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Moffett AT, Halpern SD, Weissman GE. The Effect of a Post-Bronchodilator FEV 1/FVC < 0.7 on COPD Diagnosis and Treatment: A Regression Discontinuity Design. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.05.24311519. [PMID: 39148856 PMCID: PMC11326314 DOI: 10.1101/2024.08.05.24311519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Background Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the diagnosis of chronic obstructive pulmonary disease (COPD) only in patients with a post-bronchodilator forced expiratory volume in 1 second to forced vital capacity ratio (FEV1/FVC) less than 0.7. However the impact of this recommendation on clinical practice is unknown. Research Question What is the effect of a documented post-bronchodilator FEV1/FVC < 0.7 on the diagnosis and treatment of COPD? Study Design and Methods We used a national electronic health record database to identify clinical encounters between 2007 to 2022 with patients 18 years of age and older in which a post-bronchodilator FEV1/FVC value was documented. An encounter was associated with a COPD diagnosis if a diagnostic code for COPD was assigned, and was associated with COPD treatment if a prescription for a medication commonly used to treat COPD was filled within 90 days. We used a regression discontinuity design to measure the effect of a post-bronchodilator FEV1/FVC < 0.7 on COPD diagnosis and treatment. Results Among 27 817 clinical encounters, involving 18 991 patients, a post-bronchodilator FEV1/FVC < 0.7 was present in 14 876 (53.4%). The presence of a documented post-bronchodilator FEV1/FVC < 0.7 had a small effect on the probability of a COPD diagnosis, increasing by 6.0% (95% confidence interval [CI] 1.1% to 10.9%) from 38.0% just above the 0.7 cutoff to 44.0% just below this cutoff. The presence of a documented post-bronchodilator FEV1/FVC had no effect on the probability of COPD treatment (-2.1%, 95% CI -7.2% to 3.0%). Interpretation The presence of a documented post-bronchodilator FEV1/FVC < 0.7 has only a small effect on the probability that a clinician will make a guideline-concordant diagnosis of COPD and has no effect on corresponding treatment decisions.
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Affiliation(s)
- Alexander T. Moffett
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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Huang CH, Chou KT, Perng DW, Hsiao YH, Huang CW. Using Machine Learning with Impulse Oscillometry Data to Develop a Predictive Model for Chronic Obstructive Pulmonary Disease and Asthma. J Pers Med 2024; 14:398. [PMID: 38673025 PMCID: PMC11051459 DOI: 10.3390/jpm14040398] [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: 03/21/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
We aimed to develop and validate a machine learning model using impulse oscillometry system (IOS) profiles for accurately classifying patients into three assessment-based categories: no airflow obstruction, asthma, and chronic obstructive pulmonary disease (COPD). Our research questions were as follows: (1) Can machine learning methods accurately classify obstructive disease states based solely on multidimensional IOS data? (2) Which IOS parameters and modeling algorithms provide the best discrimination? We used data for 480 patients (240 with COPD and 240 with asthma) and 84 healthy individuals for training. Physiological and IOS parameters were combined into six feature combinations. The classification algorithms tested were logistic regression, random forest, neural network, k-nearest neighbor, and support vector machine. The optimal feature combination for identifying individuals without pulmonary obstruction, with asthma, or with COPD included 15 IOS and physiological features. The neural network classifier achieved the highest accuracy (0.786). For discriminating between healthy and unhealthy individuals, two combinations of twenty-three features performed best in the neural network algorithm (accuracy of 0.929). When distinguishing COPD from asthma, the best combination included 15 features and the neural network algorithm achieved an accuracy of 0.854. This study provides compelling technical evidence and clinical justifications for advancing IOS data-driven models to aid in COPD and asthma management.
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Affiliation(s)
- Chien-Hua Huang
- Department of Eldercare, College of Nursing, Central Taiwan University of Science and Technology, Taichung 406053, Taiwan;
| | - Kun-Ta Chou
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (K.-T.C.); (D.-W.P.); (Y.-H.H.)
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (K.-T.C.); (D.-W.P.); (Y.-H.H.)
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Yi-Han Hsiao
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan; (K.-T.C.); (D.-W.P.); (Y.-H.H.)
- Faculty of Medicine, School of Medicine, National Yang-Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Chien-Wen Huang
- Division of Chest Medicine, Department of Internal Medicine, Asia University Hospital, Taichung 413505, Taiwan
- Department of Medical Laboratory Science and Biotechnology, College of Medical and Health Science, Asia University, Taichung 413305, Taiwan
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3
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Fiore M, Ricci M, Rosso A, Flacco ME, Manzoli L. Chronic Obstructive Pulmonary Disease Overdiagnosis and Overtreatment: A Meta-Analysis. J Clin Med 2023; 12:6978. [PMID: 38002593 PMCID: PMC10672453 DOI: 10.3390/jcm12226978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
This meta-analysis of observational studies aimed at estimating the overall prevalence of overdiagnosis and overtreatment in subjects with a clinical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). MedLine, Scopus, Embase and Cochrane databases were searched, and random-effect meta-analyses of proportions were stratified by spirometry criteria (Global Initiative for COPD (GOLD) or Lower Limit of Normal (LLN)), and setting (hospital or primary care). Forty-two studies were included. Combining the data from 39 datasets, including a total of 23,765 subjects, the pooled prevalence of COPD overdiagnosis, according to the GOLD definition, was 42.0% (95% Confidence Interval (CI): 37.3-46.8%). The pooled prevalence according to the LLN definition was 48.2% (40.6-55.9%). The overdiagnosis rate was higher in primary care than in hospital settings. Fourteen studies, including a total of 8183 individuals, were included in the meta-analysis estimating the prevalence of COPD overtreatment. The pooled rates of overtreatment according to GOLD and LLN definitions were 57.1% (40.9-72.6%) and 36.3% (17.8-57.2%), respectively. When spirometry is not used, a large proportion of patients are erroneously diagnosed with COPD. Approximately half of them are also incorrectly treated, with potential adverse effects and a massive inefficiency of resources allocation. Strategies to increase the compliance to current guidelines on COPD diagnosis are urgently needed.
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Affiliation(s)
- Matteo Fiore
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
| | - Matteo Ricci
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
| | - Annalisa Rosso
- Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy; (A.R.); (M.E.F.)
| | - Maria Elena Flacco
- Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy; (A.R.); (M.E.F.)
| | - Lamberto Manzoli
- Section of Hygiene and Preventive Medicine, University of Bologna, 40126 Bologna, Italy; (M.F.); (M.R.)
