The ISTH-BAT score and outcomes after endometrial ablation in women with heavy menstrual bleeding

BACKGROUND

The International Society on Thrombosis and Haemostasis bleeding assessment tool (ISTH-BAT), is used during the diagnostic workup of bleeding disorders. Data on ISTH-BAT scores in women with heavy menstrual bleeding (HMB) undergoing endometrial ablation (EA) could be essential in optimizing HMB counselling.

OBJECTIVE

To investigate the postsurgical incidence of amenorrhea, dysmenorrhea, quality of life, re-intervention after EA, and ISTH-BAT score.

METHODS

This study included women who have undergone EA because of HMB. During a follow-up of 2 to 5 years, ISTH-BAT, pictorial blood assessment chart (PBAC), and Short Form-36 survey (SF-36) were administered. At 10 years of follow-up surgical re-interventions were evaluated.

RESULTS

Seventy-one women were included of whom 77% (n = 55) had an ISTH-BAT score < 6, versus 23% (n = 16) ISTH-BAT score ≥6 (mean age 46.3 versus 42.3, p = 0.004). In the ISTH-BAT ≥6 group versus < 6 group, amenorrhea occurred in 63% (10/16) versus 82% (45/55) (p = 0.111), dysmenorrhea in 38% (6/16) versus 18% (10/55) (p = 0.111), and surgical re-intervention in 19% (3/16) versus 25% (14/55) (p = 0.582). SF-36 item (Bodily) pain was lower in the ISTH-BAT ≥6 group versus < 6 (median score 58.7 vs. 80.0, p = 0.104).

CONCLUSIONS

An ISTH-BAT score ≥6 may be related to a lower amenorrhea incidence and higher dysmenorrhea rate after EA.

Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: Results of a scoping review

BACKGROUND

Chronic disease management is important in primary care. Disease management programmes focus primarily on the respective diseases. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care (PC-IC) is an alternative approach, putting the patient at the centre of care. This asks for additional competencies for healthcare professionals involved in the execution of PC-IC. In this scoping review we researched which competencies are necessary for healthcare professionals working in collaborative teams where the focus lies within the concept of PC-IC. We also explored how these competencies can be acquired.

METHODS

Six literature databases and grey literature were searched for guidelines and peer-reviewed articles on chronic illness and multimorbidity in primary care. A data synthesis was carried out resulting in an overview of the competencies that healthcare professionals need to deliver PC-IC.

RESULTS

Four guidelines and 21 studies were included and four core competencies could be derived through the synthesis: 1. interprofessional communication, 2, interprofessional collaborative teamwork, 3. leadership and 4. patient-centred communication. Included papers mostly lack a clear description of the competencies in terms of knowledge, skills and attitudes which are necessary for a PC-IC approach and on how these competencies can be acquired.

CONCLUSION

This review provides insight on competencies necessary to provide PC-IC within primary care. Research is needed in more depth on core concepts of these competencies which will then benefit educational programmes to ensure that healthcare professionals in primary care are better equipped to deliver PC-IC for patients with chronic illness and multimorbidity.

Mental health-related quality of life is related to delirium in intensive care patients

PURPOSE

Delirium during intensive care unit (ICU) stay may be related to premorbid mental illness. In addition, delirium during ICU stay may also negatively affect long-term health-related quality of life. The aim of our study was to investigate if delirium in the ICU is related to premorbid mental quality of life and affects long-term mental quality of life after ICU stay.

METHODS

We performed a prospective cohort study in 1021 patients admitted for longer than 48 h in a medical-surgical ICU. We evaluated mental and physical quality of life using the Short-form-12 before ICU admission, at hospital discharge, and 3, 6 and 12 months after hospital discharge. Mixed model and logistic regression models were used to analyze the data.

RESULTS

Patients who experienced a delirium during ICU stay reported a worse pre-admission mental quality of life than those without delirium (p < 0.001). Furthermore, patients who suffered from delirium during their ICU stay exhibited a significant decrease in mental quality of life over time relative to patients without delirium (p = 0.035).

