do not achieve the recommended level of physical activity. It is suggested that feedback on the level of activity by using an activity monitoring device (PAM) increases awareness and may stimulate patients to increase their physical activity in daily life. Our objective was to assess the validity and usability of a simple and low-cost physical activity monitor (Polar A300^™) when compared with the validated and established Bodymedia-SenseWear^™ (SWA) device.

Methods

To assess the diagnostic equivalent, two different PAM devices were used in parallel in 20 COPD patients GOLD I to IV during 3 consecutive days of daily life. Both systems were compared in terms of steps, calories burned, daily activity time and metabolic equivalents using linear regression analysis and Bland-Altman plots. Practical usability was examined by a 16-item-questionnaire.

Results

High correlations of both devices were observed with regard to the sensed step count (r = 0.96; p < 0.01) and calories burned (r = 0.74; p < 0.01), and a lower correlation of daily activity (r = 0.25; p < 0.01) was found. Data analysis over 3 days showed that 90% of the steps (95% CI -4223 to 1887), 100% of the calories (95% CI -2798 to 1887), 90% of the daily activity data (95% CI -12.32, 4065) and 95% of the MET (95% CI -3.11 to 2.75) were within the limits of agreement. A favorable usability (system-, information- and interface quality) of the A300^™ device was shown (p < 0.01).

Conclusion

The A300^™ device with easy practical usability was shown not to be inferior for assessment of physical activity time, step count and calorie consumption in COPD patients when compared with the SWA. It is suggested to consider widespread available devices as commonly used for monitoring recreational sporting activities also in patients for assessment of physical activity in daily life.

Primary Care Physicians', Nurse Practitioners' and Physician Assistants' Knowledge, Attitudes and Beliefs Regarding COPD: 2007 To 2014

To assess current primary care physicians', nurse practitioners' (NP) and physicians assistants' (PA) knowledge, attitudes and beliefs regarding chronic obstructive pulmonary disease (COPD) and changes from a similar 2007 assessment, we surveyed attendees of 3 regional continuing medical education programs and compared the 2013/2014 responses with responses to a similar survey completed in 2007. Survey data included information on personal demographics, agreement with perceived barriers to COPD diagnosis, awareness, and use of COPD guidelines, and beliefs regarding the value of available COPD therapies. In 2013/2014, 426 primary care clinicians (278 medical doctors [MDs] and doctors of osteopathic medicine [DO] and 148 NPs/PAs) provided useable responses (overall response rate 61%). Overall these physicians were older and more experienced than the NPs/PAs but with few other differences in responses except significantly greater physician reported use of spirometry for COPD diagnosis. About half of the clinicians reported having in-office spirometers but less than two thirds reported using them for all COPD diagnoses. All respondents reported multiple barriers to COPD diagnosis but with fewer than in 2007 reporting lack of knowledge or awareness of COPD guidelines as a major barrier. The most striking difference between 2007 and 2013/2014 responses was the marked increase in beliefs by all clinicians in the ability of COPD treatments to reduce symptoms and numbers of exacerbations. These data affirm that primary care clinicians continue to report multiple barriers to COPD diagnosis including lack of easy access to spirometry and frequent failure to include spirometry in diagnostic confirmation. However, since 2007, the clinicians report a remarkable decline in therapeutic nihilism, which may enhance their interest in learning more about diagnosing and managing COPD.

A review of national guidelines for management of COPD in Europe

The quality of care can be improved by the development and implementation of evidence-based treatment guidelines. Different national guidelines for chronic obstructive pulmonary disease (COPD) exist in Europe and relevant differences may exist among them.This was an evaluation of COPD treatment guidelines published in Europe and Russia in the past 7 years. Each guideline was reviewed in detail and information about the most important aspects of patient diagnosis, risk stratification and pharmacotherapy was extracted following a standardised process. Guidelines were available from the Czech Republic, England and Wales, Finland, France, Germany, Italy, Poland, Portugal, Russia, Spain and Sweden. The treatment goals, criteria for COPD diagnosis, consideration of comorbidities in treatment selection and support for use of long-acting bronchodilators, were similar across treatment guidelines. There were differences in measures used for stratification of disease severity, consideration of patient phenotypes, criteria for the use of inhaled corticosteroids and recommendations for other medications (e.g. theophylline and mucolytics) in addition to bronchodilators.There is generally good agreement on treatment goals, criteria for diagnosis of COPD and use of long-acting bronchodilators as the cornerstone of treatment among guidelines for COPD management in Europe and Russia. However, there are differences in the definitions of patient subgroups and other recommended treatments.