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4
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Miravitlles M, Bhutani M, Hurst JR, Franssen FME, van Boven JFM, Khoo EM, Zhang J, Brunton S, Stolz D, Winders T, Asai K, Scullion JE. Implementing an Evidence-Based COPD Hospital Discharge Protocol: A Narrative Review and Expert Recommendations. Adv Ther 2023; 40:4236-4263. [PMID: 37537515 PMCID: PMC10499689 DOI: 10.1007/s12325-023-02609-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023]
Abstract
Discharge bundles, comprising evidence-based practices to be implemented prior to discharge, aim to optimise patient outcomes. They have been recommended to address high readmission rates in patients who have been hospitalised for an exacerbation of chronic obstructive pulmonary disease (COPD). Hospital readmission is associated with increased morbidity and healthcare resource utilisation, contributing substantially to the economic burden of COPD. Previous studies suggest that COPD discharge bundles may result in fewer hospital readmissions, lower risk of mortality and improvement of patient quality of life. However, evidence for their effectiveness is inconsistent, likely owing to variable content and implementation of these bundles. To ensure consistent provision of high-quality care for patients hospitalised with an exacerbation of COPD and reduce readmission rates following discharge, we propose a comprehensive discharge protocol, and provide evidence highlighting the importance of each element of the protocol. We then review care bundles used in COPD and other disease areas to understand how they affect patient outcomes, the barriers to implementing these bundles and what strategies have been used in other disease areas to overcome these barriers. We identified four evidence-based care bundle items for review prior to a patient's discharge from hospital, including (1) smoking cessation and assessment of environmental exposures, (2) treatment optimisation, (3) pulmonary rehabilitation, and (4) continuity of care. Resource constraints, lack of staff engagement and knowledge, and complexity of the COPD population were some of the key barriers inhibiting effective bundle implementation. These barriers can be addressed by applying learnings on successful bundle implementation from other disease areas, such as healthcare practitioner education and audit and feedback. By utilising the relevant implementation strategies, discharge bundles can be more (cost-)effectively delivered to improve patient outcomes, reduce readmission rates and ensure continuity of care for patients who have been discharged from hospital following a COPD exacerbation.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Vall d'Hebron University Hospital/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Mohit Bhutani
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Frits M E Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Job F M van Boven
- Department of Clinical Pharmacy & Pharmacology, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- International Primary Care Respiratory Group, Leicester, UK
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Daiana Stolz
- Clinic of Respiratory Medicine and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tonya Winders
- Global Allergy and Airways Patient Platform, Vienna, Austria
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Osaka Metropolitan University, Osaka, Japan
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Kristensen K, Olesen PH, Roerbaek AK, Nielsen L, Hansen HK, Cichosz SL, Jensen MH, Hejlesen O. Using random forest machine learning on data from a large, representative cohort of the general population improves clinical spirometry references. THE CLINICAL RESPIRATORY JOURNAL 2023; 17:819-828. [PMID: 37448113 PMCID: PMC10435934 DOI: 10.1111/crj.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 06/10/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Spirometry is associated with several diagnostic difficulties, and as a result, misdiagnosis of chronic obstructive pulmonary disease (COPD) occurs. This study aims to investigate how random forest (RF) can be used to improve the existing clinical FVC and FEV1 reference values in a large and representative cohort of the general population of the US without known lung disease. MATERIALS AND METHODS FVC, FEV1, body measures, and demographic data from 23 433 people were extracted from NHANES. RF was used to develop different prediction models. The accuracy of RF was compared with the existing Danish clinical references, an improved multiple linear regression (MLR) model, and a model from the literature. RESULTS The correlation between actual and predicted FVC and FEV1 and the 95% confidence interval for RF were found to be FVC = 0.85 (0.85; 0.86) (p < 0.001), FEV1 = 0.92 (0.92; 0.93) (p < 0.001), and existing clinical references were FVC = 0.66 (0.64; 0.68) (p < 0.001) and FEV1 = 0.69 (0.67; 0.70) (p < 0.001). Slope and intercept for the RF models predicting FVC and FEV1 were FVC 1.06 and -238.04 (mL), FEV1: 0.86 and 455.36 (mL), and for the MLR models, slope and intercept were FVC: 0.99 and 38.56 39 (mL), and FEV1: 1.01 and -56.57-57 (mL). CONCLUSIONS The results point toward machine learning models such as RF have the potential to improve the prediction of estimated lung function for individual patients. These predictions are used as reference values and are an important part of assessing spirometry measurements in clinical practice. Further work is necessary in order to reduce the size of the intercepts obtained through these results.
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Affiliation(s)
- Kris Kristensen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Pernille H. Olesen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Anna K. Roerbaek
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Louise Nielsen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Helle K. Hansen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Simon L. Cichosz
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Morten H. Jensen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
- Steno Diabetes Center North DenmarkAalborgDenmark
| | - Ole Hejlesen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
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Rumi G, Canonica GW, Foster JM, Chavannes NH, Valenti G, Contiguglia R, Rapsomaniki E, Kocks JWH, De Brasi D, Braido F. Digital Coaching Using Smart Inhaler Technology to Improve Asthma Management in Patients With Asthma in Italy: Community-Based Study. JMIR Mhealth Uhealth 2022; 10:e25879. [PMID: 36322120 PMCID: PMC9669888 DOI: 10.2196/25879] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/01/2021] [Accepted: 05/20/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Reliance on short-acting β-2 agonists and nonadherence to maintenance medication are associated with poor clinical outcomes in asthma. Digital health solutions could support optimal medication use and therefore disease control in patients with asthma; however, their use in community settings has not been determined. OBJECTIVE The primary objective of this study is to investigate community implementation of the Turbu+ program designed to support asthma self-management, including adherence to budesonide and formoterol (Symbicort) Turbuhaler, a combination inhaler for both maintenance therapy or maintenance and reliever therapy. The secondary objective is to provide health care professionals with insights into how patients were using their medication in real life. METHODS Patients with physician-diagnosed asthma were prescribed budesonide and formoterol as maintenance therapy, at a dose of either 1 inhalation twice daily (1-BID) or 2 inhalations twice daily (2-BID), or as maintenance and reliever therapy (1-BID and reliever or 2-BID and reliever in a single inhaler), and they received training on Turbu+ in secondary care centers across Italy. An electronic device attached to the patients' inhaler for ≥90 days (data cutoff) securely uploaded medication use data to a smartphone app and provided reminders, visualized medication use, and motivational nudge messages. Average medication adherence was defined as the proportion of daily maintenance inhalations taken as prescribed (number of recorded maintenance actuations per day or maintenance inhalations prescribed per day) averaged over the monitoring period. The proportion of adherent days was defined as the proportion of days when all prescribed maintenance inhalations were taken on a given day. The Wilcoxon test was used to compare the proportion of adherent days between patients in the maintenance regimen and patients in the maintenance and reliever regimen of a given dose. RESULTS In 661 patients, the mean (SD) number of days monitored was 217.2 (SD 109.0) days. The average medication adherence (maintenance doses taken/doses prescribed) was 70.2% (108,040/153,820) overall and was similar across the groups (1-BID: 6332/9520, 66.5%; 1‑BID and reliever: 43,578/61,360, 71.0%; 2-BID: 10,088/14,960, 67.4%; 2-BID and reliever: 48,042/67,980, 70.7%). The proportion of adherent days (prescribed maintenance doses/doses taken in a given day) was 56.6% (31,812/56,175) overall and was higher with maintenance and reliever therapy (1-BID and reliever vs 1-BID: 18,413/30,680, 60.0% vs 2510/4760, 52.7%; P<.001; 2-BID and reliever vs 2-BID: 8995/16,995, 52.9% vs 1894/3740, 50.6%; P=.02). Rates of discontinuation from the Turbu+ program were significantly lower with maintenance and reliever therapy compared with maintenance therapy alone (P=.01). CONCLUSIONS Overall, the high medication adherence observed during the study might be attributed to the electronic monitoring and feedback mechanism provided by the Turbu+ program.