CONCLUSION

In this large follow-up study, we demonstrated that ICU survivors who experienced a delirium during ICU stay reported a significantly worse pre-admission mental health-related quality of life and a significant decrease in mental health-related quality of life in the year after hospital discharge compared with patients without delirium.

Family screening in patients with isolated bicuspid aortic valve : Restriction to those with aortic dilatation is not justified

Aim

To determine the prevalence of undiagnosed bicuspid aortic valve (BAV) and isolated aortic dilatation in first-degree relatives (FDRs) of patients with isolated BAV and to explore the recurrence risk of BAV in different subgroups of probands with BAV. Recent American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines recommend family screening in patients with associated aortopathy only.

Methods

During follow-up visits, patients with isolated BAV received a printed invitation for their FDRs advising cardiac screening.

Results

From 2012–2019, 257 FDRs of 118 adult BAV patients were screened, among whom 63 (53%) index patients had undergone aortic valve surgery (AVS), including concomitant aortic replacement in 25 (21%). Of the non-operated index patients, 31 (26%) had aortic dilatation (> 40 mm). Mean age of the FDRs was 48 years (range 4–83) and 42% were male. The FDR group comprised 20 parents, 103 siblings and 134 offspring. Among these FDRs, 12 (4.7%) had a previously undiagnosed BAV and 23 (8.9%) had an isolated aortic dilatation. FDRs of the probands with previous AVS (n = 147) had a risk ratio for BAV of 2.25 (95% confidence interval (CI) 0.62–8.10). FDRs of the probands with BAV and repaired or unrepaired aortic dilatation (n = 127) had a risk ratio for BAV of 0.51 (95% CI 0.16–1.66).

Conclusion

Screening FDRs of patients with isolated BAV resulted in a reasonable yield of 14% new cases of BAV or isolated aortic dilatation. A trend towards an increased risk of BAV in FDRs was observed in the probands with previous AVS, whereas this risk seemed to be diminished in the probands with associated aortic dilatation. This latter finding does not support the restrictive ACC/AHA recommendation.

Electrolyte monitoring during regional citrate anticoagulation in continuous renal replacement therapy

Patients with acute kidney injury who need continuous renal replacement therapy with locoregional citrate anticoagulation are at risk of citrate accumulation with disruption of the calcium balance. We aimed to evaluate the safety of detecting citrate accumulation and adjusting electrolyte disbalances during continuous venovenous hemodialysis (CVVHD) in critically ill patients with acute kidney injury using a blood sample frequency every 6 h. A prospective single center study in critically ill intensive care unit patients who suffered from acute kidney injury with the need of renal replacement therapy. We evaluated the deviations in pH, bicarbonate and calcium during CVVHD treatment with local regional citrate anticoagulation. Values indicate median and interquartile range. Severe hypocalcemia (below 1.04 mmol/L) or hypercalcemia (above 1.31 mmol/L) occurred in 10.5% and 4.8% respectively. During treatment changes of systemic ionized calcium, post-filter ionized calcium, pH and bicarbonate were corrected with protocolized adjustments. No arrhythmias or citrate accumulation were seen. The values stabilized after 42 h and after that no statistically significant changes were observed. After 42 h of citrate CVVHD, systemic ionized calcium, pH and bicarbonate levels stabilized. A blood sample frequency every 6 h is probably safe to detect citrate accumulation and to adjust the settings of electrolytes to avoid serious electrolyte disturbances in ICU patients without severe metabolic acidosis or severe liver failure.

Family screening in patients with isolated bicuspid aortic valve in a general hospital, yield and subgroup analysis

Background

Bicuspid aortic valve (BAV) may frequently lead to aortic dilatation with risk of aortic dissection. In patients with BAV both familial clustering and aortic dilatation in first-degree relatives (FDR) without BAV has been demonstrated. Based on these findings the ESC Aortic Guidelines recommend to consider screening of FDR, while the ACC/AHA Guidelines on Valvular Heart Diseases consider screening of FDR only if the index patient has associated aortopathy. Currently, no data about the effectiveness of screening is available.