Evaluation of the Persian Transcript of the COPD Assessment Test in the Measurement of COPD Health Status in Iranian COPD Patients

AIM

Chronic obstructive pulmonary disease is a completely irreversible obstructive airway disease. The COPD assessment test (CAT) is one of the standard methods for the clinical assessment of the disease, which is translated into Persian. This study investigated the reliability of the test and its relationship with the severity of the disease.

METHODS

In this cross-sectional study, 120 patients filled out the Persian transcript of the test. After two weeks, the patients filled out the CAT test again. Obstruction severity was determined for all the patients using spirometry, and the patients were categorized into four groups according to the Global Initiative for Chronic Obstructive Lung Disease criteria. The relationship between the test scores and the disease severity wan validated.

RESULTS

The mean age of the patients was 51.5 years. The Cronbach's alpha coefficient of the Persian transcript of the test was 0.872 in the first time, and 0.885 in the second time. Intragroup reliability, test re-test and intragroup correlations were significant for all the questions (<0.001). The relationship between the test mean score and obstruction severity was significant, and the correlation between disease categorization in accordance with obstruction severity and categorization according to the test score was significant as well.

CONCLUSION

The Persian transcript of the assessment test for COPD was reliable and is directly related to the disease severity according to airflow limitation.

The quality of hereditary haemochromatosis guidelines: a comparative analysis

BACKGROUND AND OBJECTIVES

Hereditary haemochromatosis (HH) is the most prevalent genetic liver disease, with an incidence of 1/200 to 1/400 in the Caucasian population. HH patients are treated by family physicians as well as different specialists. When left untreated or insufficiently treated, the complications can become life threatening. To support and evaluate qualitative care for HH, we evaluated and compared the available structured guidelines on screening, diagnosis and management of HH patients.

METHODS

Seven appraisers systematically reviewed the retrieved guidelines. The Appraisal of Guidelines Research and Evaluation II (AGREE II) was used to score and discuss the quality and reach consensus. The content of recommendations and the evidence behind them, were evaluated.

RESULTS

Three guidelines, developed by the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL) and a DUTCH guideline were found. Fifty-seven percent of the recommendations were not shared between the guidelines, pointing to inconsistency of their content. Only two references supporting the recommendations were shared between all three guidelines. The AASLD guideline contains no information about management and follow-up. Moreover, the methodological quality of the AASLD guideline was rated insufficient, except for 'clarity and presentation' (77%). Applicability of the guidelines was scored very low in all three (AASLD: 31%, EASL: 23%, DUTCH: 35%). The DUTCH guideline was judged best.

CONCLUSIONS

Very poor consistency between available guidelines for HH hampers qualitative care and its evaluation. An updated high-quality and evidence-based guideline that covers follow-up and management of patients with HH is needed.

Continuing to confront COPD International Surveys: comparison of patient and physician perceptions about COPD risk and management

PURPOSE

Using data from the Continuing to Confront COPD International Physician and Patient Surveys, this paper describes physicians' attitudes and beliefs regarding chronic obstructive pulmonary disease (COPD) prognosis, and compares physician and patient perceptions with respect to COPD.

METHODS

In 12 countries worldwide, 4,343 patients with COPD were identified through systematic screening of population samples, and 1,307 physicians who regularly saw patients with COPD were sampled from in-country professional databases. Both patients and physicians completed surveys about their COPD knowledge, beliefs, and perceptions; physicians answered further questions about diagnostic methods and treatment choices for COPD.

RESULTS

Most physicians (79%) responded that the long-term health outlook for patients with COPD has improved over the past decade, largely attributed to the introduction of better medications. However, patient access to medication remains an issue in many countries, and some physicians (39%) and patients (46%) agreed/strongly agreed with the statement "there are no truly effective treatments for COPD". There was strong concordance between physicians and patients regarding COPD management practices, including the use of spirometry (86% of physicians and 76% of patients reporting they used/had undergone a spirometry test) and smoking cessation counseling (76% of physicians reported they counseled their smoking patients at every clinic visit, and 71% of smoking patients stated that they had received counseling in the past year). However, the groups differed in their perception about the role of smoking in COPD, with 78% of physicians versus 38% of patients strongly agreeing with the statement "smoking is the cause of most cases of COPD".