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Affiliation(s)
- Gabriele Rumi
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Università Cattolica del Sacro Cuore - Medicina Interna, Rome, Italy
| | - G Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic-Humanitas University & Research Hospital, IRCCS, Milan, Italy
| | - Juliet M Foster
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | | | | | | | | | | | - Fulvio Braido
- Department of Internal Medicine, University of Genova, Genova, Italy
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Chapman KR. Chronic Obstructive Pulmonary Disease: Is Social Injustice the Elephant in the Room? Am J Respir Crit Care Med 2021; 203:1331-1332. [PMID: 33233915 PMCID: PMC8456530 DOI: 10.1164/rccm.202011-4114ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kenneth R Chapman
- University of Toronto Toronto, Ontario, Canada and Asthma and Airway Centre University Health Network Toronto, Ontario, Canada
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Kaplan A, Cao H, FitzGerald JM, Iannotti N, Yang E, Kocks JWH, Kostikas K, Price D, Reddel HK, Tsiligianni I, Vogelmeier CF, Pfister P, Mastoridis P. Artificial Intelligence/Machine Learning in Respiratory Medicine and Potential Role in Asthma and COPD Diagnosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2255-2261. [PMID: 33618053 DOI: 10.1016/j.jaip.2021.02.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 02/09/2023]
Abstract
Artificial intelligence (AI) and machine learning, a subset of AI, are increasingly used in medicine. AI excels at performing well-defined tasks, such as image recognition; for example, classifying skin biopsy lesions, determining diabetic retinopathy severity, and detecting brain tumors. This article provides an overview of the use of AI in medicine and particularly in respiratory medicine, where it is used to evaluate lung cancer images, diagnose fibrotic lung disease, and more recently is being developed to aid the interpretation of pulmonary function tests and the diagnosis of a range of obstructive and restrictive lung diseases. The development and validation of AI algorithms requires large volumes of well-structured data, and the algorithms must work with variable levels of data quality. It is important that clinicians understand how AI can function in the context of heterogeneous conditions such as asthma and chronic obstructive pulmonary disease where diagnostic criteria overlap, how AI use fits into everyday clinical practice, and how issues of patient safety should be addressed. AI has a clear role in providing support for doctors in the clinical workplace, but its relatively recent introduction means that confidence in its use still has to be fully established. Overall, AI is expected to play a key role in aiding clinicians in the diagnosis and management of respiratory diseases in the future, and it will be exciting to see the benefits that arise for patients and doctors from its use in everyday clinical practice.
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Affiliation(s)
- Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Canada.
| | - Hui Cao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - J Mark FitzGerald
- Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Nick Iannotti
- Novartis Institutes for Biomedical Research, Cambridge, Mass
| | - Eric Yang
- Novartis Institutes for Biomedical Research, Cambridge, Mass
| | - 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, Singapore
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Ioanna Tsiligianni
- Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-Universität Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
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The use of a direct bronchial challenge test in primary care to diagnose asthma. NPJ Prim Care Respir Med 2020; 30:45. [PMID: 33067465 PMCID: PMC7567813 DOI: 10.1038/s41533-020-00202-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 09/14/2020] [Indexed: 11/09/2022] Open
Abstract
Many asthmatics in primary care have mild symptoms and lack airflow obstruction. If variable expiratory airflow limitation cannot be determined by spirometry or peak expiratory flow, despite a history of respiratory symptoms, a positive bronchial challenge test (BCT) can confirm the diagnosis of asthma. However, BCT is traditionally performed in secondary care. In this observational real-life study, we retrospectively analyze 5-year data of a primary care diagnostic center carrying out BCT by histamine provocation. In total, 998 primary care patients aged ≥16 years underwent BCT, without any adverse events reported. To explore diagnostic accuracy, we examine 584 patients with a high pretest probability of asthma. Fifty-seven percent of these patients have a positive BCT result and can be accurately diagnosed with asthma. Our real-life data show BCT is safe and feasible in a suitably equipped primary care diagnostic center. Furthermore, it could potentially reduce diagnostic referrals to secondary care.
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Leonardsen AC, Gulbrandsen T, Wasenius C, Fossen LT. Nursing perspectives and strategies in patients with respiratory insufficiency. Nurs Crit Care 2020; 27:27-35. [PMID: 32954605 DOI: 10.1111/nicc.12555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Approximately 30% of patients admitted to an intensive care unit experience respiratory distress. The COVID-19 pandemic has led to an enormous increase in patients with respiratory symptoms. Nurse competence is essential for ensuring quality treatment and care for these patients; however, research on nursing strategies for patients with respiratory insufficiency is limited. AIM This study explored nurses' perspectives on and nursing strategies in patients with respiratory insufficiency when admitted to three different intensive care units. DESIGN The study had an exploratory, descriptive, qualitative design. METHODS Four focus group interviews with a total of 20 nurses, critical care nurses, and critical care nursing students were conducted. Data were analysed using content analysis. RESULTS Participants' perspectives fell into two main themes: "nurse competence" and "the art of balancing." "Nurse competence" incorporated the sub-themes "observations and assessments," "to make decisions," and "collaboration." The theme 'the art of balancing' incorporated the sub-themes "nursing interventions," "patients feeling safe," and "patient participation." CONCLUSION This study contributes new knowledge about nurses' perspectives on patients with respiratory insufficiency. Nurse competence was assumed essential to observe, assess, and treat patients with respiratory insufficiency. Nursing strategies included balancing nursing interventions, conducting medical treatment, and taking a whole-person approach to patients' needs. RELEVANCE TO CLINICAL PRACTICE The COVID-19 pandemic has shown the need for nurse competence in caring for patients with respiratory insufficiency. This study adds to existing literature emphasizing the need for competence in health care services. Caring for patients with respiratory insufficiency requires nurses with experience; competence in observation, assessment, and medical treatment; and a whole-person approach to patients' needs.
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Nantanda R, Kayingo G, Jones R, van Gemert F, Kirenga BJ. Training needs for Ugandan primary care health workers in management of respiratory diseases: a cross sectional survey. BMC Health Serv Res 2020; 20:402. [PMID: 32393227 PMCID: PMC7212561 DOI: 10.1186/s12913-020-05135-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 03/20/2020] [Indexed: 11/12/2022] Open
Abstract
Background Respiratory diseases are among the leading causes of morbidity and mortality in Uganda, but there is little attention and capacity for management of chronic respiratory diseases in the health programmes. This survey assessed gaps in knowledge and skills among healthcare workers in managing respiratory illnesses. Methods A cross sectional study was conducted among primary care health workers, specialist physicians and healthcare planners to assess gaps in knowledge and skills and, training needs in managing respiratory illnesses. The perspectives of patients with respiratory diseases were also sought. Data were collected using questionnaires, patient panel discussions and review of pre-service training curricula for clinicians and nurses. Survey Monkey was used to collect data and descriptive statistical analysis was undertaken for quantitative data, while thematic content analysis techniques were utilized to analyze qualitative data. Results A total of 104 respondents participated in the survey and of these, 76.9% (80/104) were primary care health workers, 16.3% (17/104) specialist clinicians and 6.7% (7/104) healthcare planners. Over 90% of the respondents indicated that more than half of the patients in their clinics presented with respiratory symptoms. More than half (52%) of the primary care health workers were not comfortable in managing chronic respiratory diseases like asthma and COPD. Only 4% of them were comfortable performing procedures like pulse oximetry, nebulization, and interpreting x-rays. Majority (75%) of the primary care health workers had received in-service training but only 4% of the sessions focused on respiratory diseases. The pre-service training curricula included a wide scope of respiratory diseases, but the actual training had not sufficiently prepared health workers to manage respiratory diseases. The patients were unsatisfied with the care in primary care and reported that they were often treated for the wrong illnesses. Conclusions Respiratory illnesses contribute significantly to the burden of diseases in primary care facilities in Uganda. Management of patients with respiratory diseases remains a challenge partially because of inadequate knowledge and skills of the primary care health workers. A training programme to improve the competences of health workers in respiratory medicine is highly recommended.
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Affiliation(s)
- Rebecca Nantanda
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda.
| | | | - Rupert Jones
- Peninsula Medical School, Plymouth University, Plymouth, UK
| | - Frederik van Gemert
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Bruce J Kirenga
- Makerere University Lung Institute, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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12
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The role of objective tests to support a diagnosis of asthma in children. Paediatr Respir Rev 2020; 33:52-57. [PMID: 30954449 DOI: 10.1016/j.prrv.2019.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/10/2018] [Accepted: 02/14/2019] [Indexed: 02/03/2023]
Abstract
In many healthcare settings asthma in children is a clinical diagnosis based on parental reported symptoms. These include intermittent episodes of wheezing, breathlessness and periodic nocturnal dry cough. Increased symptoms often coincide with colds. Confirming a diagnosis of asthma in children can be difficult and recent reports highlight that misdiagnosis, including over- and under-diagnosis of asthma are common. Recent UK National Institute of Health and Care Excellence guidelines recommend diagnostic algorithms for children from five years and adults to support a clinical suspicion of asthma. Spirometry, bronchodilator reversibility and fractional exhaled nitric oxide testing are the first line tests to diagnose asthma in children. The introduction of these tests across all healthcare settings has the potential to reduce misdiagnosis, improve asthma management and reduce healthcare spending for asthma.