Purpose

To investigate the yield of screening FDR of patients with isolated BAV and to explore subgroups with FDR of patients who had needed surgery or of patients with aortic dilatation. We hypothesized that aortic dilatation (&gt;40mm) in the index patient is not a risk factor for BAV in FDR.

Methods

From 2012, patients with BAV visiting the outpatient clinic of a teaching hospital, received information advising cardiac screening of FDR. FDR of patients with isolated BAV who were referred, were included. From the 10 index patients from other hospitals, information was retrieved. [Fig.1]

Results

Referred were FDR from 118 index patients (mean age 60 years, standard deviation [SD] 14, range 15–90 years, 82 males [70%]). Of all index patients 63 (53%) had undergone aortic valve replacement, including concomitant ascending aorta replacement in 25 (21%). In the non-operated index patients, 31 (26%) had dilatation (&gt;40mm) of sinus of Valsalva and/or tubular ascending aorta.

Screened were 257 FDR (median 2 per index patient) comprising 20 parents (8%), 103 siblings (40%) and 134 offspring (52%). Mean age of FDR was 48 years (SD16, range 4–83 years) and 89 subjects (42%) were male. The diagnostic imaging modality was echocardiography in 240 cases (93%) and MRI in 17 cases. Ten FDR had an already known BAV and were not included in the screening.

Among the 257 FDR, we diagnosed 12 new BAV (4.7%, 95% confidence interval [CI]2.9–8.0%) (mean age 44 years, 50% male). Additionally, we diagnosed 23 new isolated aorta dilatations (8.9%; 95% CI 6.0–13%) at level of sinus of Valsalva and/or tubular ascending aorta (mean age 57 years, 18 [78%] were male) [Fig. 1]. Among them, 11 had hypertension.

FDR (n=147) of index patients with BAV and previous aortic valve surgery (n=63), had a risk ratio (RR) of 2.25 (95% CI 0.62–8.10) of having a BAV. FDR (n=126) of index patients with BAV and repaired or unrepaired aortic dilatation (n=56) had RR 0.35 (95% CI 0.10–1.25) of having a BAV.

Conclusions

Screening FDR of patients with isolated BAV resulted in a reasonable yield of 14% new cases with BAV or isolated aortic dilatation. The RR of the subgroup with aorta dilatation did not justify the limitation of the FDR as suggested in the ACC/AHA Guidelines.

Figure 1. Flowchart of screening and result

Funding Acknowledgement

Type of funding source: None

Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice

Background

Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice.

Methods

We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands.

From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression.

Results

We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI.

Conclusion

CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

A Smart Mobile Health Tool Versus a Paper Action Plan to Support Self-Management of Chronic Obstructive Pulmonary Disease Exacerbations: Randomized Controlled Trial

Background

Many patients with chronic obstructive pulmonary disease (COPD) suffer from exacerbations, a worsening of their respiratory symptoms that warrants medical treatment. Exacerbations are often poorly recognized or managed by patients, leading to increased disease burden and health care costs.

Objective

This study aimed to examine the effects of a smart mobile health (mHealth) tool that supports COPD patients in the self-management of exacerbations by providing predictions of early exacerbation onset and timely treatment advice without the interference of health care professionals.

Methods

In a multicenter, 2-arm randomized controlled trial with 12-months follow-up, patients with COPD used the smart mHealth tool (intervention group) or a paper action plan (control group) when they experienced worsening of respiratory symptoms. For our primary outcome exacerbation-free time, expressed as weeks without exacerbation, we used an automated telephone questionnaire system to measure weekly respiratory symptoms and treatment actions. Secondary outcomes were health status, self-efficacy, self-management behavior, health care utilization, and usability. For our analyses, we used negative binomial regression, multilevel logistic regression, and generalized estimating equation regression models.

Results

Of the 87 patients with COPD recruited from primary and secondary care centers, 43 were randomized to the intervention group. We found no statistically significant differences between the intervention group and the control group in exacerbation-free weeks (mean 30.6, SD 13.3 vs mean 28.0, SD 14.8 weeks, respectively; rate ratio 1.21; 95% CI 0.77-1.91) or in health status, self-efficacy, self-management behavior, and health care utilization. Patients using the mHealth tool valued it as a more supportive tool than patients using the paper action plan. Patients considered the usability of the mHealth tool as good.