CONCLUSION

The Continuing to Confront COPD International Surveys demonstrate that while physicians and patients largely agreed about COPD management practices and the need for more effective treatments for COPD, a gap exists about the causal role of smoking in COPD.

Continuing to Confront COPD International Physician Survey: physician knowledge and application of COPD management guidelines in 12 countries

Aim

Utilizing data from the Continuing to Confront COPD (chronic obstructive pulmonary disease) International Physician Survey, this study aimed to describe physicians’ knowledge and application of the GOLD (Global initiative for chronic Obstructive Lung Disease) Global Strategy for the Diagnosis, Management and Prevention of COPD diagnosis and treatment recommendations and compare performance between primary care physicians (PCPs) and respiratory specialists.

Materials and methods

Physicians from 12 countries were sampled from in-country professional databases; 1,307 physicians (PCP to respiratory specialist ratio three to one) who regularly consult with COPD, emphysema, or chronic bronchitis patients were interviewed online, by telephone or face to face. Physicians were questioned about COPD risk factors, prognosis, diagnosis, and treatment, including knowledge and application of the GOLD global strategy using patient scenarios.

Results

Physicians reported using spirometry routinely (PCPs 82%, respiratory specialists 100%; P<0.001) to diagnose COPD and frequently included validated patient-reported outcome measures (PCPs 67%, respiratory specialists 81%; P<0.001). Respiratory specialists were more likely than PCPs to report awareness of the GOLD global strategy (93% versus 58%, P<0.001); however, when presented with patient scenarios, they did not always perform better than PCPs with regard to recommending GOLD-concordant treatment options. The proportion of PCPs and respiratory specialists providing first- or second-choice treatment options concordant with GOLD strategy for a GOLD B-type patient was 38% versus 67%, respectively. For GOLD C and D-type patients, the concordant proportions for PCPs and respiratory specialists were 40% versus 38%, and 57% versus 58%, respectively.

Conclusion

This survey of physicians in 12 countries practicing in the primary care and respiratory specialty settings showed high awareness of COPD-management guidelines. Frequent use of guideline-recommended COPD diagnostic practices was reported; however, gaps in the application of COPD-treatment recommendations were observed, warranting further evaluation to understand potential barriers to adopt guideline recommendations.

Real-life GOLD 2011 implementation: the management of COPD lacks correct classification and adequate treatment

Chronic obstructive pulmonary disease (COPD) is a serious, yet preventable and treatable, disease. The success of its treatment relies largely on the proper implementation of recommendations, such as the recently released Global Strategy for Diagnosis, Management, and Prevention of COPD (GOLD 2011, of late December 2011). The primary objective of this study was to examine the extent to which GOLD 2011 is being used correctly among Czech respiratory specialists, in particular with regard to the correct classification of patients. The secondary objective was to explore what effect an erroneous classification has on inadequate use of inhaled corticosteroids (ICS). In order to achieve these goals, a multi-center, cross-sectional study was conducted, consisting of a general questionnaire and patient-specific forms. A subjective classification into the GOLD 2011 categories was examined, and then compared with the objectively computed one. Based on 1,355 patient forms, a discrepancy between the subjective and objective classifications was found in 32.8% of cases. The most common reason for incorrect classification was an error in the assessment of symptoms, which resulted in underestimation in 23.9% of cases, and overestimation in 8.9% of the patients' records examined. The specialists seeing more than 120 patients per month were most likely to misclassify their condition, and were found to have done so in 36.7% of all patients seen. While examining the subjectively driven ICS prescription, it was found that 19.5% of patients received ICS not according to guideline recommendations, while in 12.2% of cases the ICS were omitted, contrary to guideline recommendations. Furthermore, with consideration to the objectively-computed classification, it was discovered that 15.4% of patients received ICS unnecessarily, whereas in 15.8% of cases, ICS were erroneously omitted. It was therefore concluded that Czech specialists tend either to under-prescribe or overuse inhaled corticosteroids.

Chronic obstructive pulmonary disease and exacerbations: clinician insights from the global Hidden Depths of COPD survey

OBJECTIVE

This real-life, global study aimed to investigate current views of and clinical practice in the management of COPD and its exacerbations, among clinicians from both the primary and secondary care settings.