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Thomas ET, Glasziou P, Dobler CC. Use of the terms "overdiagnosis" and "misdiagnosis" in the COPD literature: a rapid review. Breathe (Sheff) 2019; 15:e8-e19. [PMID: 31031840 PMCID: PMC6481986 DOI: 10.1183/20734735.0354-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Challenges in the diagnostic process of chronic obstructive pulmonary disease (COPD) can result in diagnostic misclassifications, including overdiagnosis. The term "overdiagnosis" in general has been associated with variable definitions. In connection with efforts to reduce low-value care, "overdiagnosis" has been defined as a true positive diagnosis of a condition that is not associated with any harm in the diagnosed person. It is, however, unclear how the term "overdiagnosis" is used in the COPD literature. We conducted a rapid review of the literature to explore how the terms "overdiagnosis" and "misdiagnosis" are used in the context of COPD. Electronic searches of Medline were conducted from inception to October 2018, to identify primary studies that reported on over- and/or misdiagnosis of COPD using these terms. 28 articles were included in this review. Overdiagnosis and misdiagnosis in COPD were found to be used to describe five main concepts: 1) physician COPD diagnosis despite normal spirometry (14 studies); 2) discordant results for COPD diagnosis based on different spirometry-based definitions for airflow obstruction (10 studies); 3) COPD diagnosis based on pre-bronchodilator spirometry results (three studies); 4) comorbidities (e.g. heart failure or asthma) that affect spirometry and have clinical features which overlap with COPD (two studies); and 5) normalisation of abnormal (post-bronchodilator) spirometry at follow-up (one study). The terms "overdiagnosis" and "misdiagnosis" were often used interchangeably and almost always referred to a false positive diagnosis. Performing (technically correct) spirometry with correct interpretation of the results could probably reduce misdiagnosis in a large proportion of the misdiagnosed cases of COPD. In addition, guidelines need to provide a more acceptable consensus spirometric definition of airflow obstruction. KEY POINTS In the COPD literature, the terms "overdiagnosis" and "misdiagnosis" are often used interchangeably and almost always refer to a false positive diagnosis.Use of spirometry with correct interpretation of the results can avoid a substantial proportion of cases of misdiagnosis of COPD. EDUCATIONAL AIMS To explore the use of the terms "overdiagnosis" and "misdiagnosis" in the COPD literature.To identify the main sources of overdiagnosis and misdiagnosis in COPD.
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Affiliation(s)
- Elizabeth T Thomas
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
- Gold Coast University Hospital, Southport, Australia
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Claudia C Dobler
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
- Gold Coast University Hospital, Southport, Australia
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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14
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Diab N, Gershon AS, Sin DD, Tan WC, Bourbeau J, Boulet LP, Aaron SD. Underdiagnosis and Overdiagnosis of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2018; 198:1130-1139. [DOI: 10.1164/rccm.201804-0621ci] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Nermin Diab
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrea S. Gershon
- Department of Medicine, The University of Toronto, Toronto, Ontario, Canada
| | - Don D. Sin
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wan C. Tan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean Bourbeau
- Department of Medicine, McGill University, Montreal, Quebec, Canada; and
| | | | - Shawn D. Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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15
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Chapman KR. Increasing Awareness of COPD: Two Steps Forward, One Step Back. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:228-230. [PMID: 30723779 DOI: 10.15326/jcopdf.5.4.2018.0154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Kenneth R Chapman
- University of Toronto Asthma and Airway Centre, University Health Network, Toronto, Ontario
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16
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Relationship of Inhaled Corticosteroid Adherence to Asthma Exacerbations in Patients with Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1989-1998.e3. [PMID: 29627457 DOI: 10.1016/j.jaip.2018.03.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with asthma and elevated blood eosinophils are at increased risk of severe exacerbations. Management of these patients should consider nonadherence to inhaled corticosteroid (ICS) therapy as a factor for increased exacerbation risk. OBJECTIVE The objective of this study was to investigate whether poor adherence to ICS therapy explains the occurrence of asthma exacerbations in patients with elevated blood eosinophil levels. METHODS This historical cohort study identified patients within the Optimum Patient Care Research Database, aged 18 years or more, at Global Initiative for Asthma step 3 or 4, with 2 or more ICS prescriptions during the year before the clinical review. Patient characteristics and adherence (based on prescription refills and patient self-report) for ICS therapy were analyzed for those with elevated (>400 cells/μL) or normal (≤400 cells/μL) blood eosinophils. RESULTS We studied 7195 patients (66% female, mean age 60 years) with median eosinophil count of 200 cells/μL and found 81% to be not fully adherent to ICS therapy. A total of 1031 patients (14%) had elevated blood eosinophil counts (58% female, mean age 60 years), 83% of whom were not fully adherent to ICS. An increased proportion of adherent patients in the elevated blood eosinophil group had 2 or more exacerbations (14.0% vs 7.2%; P = .003) and uncontrolled asthma (73% vs 60.8%; P = .004) as compared with non-fully adherent patients. CONCLUSIONS Approximately 1 in 7 patients had elevated eosinophils. Adherence to ICS therapy was not associated with decreased exacerbations for these patients. Additional therapy should be considered for these patients, such as biologics, which have been previously shown to improve control in severe uncontrolled eosinophilic asthma.
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Gershon AS, Thiruchelvam D, Chapman KR, Aaron SD, Stanbrook MB, Bourbeau J, Tan W, To T. Health Services Burden of Undiagnosed and Overdiagnosed COPD. Chest 2018; 153:1336-1346. [PMID: 29425675 DOI: 10.1016/j.chest.2018.01.038] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 01/15/2018] [Accepted: 01/26/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Misdiagnosis of COPD is common. The goal of this study was to quantify the health services burden of undiagnosed and overdiagnosed COPD in a real-world, North American population. METHODS A population-based cohort study was conducted. Presence of COPD using spirometry was ascertained in randomly selected adults aged ≥ 40 years from Ontario, Canada, who participated in the Canadian Obstructive Lung Disease study. The presence of physician-diagnosed COPD was ascertained for the same subjects by using linked health administrative data. Participants were then categorized into four groups: correctly diagnosed, undiagnosed, overdiagnosed, and no COPD according to either criteria. Age- and sex-standardized rates of hospitalizations, ED visits, and ambulatory care visits in each group were determined and compared. RESULTS Of 1,403 participants, 13.7% had undiagnosed COPD, 5.1% were overdiagnosed, and 3.7% had correctly diagnosed COPD. Subjects with overdiagnosed COPD had significantly higher rates of hospitalizations, ED visits, and ambulatory care visits, and subjects with moderate to severe undiagnosed COPD had higher rates of hospitalizations, than subjects in the non-COPD population. CONCLUSIONS Undiagnosed and overdiagnosed COPD contribute to significant health care burden. Given that misdiagnosed COPD was fivefold more common than correctly diagnosed COPD, these findings point to a substantial misdiagnosis-associated burden of disease that might be prevented, at least in part, with a correct diagnosis.