Conclusions

This study did not show beneficial effects of a smart mHealth tool on exacerbation-free time, health status, self-efficacy, self-management behavior, and health care utilization in patients with COPD compared with the use of a paper action plan. Participants were positive about the supportive function and the usability of the mHealth tool. mHealth may be a valuable alternative for COPD patients who prefer a digital tool instead of a paper action plan.

Trial Registration

ClinicalTrials.gov NCT02553096; https://clinicaltrials.gov/ct2/show/NCT02553096.

The Relationship Between Real-World Inhaled Corticosteroid Adherence and Asthma Outcomes: A Multilevel Approach

BACKGROUND

Low inhaled corticosteroid (ICS) adherence is associated with increased asthma burden. This relationship is likely bidirectional, and may vary across adherence stages (initiation, implementation, and persistence). Studies rarely examine reciprocal influences.

OBJECTIVE

To investigate the relationship between ICS implementation and asthma-related outcomes over 2 years, considering bidirectionality and temporal sequence.

METHODS

Primary care records (1987-2012) from the Optimum Patient Care Research Database, United Kingdom, were used. Eligible patients were 6 years or older and had 3 or more years of continuous registration starting 1 year before ICS initiation (index date), physician-diagnosed asthma, 2 or more ICS and/or short-acting β-agonist prescriptions each follow-up year, and no long-acting β-agonists, leukotriene receptor antagonists, or maintenance oral corticosteroids in the preceding year. ICS implementation (percentage of days covered) and risk domain asthma control (RDAC; no asthma-related hospitalizations, emergency visits, or outpatient visits and no oral corticosteroid or antibiotic prescriptions with evidence of respiratory review) were estimated for each prescription interval (period between 2 successive prescriptions). Multilevel analyses modeled bidirectional relationships between ICS implementation and RDAC (and its components), controlling for sociodemographic and clinical characteristics.

RESULTS

In prescription data from 10,472 patients, ICS implementation in the preceding interval did not predict RDAC, but was weakly positively associated with simultaneous RDAC. Being male, non-current smoker, without chronic obstructive pulmonary disease diagnosis, and with fewer than 4 comorbidities significantly increased odds of RDAC. Asthma-related antibiotics and outpatient visits in the same interval and short-acting β-agonist overuse in the preceding and same interval predicted lower ICS implementation.

CONCLUSIONS

Patients may adapt their ICS use to their current needs without this impacting later RDAC.

Effects of the Spirometry Learning Module on the knowledge, confidence, and experience of spirometry operators

Our study measures effects of the Spirometry Learning Module (SLM) on health-care professionals' knowledge of spirometry test quality and perceived confidence, experience, and understanding of spirometry measurements and interpretation. Professionals from both primary and hospital-based settings enrolled in the SLM, a training model focusing on spirometry test performance and interpretation, including an online interactive learning component and a face-to-face workshop. Participants were asked to submit patient spirometry assessment worksheets for feedback on quality and interpretation. Data were collected at baseline, SLM completion (20 weeks), and 12 months after SLM completion. Knowledge of spirometry test quality was evaluated with questions relating to five case-based assessments of common spirometric patterns. Perceived confidence, experience, and knowledge in test performance were measured using a 7-point Likert scale. The Friedman test combined with post hoc analyses were used to analyse differences between baseline, 20-week, and 12-month post completion. Qualitative interviews were performed to assess reasons for non-completion. Of the 90 participants enrolled in the SLM and consented to research, 48 completed the 20-week measurement and 11 completed the 12-month measurement. Statistically significant improvements were detected in all outcomes in participants who completed the SLM to 20-week and 12-month follow-up assessments (all p values < 0.01). Barriers to completion were limited access to patients requiring spirometry, high clinic workload, and having a different spirometer at the workplace compared to the one used during SLM demonstrations. Our data suggest that participants' confidence, experience, and knowledge regarding spirometry may improve through SLM completion.