METHODOLOGY

We devised an online questionnaire about COPD management and invited 13,613 general practitioners (GPs) and respiratory specialists to respond. Participating clinicians, recruited from an established research panel, treated a minimum of 10 (GPs) or 20 (respiratory specialists) patients with COPD per month. Completed responses were collected from 1400 clinicians from 14 countries.

RESULTS

A third of GPs and respiratory specialists reported that the main goal of COPD management was to improve patients' quality of life; only 14% of GPs thought that the prevention of exacerbations was a priority. The study showed a strong preference for inhaled corticosteroids in combination with other treatments, rather than as sole therapy, in line with global guidelines. Fewer GPs than respiratory specialists routinely recommended anticholinergics, pulmonary rehabilitation or oxygen therapy. Clinicians reported that 55% (GPs) and 57% (respiratory specialists) of their COPD patients had experienced an exacerbation in the previous 12 months. Although higher than those reported in clinical trials, these rates were lower than patients' own estimates from a corresponding patient survey, even in mild COPD patients (62%; 80% in severe patients). Despite this, 74% of GPs and 67% of respiratory physicians reported satisfaction with therapies to prevent exacerbations.

CONCLUSIONS

This global survey revealed that clinicians' main goal when managing COPD was to improve the lives of their patients, and that few viewed reducing exacerbations as a priority. Despite a relatively high level of adherence to treatment recommendations, it appears that clinicians, particularly GPs, underestimate the frequency and impact of exacerbations. These results suggest a need to raise awareness of exacerbations among both GPs and respiratory specialists.

Atorvastatin improves endothelial progenitor cell function and reduces pulmonary hypertension in patients with chronic pulmonary heart disease

OBJECTIVE

To explore the effects of atorvastatin on the migration and adhesion of endothelial progenitor cells (EPCs) and on pulmonary artery pressure (PAP) in patients with chronic pulmonary heart disease.

METHODS

A total of 68 patients with chronic pulmonary heart disease were randomly assigned to either a control group (n=35) or a treatment group (n=33). In addition, 30 healthy volunteers (17 male, 13 female) were enrolled as healthy controls. Atorvastatin (20 mg per day) was administered to the treatment group. The migration and adhesion activities of EPCs in peripheral blood were assessed before and six months after the treatment. PAP was measured using echocardiography before and after the treatment.

RESULTS

EPC number, migration ability and adhesion activity in the peripheral blood of patients in the control and treatment groups were lower than in patients in the healthy control group at baseline (all P<0.05). After six months of atorvastatin therapy, the number of EPCs in the treatment group was greater than in the control group (P<0.05). Migration and adhesion functions of EPCs in the treatment group were greater than in the control group (all P<0.05). The reduction in PAP in the treatment group was greater than in the untreated control group following six months of therapy (P<0.05).

CONCLUSION

Atorvastatin therapy increased the migration and adhesion activities of EPCs in patients with chronic pulmonary heart disease. Atorvastatin treatment was also associated with a reduction in PAP in these patients.

Low intensity, long-term outpatient rehabilitation in COPD: a randomised controlled trial

Background

Most pulmonary rehabilitation programmes currently involve 2–3 sessions per week as recommended by international guidelines. We aimed to investigate whether relevant improvements in physical capabilities and quality of life in patients with chronic obstructive pulmonary disease (COPD) could be achieved by a long-term, low intensity, once weekly rehabilitation programme using limited resources.

Methods

100 patients with moderate to severe COPD were randomised to a continuous outpatient interdisciplinary rehabilitation programme or standard care. Physiotherapy-led supervised outpatient training sessions were performed once weekly in addition to educational elements. Outcome measures at baseline and after 26 weeks were 6-minute-walk-test, cycle ergometry, and health-related quality of life.

Results

37 patients in the training group and 44 patients in the control group completed the study. After 26 weeks there were clinically significant differences between the groups for 6 minute-walk-distance (+59 m, 95% CI 28–89 m), maximum work load (+7.4 Watt, 95% CI 0.5-13.4 Watt) and St. George’s Respiratory Questionnaire score (−5 points, 95% CI −10 to −1 points). Total staff costs of the programme per participant were ≤ €625.

Conclusion

Clinically meaningful improvements in physical capabilities and health-related quality of life may be achieved using long-term pulmonary rehabilitation programmes of lower intensity than currently recommended. Trial registration: clinicaltrials.gov NCT01195402.