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Affiliation(s)
- Andrea S Gershon
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; The Hospital for Sick Children, Toronto, ON, Canada.
| | | | - Kenneth R Chapman
- University of Toronto, Toronto, ON, Canada; Asthma and Airway Centre, Toronto Western Hospital, Toronto, ON, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Matthew B Stanbrook
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Asthma and Airway Centre, Toronto Western Hospital, Toronto, ON, Canada
| | - Jean Bourbeau
- McGill University, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Wan Tan
- University of British Columbia, UBC James Hogg Research Centre, Institute for Heart Lung Health, St. Paul's Hospital, Vancouver, BC, Canada
| | - Teresa To
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; The Hospital for Sick Children, Toronto, ON, Canada
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Chisholm A, Price DB, Pinnock H, Lee TT, Roa C, Cho SH, David-Wang A, Wong G, van der Molen T, Ryan D, Castillo-Carandang N, Yong YV. Personalising care of adults with asthma from Asia: a modified e-Dephi consensus study to inform management tailored to attitude and control profiles. NPJ Prim Care Respir Med 2017; 27:16089. [PMID: 28055000 PMCID: PMC5215112 DOI: 10.1038/npjpcrm.2016.89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 08/10/2016] [Accepted: 09/25/2016] [Indexed: 12/05/2022] Open
Abstract
REALISE Asia—an online questionnaire-based study of Asian asthma patients—identified five patient clusters defined in terms of their control status and attitude towards their asthma (categorised as: ‘Well-adjusted and at least partly controlled’; ‘In denial about symptoms’; ‘Tolerating with poor control’; ‘Adrift and poorly controlled’; ‘Worried with multiple symptoms’). We developed consensus recommendations for tailoring management of these attitudinal–control clusters. An expert panel undertook a three-round electronic Delphi (e-Delphi): Round 1: panellists received descriptions of the attitudinal–control clusters and provided free text recommendations for their assessment and management. Round 2: panellists prioritised Round 1 recommendations and met (or joined a teleconference) to consolidate the recommendations. Round 3: panellists voted and prioritised the remaining recommendations. Consensus was defined as Round 3 recommendations endorsed by >50% of panellists. Highest priority recommendations were those receiving the highest score. The multidisciplinary panellists (9 clinicians, 1 pharmacist and 1 health social scientist; 7 from Asia) identified consensus recommendations for all clusters. Recommended pharmacological (e.g., step-up/down; self-management; simplified regimen) and non-pharmacological approaches (e.g., trigger management, education, social support; inhaler technique) varied substantially according to each cluster’s attitude to asthma and associated psychosocial drivers of behaviour. The attitudinal–control clusters defined by REALISE Asia resonated with the international panel. Consensus was reached on appropriate tailored management approaches for all clusters. Summarised and incorporated into a structured management pathway, these recommendations could facilitate personalised care. Generalisability of these patient clusters should be assessed in other socio-economic, cultural and literacy groups and nationalities in Asia.
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Affiliation(s)
| | - David B Price
- Department of Primary Care Respiratory Medicine, University of Aberdeen, Aberdeen, UK.,Observational & Pragmatic Research Institute Pte Ltd, Singapore
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Tan Tze Lee
- National University Hospital, Singapore, Singapore
| | - Camilo Roa
- Section of Pulmonary Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Sang-Heon Cho
- Seoul National University College of Medicine, Seoul, Korea
| | - Aileen David-Wang
- Section of Pulmonary Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Gary Wong
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Thys van der Molen
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dermot Ryan
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nina Castillo-Carandang
- Department of Clinical Epidemiology, College of Medicine; and Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Yee Vern Yong
- Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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Chambers D, Booth A, Baxter SK, Johnson M, Dickinson KC, Goyder EC. Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BackgroundCurrent NHS policy favours the expansion of diagnostic testing services in community and primary care settings.ObjectivesOur objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.Review methodsWe performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.ResultsWe identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.ConclusionsIn the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.LimitationsWe have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.Future workThere is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan K Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maxine Johnson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine C Dickinson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth C Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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20
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Pols DHJ, Wartna JB, Moed H, van Alphen EI, Bohnen AM, Bindels PJE. Atopic dermatitis, asthma and allergic rhinitis in general practice and the open population: a systematic review. Scand J Prim Health Care 2016; 34:143-50. [PMID: 27010253 PMCID: PMC4977936 DOI: 10.3109/02813432.2016.1160629] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/31/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To examine whether significant differences exist between the self-reported prevalence of atopic disorders in the open population compared with physician diagnosed prevalence of atopic disorders in general practice. METHODS Medline (OvidSP), PubMed Publisher, EMBASE, Google Scholar and the Cochrane Controlled Clinical Trials Register databases were systematically reviewed for articles providing data on the prevalence of asthma, allergic rhinitis and eczema in a GP setting. Studies were only included when they had a cross-sectional or cohort design and included more than 100 children (aged 0-18 years) in a general practice setting. All ISAAC studies (i.e. the open population) that geographically matched a study selected from the first search, were also included. A quality assessment was conducted. The primary outcome measures were prevalence of eczema, asthma and allergic rhinitis in children aged 0-18 years. RESULTS The overall quality of the included studies was good. The annual and lifetime prevalences of the atopic disorders varied greatly in both general practice and the open population. On average, the prevalence of atopic disorders was higher in the open population. CONCLUSION There are significant differences between the self-reported prevalence of atopic disorders in the open population compared with physician diagnosed prevalence of atopic disorders in general practice. Data obtained in the open population cannot simply be extrapolated to the general practice setting. This should be taken into account when considering a research topic or requirements for policy development. GPs should be aware of the possible misclassification of allergic disorders in their practice. Key Points Epidemiological data on atopic disorders in children can be obtained from various sources, each having its own advantages and limitations. On average, the prevalence of atopic disorders is higher in the open population. GPs should take into account the possible misclassification of atopic disorders in their practice population. Policymakers should be aware that data obtained in the open population cannot simply be extrapolated to the general practice setting.
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Affiliation(s)
- D. H. J. Pols
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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Skinner TR, Scott IA, Martin JH. Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen Med 2016; 9:137-46. [PMID: 27284262 PMCID: PMC4881921 DOI: 10.2147/ijgm.s96741] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Misdiagnosis, either over- or underdiagnosis, exposes older patients to increased risk of inappropriate or omitted investigations and treatments, psychological distress, and financial burden. Objective To evaluate the frequency and nature of diagnostic errors in 16 conditions prevalent in older patients by undertaking a systematic literature review. Data sources and study selection Cohort studies, cross-sectional studies, or systematic reviews of such studies published in Medline between September 1993 and May 2014 were searched using key search terms of “diagnostic error”, “misdiagnosis”, “accuracy”, “validity”, or “diagnosis” and terms relating to each disease. Data synthesis A total of 938 articles were retrieved. Diagnostic error rates of >10% for both over- and underdiagnosis were seen in chronic obstructive pulmonary disease, dementia, Parkinson’s disease, heart failure, stroke/transient ischemic attack, and acute myocardial infarction. Diabetes was overdiagnosed in <5% of cases. Conclusion Over- and underdiagnosis are common in older patients. Explanations for over-diagnosis include subjective diagnostic criteria and the use of criteria not validated in older patients. Underdiagnosis was associated with long preclinical phases of disease or lack of sensitive diagnostic criteria. Factors that predispose to misdiagnosis in older patients must be emphasized in education and clinical guidelines.
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Affiliation(s)
- Thomas R Skinner
- Department of Internal Medicine, Sunshine Coast Health Service District, Nambour Hospital, Nambour, QLD, Australia
| | - Ian A Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia; Southern School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jennifer H Martin
- Southern School of Medicine, University of Queensland, Brisbane, QLD, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, Greenhalgh J, Roland M. Outpatient services and primary care: scoping review, substudies and international comparisons. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04150] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.