Primary care cohort study in the sequence of diagnosing chronic respiratory diseases and prescribing inhaled corticosteroids

To prevent unnecessary use of inhaled corticosteroids (ICS), ICS treatment should only be started when the diagnostic process of asthma and COPD is completed. Little is known about the chronological order between these diagnoses and the start of ICS. We performed a retrospective cohort study, based on electronic medical records of 178 Dutch general practices, to explore the temporal relations between starting continuous use of ICS and receiving a diagnosis of asthma and/or COPD. The database included information of patients who were registered with a diagnosis of asthma and/or COPD in one of the practices during January 1, 2012 and December 31, 2013. Two or more successive prescriptions of ICS within 6 months were considered as continuous ICS treatment. The chronological order of events based on available dates were analysed using descriptive analyses. For 8507 patients with asthma, 4024 patients with COPD, and 801 patients with asthma-COPD overlap (ACO), the order of events could be analysed. In total, 1857 (14.4%) patients started ICS prior to their diagnosis, 11.5, 20.8, and 10.0% of patients with asthma, COPD, and ACO, respectively. In 53.4% of the patients, the first prescription of ICS was a combination inhaler with a long-acting bronchodilator. In this real-life primary care cohort, one in seven patients started ICS treatment prior to their diagnosis and approximately half of the patients started with a combination inhaler. Our findings suggest that there is relevant room for improvement in the pharmaceutical management of patients with these chronic respiratory diseases.

The Global Lung Function Initiative 2012 Equations Are as Well-Suited as Local Population Derived Equations to a Sample of Healthy Professional Firefighters

BACKGROUND AND OBJECTIVE

We aimed to assess the validity of using the Global Lung Function Initiative's (GLI) 2012 equations to interpret lung function data in a healthy workforce of South Australian Metropolitan Fire Service (SAMFS) personnel.

METHODS

Spirometry data from 212 healthy, nonsmoking SAMFS firefighters were collected and predicted normal values were calculated using both the GLI and local population derived (Gore) equations for forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC. Two-tailed paired sample Student's t-tests, Bland-Altman assessments of agreement, and z-scores were used to compare the two prediction methods.

RESULTS

The equations showed good agreement for mean predicted FEV1, FVC, and FEV1/FVC. Mean z-scores were similar for FEV1 and FVC, although not FEV1/FVC, but greater than 0.5. Differences between the calculated lower limits of normal (LLN) were significant (p < 0.01), clinically meaningful, and resulted in an 8% difference in classification of abnormality using the FEV1/FVC ratio.

CONCLUSIONS

The GLI equations predicted similar lung function as population-specific equations and resulted in a lower incidence of obstruction in this sample of healthy SAMFS firefighters. Further, interpretation of spirometry data as abnormal should be based on both an FEV1 and FEV1/FVC ratio < LLN.

PELICAN: Content evaluation of patient-centered care for children with asthma based on an online tool

BACKGROUND

We assessed the content of an intervention which integrates individual goals in outpatient clinic asthma management (based on self management principles) of children 6-12 years of age.

METHODS

This is a content evaluation study and was part of a randomized controlled multicenter trial with 9 months follow-up in five Dutch outpatient asthma clinics among children with asthma aged 6-12 years. Information on children's individual problems and their level of impairment (as indicated by the Pelican instrument), asthma management goals, and actions (as indicated by written action plans) was collected. Satisfaction of parents, children, and nurses were assessed with questionnaires and analyzed with descriptive statistics.

RESULTS

Most frequently identified problems by children (n = 42) were "cough," "cigarette smoke," and "shortness of breath." Eighty-two percent of items that were selected by children showed room for improvement. About 2-7 actions were formulated and children had an active role in more than 76% of the actions. "Using rescue medication prior to activities/triggers," and "talk to others about your asthma" were most frequently recommended. Children thought the Pelican instrument was easy (95%) and fun (65%) and both parents and nurses were positive about the incorporation of the program in asthma management. Following barriers were found: (1) only 25% of goals was formulated according to SMART principles; (2) traditional management aspects (such as medication use) are often treated instead of individual problems of children.