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Affiliation(s)
| | | | | | | | - Ellen Nolte
- RAND Europe, Cambridge, UK
- European Observatory on Health Systems and Policies, London School of Economics and Political Science and London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanne Greenhalgh
- Faculty of Education, Social Sciences and Law, University of Leeds, Leeds, UK
| | - Martin Roland
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Roberts NJ, Patel IS, Partridge MR. The diagnosis of COPD in primary care; gender differences and the role of spirometry. Respir Med 2015; 111:60-3. [PMID: 26733228 DOI: 10.1016/j.rmed.2015.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 12/14/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Females with exacerbations of Chronic Obstructive Pulmonary Disease now account for one half of all hospital admissions for that condition and rates have been increasing over the last few decades. Differences in presentations of disease between genders have been shown in several conditions and this study explores whether there are inter gender biases in probable diagnoses in those suspected to have COPD. METHODS 445 individuals with a provisional diagnosis by their General Practitioner of "suspected COPD" or "definite COPD" were referred to a community Respiratory Assessment unit (CRAU) for tests including spirometry. Gender, demographics, respiratory symptoms and respiratory medical history were recorded. The provisional diagnoses were compared with the final diagnosis made after spirometry and respiratory specialist nurse review and the provisional diagnosis was either confirmed as correct or refuted as unlikely. RESULTS Significantly more men (87.5%) had their diagnosis of "definite COPD" confirmed compared to 73.9% of women (p = 0.021). When the GP suggested a provisional diagnosis of "suspected COPD" (n = 265) at referral, this was confirmed in 60.9% of men and only 43.2% of women (p = 0.004). There was a different symptom pattern between genders with women being more likely to report allergies, symptoms starting earlier in life, and being less likely than men to report breathlessness as the main symptom. CONCLUSIONS These results may suggest a difference between genders in some of the clinical features of COPD and a difference in likelihood of a GPs provisional diagnosis of COPD being correct. The study reiterates the absolute importance of spirometry in the diagnosis of COPD.
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Affiliation(s)
- N J Roberts
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom.
| | - I S Patel
- Kings College Hospital NHS Foundation Trust London, London, United Kingdom
| | - M R Partridge
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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José BPDS, Camargos PAM, Cruz Filho ÁASD, Corrêa RDA. Diagnostic accuracy of respiratory diseases in primary health units. Rev Assoc Med Bras (1992) 2015; 60:599-612. [PMID: 25650863 DOI: 10.1590/1806-9282.60.06.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 03/24/2014] [Indexed: 11/22/2022] Open
Abstract
Respiratory diseases are responsible for about a fifth of all deaths worldwide and its prevalence reaches 15% of the world population. Primary health care (PHC) is the gateway to the health system, and is expected to resolve up to 85% of health problems in general. Moreover, little is known about the diagnostic ability of general practitioners (GPs) in relation to respiratory diseases in PHC. This review aims to evaluate the diagnostic ability of GPs working in PHC in relation to more prevalent respiratory diseases, such as acute respiratory infections (ARI), tuberculosis, asthma and chronic obstructive pulmonary disease (COPD). 3,913 articles were selected, totaling 30 after application of the inclusion and exclusion criteria. They demonstrated the lack of consistent evidence on the accuracy of diagnoses of respiratory diseases by general practitioners. In relation to asthma and COPD, studies have shown diagnostic errors leading to overdiagnosis or underdiagnosis depending on the methodology used. The lack of precision for the diagnosis of asthma varied from 54% underdiagnosis to 34% overdiagnosis, whereas for COPD this ranged from 81% for underdiagnosis to 86.1% for overdiagnosis. For ARI, it was found that the inclusion of a complementary test for diagnosis led to an improvement in diagnostic accuracy. Studies show a low level of knowledge about tuberculosis on the part of general practitioners. According to this review, PHC represented by the GP needs to improve its ability for the diagnosis and management of this group of patients constituting one of its main demands.
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Affiliation(s)
- Bruno Piassi de São José
- UFMG Pneumology Outpatient Clinic, Hospital das Clínicas, Federal University of Minas Gerais Medical School, Belo Horizonte, MG, Brazil
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Partridge MR. Enhancing the diagnosis and management of COPD in Primary care. Multidiscip Respir Med 2014; 9:62. [PMID: 25516797 PMCID: PMC4267135 DOI: 10.1186/2049-6958-9-62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 11/18/2014] [Indexed: 11/23/2022] Open
Affiliation(s)
- Martyn R Partridge
- Airway Diseases Section, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London, SW3 6LY UK
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Jutel M, Papadopoulos NG, Gronlund H, Hoffman HJ, Bohle B, Hellings P, Braunsthal GJ, Muraro A, Schmid-Grendelmeier P, Zuberbier T, Agache I, Agache I. Recommendations for the allergy management in the primary care. Allergy 2014; 69:708-18. [PMID: 24628378 DOI: 10.1111/all.12382] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2014] [Indexed: 01/13/2023]
Abstract
The majority of patients seeking medical advice for allergic diseases are first seen in a primary care setting. Correct diagnosis with identification of all offending allergens is an absolute prerequisite for appropriate management of allergic disease by the general practitioner. Allergy diagnostic tests recommended for use in primary care are critically reviewed in accordance with the significant workload in a primary care setting. Simplified pathways for recognition and diagnosis of allergic diseases are proposed, that should be further adapted to local (national) conditions.
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Affiliation(s)
- M. Jutel
- Department of Clinical Immunology; Wroclaw Medical University; Wroclaw Poland
| | - N. G. Papadopoulos
- 2nd Pediatric Clinic, Allergy Department; University of Athens; Athens Greece
| | - H. Gronlund
- Center for Allergy Research; Karolinska Institutet; Stockholmm Sweden
| | - H.-J. Hoffman
- Department of Respiratory Diseases; Aarhus University Hospital; Aarhus Denmark
| | - B. Bohle
- Department of Pathophysiology; Medical University of Vienna; Vienna Austria
| | - P. Hellings
- Department of Orothinolaryngology; University Hospitals Leuven; Leuven Belgium
| | - G.-J. Braunsthal
- Department of Pulmonology; St. Franciscus Gasthuis; Rotterdam The Netherlands
| | - A. Muraro
- Department of Pediatrics; Referral Centre for Food Allergy; Padua General University Hospital; Padua Italy
| | | | - T. Zuberbier
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - I. Agache
- Department of Allergy and Clinical Immunology; SC Theramed SRL; Brasov Romania
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Tan WC, Bourbeau J, Hernandez P, Chapman KR, Cowie R, FitzGerald JM, Marciniuk DD, Maltais F, Buist AS, O'Donnell DE, Sin DD, Aaron SD. Exacerbation-like respiratory symptoms in individuals without chronic obstructive pulmonary disease: results from a population-based study. Thorax 2014; 69:709-17. [PMID: 24706040 PMCID: PMC4112491 DOI: 10.1136/thoraxjnl-2013-205048] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
RATIONALE Exacerbations of COPD are defined clinically by worsening of chronic respiratory symptoms. Chronic respiratory symptoms are common in the general population. There are no data on the frequency of exacerbation-like events in individuals without spirometric evidence of COPD. AIMS To determine the occurrence of 'exacerbation-like' events in individuals without airflow limitation, their associated risk factors, healthcare utilisation and social impacts. METHOD We analysed the cross-sectional data from 5176 people aged 40 years and older who participated in a multisite, population-based study on lung health. The study cohort was stratified into spirometrically defined COPD (post-bronchodilator FEV1/FVC < 0.7) and non-COPD (post bronchodilator FEV1/FVC ≥ 0.7 and without self-reported doctor diagnosis of airway diseases) subgroups and then into those with and without respiratory 'exacerbation-like' events in the past year. RESULTS Individuals without COPD had half the frequency of 'exacerbation-like' events compared with those with COPD. In the non-COPD group, the independent associations with 'exacerbations' included female gender, presence of wheezing, the use of respiratory medications and self-perceived poor health. In the non-COPD group, those with exacerbations were more likely than those without exacerbations to have poorer health-related quality of life (12-item Short-Form Health Survey), miss social activities (58.5% vs 18.8%), miss work for income (41.5% vs 17.3%) and miss housework (55.6% vs 16.5%), p<0.01 to <0.0001. CONCLUSIONS Events similar to exacerbations of COPD can occur in individuals without COPD or asthma and are associated with significant health and socioeconomic outcomes. They increase the respiratory burden in the community and may contribute to the false-positive diagnosis of asthma or COPD.