CONCLUSION

Implementation of patient-centered care based on the Pelican instrument is recommended in specialized care, although more extensive training of nurses in PCC will improve the successful execution of the evaluated treatment. Pediatr Pulmonol. 2016;51:993-1003. © 2016 Wiley Periodicals, Inc.

How GPs value guidelines applied to patients with multimorbidity: a qualitative study

OBJECTIVES

To explore and describe the value general practitioner (GPs) attribute to medical guidelines when they are applied to patients with multimorbidity, and to describe which benefits GPs experience from guideline adherence in these patients. Also, we aimed to identify limitations from guideline adherence in patients with multimorbidity, as perceived by GPs, and to describe their empirical solutions to manage these obstacles.

DESIGN

Focus group study with purposive sampling of participants. Focus groups were guided by an experienced moderator who used an interview guide. Interviews were transcribed verbatim. Data analysis was performed by two researchers using the constant comparison analysis technique and field notes were used in the analysis. Data collection proceeded until saturation was reached.

SETTING

Primary care, eastern part of The Netherlands.

PARTICIPANTS

Dutch GPs, heterogeneous in age, sex and academic involvement.

RESULTS

25 GPs participated in five focus groups. GPs valued the guidance that guidelines provide, but experienced shortcomings when they were applied to patients with multimorbidity. Taking these patients' personal circumstances into account was regarded as important, but it was impeded by a consistent focus on guideline adherence. Preventative measures were considered less appropriate in (elderly) patients with multimorbidity. Moreover, the applicability of guidelines in patients with multimorbidity was questioned. GPs' extensive practical experience with managing multimorbidity resulted in several empirical solutions, for example, using their 'common sense' to respond to the perceived shortcomings.

CONCLUSIONS

GPs applying guidelines for patients with multimorbidity integrate patient-specific factors in their medical decisions, aiming for patient-centred solutions. Such integration of clinical experience and best evidence is required to practise evidence-based medicine. More flexibility in pay-for-performance systems is needed to facilitate this integration. Several improvements in guideline reporting are necessary to enhance the applicability of guidelines in patients with multimorbidity.

The Effect of Comorbidity on Glycemic Control and Systolic Blood Pressure in Type 2 Diabetes: A Cohort Study with 5 Year Follow-Up in Primary Care

Aims

To explore the longitudinal effect of chronic comorbid diseases on glycemic control (HbA₁C) and systolic blood pressure (SBP) in type 2 diabetes patients.

Methods

In a representative primary care cohort of patients with newly diagnosed type 2 diabetes in The Netherlands (n = 610), we tested differences in the five year trend of HbA₁C and SBP according to comorbidity profiles. In a mixed model analysis technique we corrected for relevant covariates. Influence of comorbidity (a chronic disease already present when diabetes was diagnosed) was tested as total number of comorbid diseases, and as presence of specific disease groups, i.e. cardiovascular, mental, and musculoskeletal disease, malignancies, and COPD. In subgroup effect analyses we tested if potential differences were modified by age, sex, socioeconomic status, and BMI.

Results

The number of comorbid diseases significantly influenced the SBP trend, with highest values after five years for diabetes patients without comorbidity (p = 0.005). The number of diseases did not influence the HbA₁C trend (p = 0.075). Comorbid musculoskeletal disease resulted in lower HbA₁C at the time of diabetes diagnosis, but in higher values after five years (p = 0.044). Patients with cardiovascular diseases had sustained elevated levels of SBP (p = 0.014). Effect modification by socioeconomic status was observed in some comorbidity subgroups.

Conclusions

Presence of comorbidity in type 2 diabetes patients affected the long-term course of HbA₁C and SBP in this primary care cohort. Numbers and types of comorbidity showed differential effects: not the simple sum of diseases, but specific types of comorbid disease had a negative influence on long-term diabetes control parameters. The complex interactions between comorbidity, diabetes control and effect modifiers require further investigation and may help to personalize treatment goals.

Rhinosinusitis in morbidity registrations in Dutch General Practice: a retro-spective case-control study

Background

There is only limited accurate data on the epidemiology of rhinosinusitis in primary care.