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Affiliation(s)
- W C Tan
- UBC James Hogg Research Center, Providence Heart + Lung Institute, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, McGill University, Montréal, Quebec, Canada
| | - P Hernandez
- Respirology Division, Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - K R Chapman
- Asthma & Airway Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - R Cowie
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - J M FitzGerald
- University of British Columbia, Institute for Heart and Lung Health, Vancouver, British Columbia, Canada
| | - D D Marciniuk
- Division of Respirology, Critical Care and Sleep Medicine, and Airway research Group, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - F Maltais
- Centre de Pneumologie, Institute Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Canada
| | - A S Buist
- Oregon Health and Science University, Portland, Oregon, USA
| | - D E O'Donnell
- Division of Respiratory & Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - D D Sin
- UBC James Hogg Research Center, Providence Heart + Lung Institute, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - S D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Strong M, Green A, Goyder E, Miles G, Lee ACK, Basran G, Cooke J. Accuracy of diagnosis and classification of COPD in primary and specialist nurse-led respiratory care in Rotherham, UK: a cross-sectional study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2014; 23:67-73. [PMID: 24477772 PMCID: PMC6442286 DOI: 10.4104/pcrj.2014.00005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 10/02/2013] [Accepted: 12/12/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Studies have suggested that chronic obstructive pulmonary disease (COPD) is commonly misdiagnosed and misclassified in primary care, but less is known about the quality of diagnosis in specialist respiratory care. AIMS To measure the accuracy of COPD diagnosis and classification of airway obstruction in primary care and at a specialist respiratory centre, and to explore associations between misdiagnosis and misclassification and a range of explanatory factors. METHODS Data were obtained for 1,205 referrals to a specialist respiratory centre between 2007 and 2010. Standard analysis methods were used. RESULTS The majority of patients were referred for pulmonary rehabilitation (676/1,205, 56%). Of 1,044 patients with a primary care diagnosis of COPD, 211 (20%) had spirometry inconsistent with COPD. In comparison, of 993 specialist centre diagnoses, 65 (6.5%) had inconsistent spirometry. There was poor agreement between the airflow obstruction grade recorded on the referral and that based on spirometry (kappa=0.26, n=448), whereas agreement between the respiratory centre assessment of airflow obstruction and spirometry was good (kappa=0.88, n=1,016). Referral by practice nurse was associated with accuracy of airflow obstruction classification in primary care (OR 1.85, 95% CI 1.33 to 2.57). Males were more likely than females to have an accurate specialist care classification of airway obstruction (OR 1.40, 95% CI 1.01 to 1.93). Grade of airway obstruction changed between referral and assessment in 56% of cases. CONCLUSIONS In primary care, a proportion of patients diagnosed with COPD do not have COPD, and misclassification of grade of airflow obstruction is common. Misdiagnosis and misclassification is less common in the specialist care setting of BreathingSpace.
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Affiliation(s)
- Mark Strong
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Angela Green
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for South Yorkshire, NHS Rotherham Clinical Commissioning Group, Rotherham, UK
| | - Elizabeth Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gail Miles
- BreathingSpace, The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Andrew CK Lee
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gurnam Basran
- BreathingSpace, The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Jo Cooke
- NIHR CLAHRC for South Yorkshire, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Bjermer L, Alving K, Diamant Z, Magnussen H, Pavord I, Piacentini G, Price D, Roche N, Sastre J, Thomas M, Usmani O. Current evidence and future research needs for FeNO measurement in respiratory diseases. Respir Med 2014; 108:830-41. [PMID: 24636813 DOI: 10.1016/j.rmed.2014.02.005] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 01/12/2014] [Accepted: 02/08/2014] [Indexed: 12/18/2022]
Abstract
Although not yet widely implemented, fraction of exhaled nitric oxide (FeNO) has emerged in recent years as a potentially useful biomarker for the assessment of airway inflammation both in undiagnosed patients with non-specific respiratory symptoms and in those with established airway disease. Research to date essentially suggests that FeNO measurement facilitates the identification of patients exhibiting T-helper cell type 2 (Th2)-mediated airway inflammation, and effectively those in whom anti-inflammatory therapy, particularly inhaled corticosteroids (ICS), is beneficial. In some studies, FeNO-guided management of patients with established airway disease is associated with lower exacerbation rates, improvements in adherence to anti-inflammatory therapy, and the ability to predict risk of future exacerbations or decline in lung function. Despite these data, concerns regarding the applicability and utility of FeNO in clinical practice still remain. This article reviews the current evidence, both supportive and critical of FeNO measurement, in the diagnosis and management of asthma and other inflammatory airway diseases. It additionally provides suggestions regarding the practical application of FeNO measurement: how it could be integrated into routine clinical practice, how its utility could be assessed and its true value to both clinicians and patients could be established. Although some unanswered questions remain, current evidence suggests that FeNO is potentially a valuable tool for improving the personalised management of inflammatory airway diseases.
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Affiliation(s)
- Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skane University Hospital, 22185 Lund, Sweden.
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Zuzana Diamant
- Department of Respiratory Medicine and Allergology, Skane University Hospital, 22185 Lund, Sweden; Department of General Practice & QPS-NL, Groningen, The Netherlands
| | - Helgo Magnussen
- Pulmonary Research Institute at Lung Clinic Grosshansdorf, Germany
| | - Ian Pavord
- Department of Respiratory Medicine, Thoracic Surgery and Allergy, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Giorgio Piacentini
- Faculty of Medicine, University of Verona, Italy; Department of Paediatrics, Policlinico GB Rossi, Verona, Italy
| | | | - Nicolas Roche
- University Paris Descartes, Respiratory and Intensive Care Medicine Department, Cochin Hospital Group, Paris, France
| | - Joaquin Sastre
- Fundacion Jimenez Diaz, Allergy Service and CIBERES, Institute Carlos III, Madrid, Spain
| | | | - Omar Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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30
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Custovic A, Johnston SL, Pavord I, Gaga M, Fabbri L, Bel EH, Le Souëf P, Lötvall J, Demoly P, Akdis CA, Ryan D, Mäkelä MJ, Martinez F, Holloway JW, Saglani S, O'Byrne P, Papi A, Sergejeva S, Magnan A, Del Giacco S, Kalayci O, Hamelmann E, Papadopoulos NG. EAACI position statement on asthma exacerbations and severe asthma. Allergy 2013; 68:1520-31. [PMID: 24410781 PMCID: PMC7159478 DOI: 10.1111/all.12275] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2013] [Indexed: 02/02/2023]
Abstract
Asthma exacerbations and severe asthma are linked with high morbidity, significant mortality and high treatment costs. Recurrent asthma exacerbations cause a decline in lung function and, in childhood, are linked to development of persistent asthma. This position paper, from the European Academy of Allergy and Clinical Immunology, highlights the shortcomings of current treatment guidelines for patients suffering from frequent asthma exacerbations and those with difficult‐to‐treat asthma and severe treatment‐resistant asthma. It reviews current evidence that supports a call for increased awareness of (i) the seriousness of asthma exacerbations and (ii) the need for novel treatment strategies in specific forms of severe treatment‐resistant asthma. There is strong evidence linking asthma exacerbations with viral airway infection and underlying deficiencies in innate immunity and evidence of a synergism between viral infection and allergic mechanisms in increasing risk of exacerbations. Nonadherence to prescribed medication has been identified as a common clinical problem amongst adults and children with difficult‐to‐control asthma. Appropriate diagnosis, assessment of adherence and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors) have to be a priority in clinical assessment of all patients with difficult‐to‐control asthma. Further studies with improved designs and new diagnostic tools are needed to properly characterize (i) the pathophysiology and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma.