This study was conducted to assess the incidence of acute and chronic rhinosinusitis by analysing data from two Dutch general practice registration projects. Several patient characteristics and diseases are related to the diagnosis rhinosinusitis.

Methods

The Continuous Morbidity Registration (CMR) and the Transitionproject (TP) are used to analyse the data on rhinosinusitis in primary practice. Both registries use codes to register diagnoses.

Results

In the CMR 3244 patients are registered with rhinosinusitis and in the TP 5424 CMR: The absolute incidence of (acute) rhinosinusitis is 5191 (18.8 per 1000 patient years). Regarding an odds ratio of 5.58, having nasal polyps is strongest related to rhinosinusitis compared to the other evaluated comorbidities. A separate code for chronic rhinosinusitis exists, but is not in use.

TP: Acute and chronic rhinosinusitis are coded as one diagnosis. The incidence of rhinosinusitis is 5574 or 28.7 per 1000 patient years. Patients who visit their general practitioner with “symptoms/complaints of sinus”, allergic rhinitis and “other diseases of the respiratory system” have the highest chances to be diagnosed with rhinosinusitis. Medication is prescribed in 90.6 % of the cases.

Conclusions

Rhinosinusitis is a common diagnosis in primary practice. In the used registries no difference could be made between acute and chronic rhinosinusitis, but they give insight in comorbidity and interventions taken by the GP in case of rhinosinusitis.

Are asthma patients at increased risk of clinical depression? A longitudinal cohort study

OBJECTIVE

In this study, we assessed whether adult patients with asthma are more likely to be diagnosed with depression than diabetes patients or "healthy" controls during follow-up in primary care.

METHODS

Data from the Nijmegen Continuous Morbidity Registration were used to assess the risk for a first depression. Patients with asthma were compared with patients with diabetes and with two healthy controls matched on age, gender, socioeconomic status and attending general practice. With Cox proportional hazard analysis, we compared the risk of depression between these groups. These analyses were corrected for relevant covariates including a time-depending variable for multimorbidity. Explorative subgroup analyses were done for age, gender, socioeconomic status and multimorbidity.

RESULTS

Cumulative incidence of depression in asthma patients was 5.2%, in DM patients 4.1% and in control subjects 3.3%. The hazard ratios for a first episode of depression in the asthma patients (n = 795) compared to DM patients (n = 1033) and control subjects after correction for covariates were 1.11 (95% CI 0.60-2.04) and 1.18 (95% CI 0.78-1.79), respectively. Exploratory analyses showed that asthma patients without multimorbidity were at higher risk for a depression compared to reference groups, while asthma patients with multimorbidity were at lower risk for depression.

CONCLUSION

Asthma patients were not more likely to be diagnosed with a first depression compared to "healthy" control subjects or diabetes patients. The influence of multimorbidity on depression risk in asthma patients warrants further study.

PELICAN: a cluster-randomized controlled trial in Dutch general practices to assess a self-management support intervention based on individual goals for children with asthma

OBJECTIVE

Insufficient asthma management leads to impaired health-related quality of life (HRQL). The aim of this study is to assess whether individualized self-management (ISM) support will improve HRQL in children with asthma compared to enhanced usual care (EUC) in Dutch general practices.

METHODS

A cluster-randomized controlled trial with 9-month follow-up. ISM is a nurse-led intervention that is optimized to the needs of children, leading to a written action plan. Power calculation demanded inclusion of 170 children (aged 6-11 years) diagnosed with asthma and active medication use.

RESULTS

Outcomes were HRQL of the child (Paediatric Asthma Quality of Life Questionnaire, PAQLQ-s) and several secondary outcomes. Data of 29 children (mean age 8.6 years, SD 1.7) were analyzed; ISM (n = 15) or EUC (n = 14). Logistic regression analysis (minimal clinical important difference; MCID ≥ 0.5) and descriptive analyses were performed. Despite high PAQLQ-s score at baseline (median ISM 6.35, EUC 6.02), a substantial number of subjects from both groups showed MCID of HRQL (ISM 33%, EUC 57%). Treatment differences on HRQL were not significant (OR 0.38, 95% CI 0.08, 1.69). Secondary outcomes did not show significant differences either, with exception of PAQLQ-s symptoms domain score in favor of EUC.