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Affiliation(s)
- A. Custovic
- Centre Lead for Respiratory Medicine; Institute of Inflammation & Repair; University of Manchester; University Hospital of South Manchester; Manchester UK
| | - S. L. Johnston
- Airway Disease Infection Section; National Heart & Lung Institute; Imperial College London; Norfolk Place London UK
| | - I. Pavord
- Department of Respiratory Medicine; Thoracic Surgery and Allergy University Hospitals of Leicester NHS Trust; Glenfield Hospital; Leicester UK
| | - M. Gaga
- 7th Respiratory Medicine Department and Asthma Centre; Athens Chest Hospital; Athens Greece
| | - L. Fabbri
- Department of Oncology Haematology and Respiratory Diseases; University of Modena & Reggio Emilia; Modena Italy
| | - E. H. Bel
- Department of Respiratory Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
| | - P. Le Souëf
- Department of Respiratory Medicine; University of Western Australia; Princess Margaret Hospital for Children; Perth WA Australia
| | - J. Lötvall
- Krefting Research Centre Sahlgrenska Academy; University of Gothenburg; Göteborg Sweden
| | - P. Demoly
- Allergology Unit; Département de Pneumologie-Addictologie; Hôpital de Villeneuve - Inserm U657; Montpellier France
| | - C. A. Akdis
- Swiss Institute of Allergy & Asthma Research (SIAF); University of Zurich; Davos
- Christine-Kühne Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - D. Ryan
- Woodbrook Medical Centre; Loughborough UK
| | - M. J. Mäkelä
- Skin and Allergy Hospital; Helsinki University Central Hospital; HUS Finland
| | - F. Martinez
- University of Arizona; Arizona Health Sciences Center; Pediatric Pulmonary Center; Tucson AZ USA
| | - J. W. Holloway
- University of Southampton; Faculty of Medicine Southampton General Hospital; Southampton UK
| | - S. Saglani
- National Heart & Lung Institute; Imperial College London; London UK
| | - P. O'Byrne
- Department of Medicine; Michael G DeGroote School of Medicine; McMaster University Faculty of Health Sciences; Hamilton ON Canada
| | - A. Papi
- Research Center on Asthma and COPD; University of Ferrara; Ferrara Italy
| | - S. Sergejeva
- Institute of Technology; University of Tartu; Tartu Estonia
| | - A. Magnan
- INSERM UMR915; l'institut du thorax; Faculté de Médecine; & Université de Nantes; Nantes France
| | - S. Del Giacco
- Department of Medical Science; University of Cagliari; Cagliari Italy
| | - O. Kalayci
- Pediatric Allergy and Asthma Unit; Ihsan Dogramaci Children's Hospital; Hacettepe University School of Medicine; Ankara Turkey
| | - E. Hamelmann
- Department of Pediatric Pneumology & Immunology; Charité Universitäts Berlin; Berlin Germany
- Department of Pediatrics; Ruhr-University Bochum; Bochum Germany
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Abstract
PURPOSE OF REVIEW There is ongoing controversy about the relationship between atopy and asthma. RECENT FINDINGS In clinical practice, specific IgE and skin test results should not be reported as 'positive' or 'negative', but as the level of IgE and the size of skin test wheal diameter. In assessment of children with severe asthma, these tests are not mutually exclusive but complementary, and both should be carried out and quantified. In the near future, their diagnostic accuracy in children with wheezing may be improved by the measurement of allergen-specific IgG. It is becoming increasingly clear that asthma is not a single disease, but a collection of several diseases with similar/same symptoms. These distinct disease entities (endotypes) may share similar observable characteristics (phenotypes), but arise via different pathophysiological mechanisms. Observable phenotypic features (e.g. sputum inflammatory phenotypes) are not stable in children with asthma. The discovery of novel, latent endotypes of asthma will require integration of a time component to take into account the phenotype instability and longitudinal changes. Not only asthma, but also 'atopy' encompasses a number of different endotypes which differ in their association with asthma. SUMMARY Novel endotypes of atopy and asthma which better reflect the unique pathophysiological processes underlying different diseases in the atopy and asthma syndromes can be defined through the fusion of computational thinking and novel mathematical approaches with biomedical science. These novel endotypes may be more relevant for epidemiological, genetic and therapeutic studies.
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Lamprecht B, Mahringer A, Soriano JB, Kaiser B, Buist AS, Studnicka M. Is spirometry properly used to diagnose COPD? Results from the BOLD study in Salzburg, Austria: a population-based analytical study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:195-200. [PMID: 23538703 PMCID: PMC6442781 DOI: 10.4104/pcrj.2013.00032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 11/24/2012] [Accepted: 01/07/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current guidelines recommend spirometry to confirm a diagnosis of chronic obstructive pulmonary disease (COPD). AIMS To investigate whether a self-reported diagnosis of COPD is associated with prior spirometry and whether a correct diagnosis of COPD is more likely when spirometry was performed. METHODS We used data from the population-based Austrian Burden of Obstructive Lung Disease (BOLD) study. Participants were aged >40 years and completed post-bronchodilator spirometry. Reported COPD diagnosis and reported prior lung function test were based on questionnaire. Persistent airflow limitation was defined as post-bronchodilator forced expiratory volume in one second/forced vital capacity ratio <0.7, corresponding with COPD Global initiative for chronic Obstructive Lung Disease (GOLD) grade I+, and GOLD grade II+ was also investigated. A correct diagnosis of COPD was defined as a reported physician's diagnosis of COPD and the presence of persistent airflow limitation. RESULTS 68 (5.4%) of 1,258 participants reported a prior physician's diagnosis of COPD. Of these, only 17 (25.0%) reported a lung function test within the past 12 months and 46 (67.6%) at any time in the past. The likelihood for a correct COPD GOLD grade I+ diagnosis was similar among subjects reporting a lung function test during the last 12 months (likelihood ratio 2.07, 95% CI 0.89 to 5.50) and those not reporting a lung function during the last 12 months (likelihood ratio 2.78, 95% CI 1.58 to 4.87). Similar likelihood ratios were seen when GOLD grade II+ was investigated and when lung function was reported at any time in the past. CONCLUSIONS One-third of subjects with a reported diagnosis of COPD never had a lung function test. When spirometry was reported, this did not increase the likelihood of a correct COPD diagnosis.
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Affiliation(s)
- Bernd Lamprecht
- Department of Pulmonary Medicine, Paracelsus Medical University Hospital, Salzburg, Austria.
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Marks GB. Evaluation of patients with symptoms of chronic lung disease in primary care. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:145-7. [PMID: 23708115 PMCID: PMC6442807 DOI: 10.4104/pcrj.2013.00054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Guy B Marks
- Clinical Professor and Head, Respiratory and Environmental Epidemiology, Woolcock Institute of Medical Research, Sydney, Australia
- Senior Staff Specialist Physician, Department of Respiratory Medicine, Liverpool Hospital, Sydney, Australia
- PO Box M77 Missenden Road PO, NSW 2050, Australia Tel: +61 2 9114 0466 Fax: +61 2 9114 0412 E-mail:
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