CONCLUSION

Due to recruitment problems and underpowered analyses, no firm conclusions on the effectiveness of ISM support for childhood asthma in primary care could be drawn. Still, this study can be considered a valuable pilot study and in the future, there might be better capacity in general practices to commit to such treatment.

Using the DOSE index to predict changes in health status of patients with COPD: a prospective cohort study

Background:

The severity of chronic obstructive pulmonary disease (COPD) should not be based on the level of airflow limitation alone. A multicomponent index such as the DOSE index (dyspnoea score (D), level of airflow obstruction (O), current smoking status (S), and exacerbations (E)) has the potential to predict important future outcomes in patients with COPD more effectively than the forced expiratory volume in one second. Health status deterioration should be prevented in COPD patients.

Aims:

To investigate whether the DOSE index can predict which patients are at risk of a clinically relevant change in health status.

Methods:

A prospective cohort study was performed using data from primary and secondary care. The DOSE score was determined at baseline and the 2-year change in the Clinical COPD Questionnaire (CCQ) score was calculated. Linear regression analysis was performed for the effect of a high DOSE score (≥4) on the change in CCQ score.

Results:

The study population consisted of 209 patients (112 patients from primary care). Overall, a high DOSE score was a significant predictor of a change in CCQ score after 2 years (0.41, 95% CI 0.13 to 0.70), particularly in primary care patients.

Conclusions:

A DOSE score of ≥4 has the ability to identify COPD patients with a greater risk of future worsening in health status.

Validity, reliability and discriminative capacity of an electronic quality of life instrument (Pelican) for childhood asthma in the Netherlands

PURPOSE

To assess psychometric properties of the Pelican instrument, an online Dutch self-administered Quality of Life instrument for childhood asthma for scientific and clinical use.

METHODS

A cohort study was done in two asthma populations and healthy children. One asthma population had assessment at start, 4 and 8 weeks. The other asthma population and healthy children had one assessment. All children were aged 6-12 years. Children completed the Pelican instrument, Paediatric Asthma Quality of Life Questionnaire, feeling thermometer and Childhood Asthma Control Test. Lung function and fraction exhaled nitric oxide were measured. Parents completed Functional Status II, Asthma Control Questionnaire, Childhood Asthma Control Test questionnaires and symptom diaries. We assessed interpretability, structural validity, internal consistency, reliability, construct and discriminative validity of the Pelican instrument.

RESULTS

Eighty-five asthmatic (mean age 8.5 years) and 49 healthy children (mean age 8.4 years) participated. The Pelican instrument has 5 domains with 21 items after factor analysis. Internal consistency was 0.89 (CI 0.85-0.92), domain reliability showed Cronbach's α's from 0.64 to 0.76 and item-to-scale correlations from 0.61 to 0.81. Test-retest reliability was confirmed ICC = 0.88 (CI 0.79-0.93). Construct validity was demonstrated by significant moderate correlations with other relevant asthma outcomes like PAQLQ (r = -0.59, p < 0.01). Discriminative capacity between controlled or uncontrolled asthma (t = 3.20, p < 0.01, Δ = 0.64) and asthma versus healthy subjects (t = 6.31, p < 0.01, Δ = 0.94) was found.

CONCLUSIONS

The psychometric properties of the Pelican instrument were acceptable in Dutch paediatric asthma patients between 6 and 12 years old.

COPD prognosis in relation to diagnostic criteria for airflow obstruction in smokers

The aim of this study was to establish which cut-off point for the forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio (i.e. fixed 0.70 or lower limit of normal (LLN) cut-off point) best predicts accelerated lung function decline and exacerbations in middle-aged smokers. We performed secondary analyses on the Lung Health Study dataset. 4045 smokers aged 35-60 years with mild-to-moderate obstructive pulmonary disease were subdivided into categories based on presence or absence of obstruction according to both FEV1/FVC cut-off points. Post-bronchodilator FEV1 decline served as the primary outcome to compare subjects between the categories. 583 (14.4%) subjects were nonobstructed and 3230 (79.8%) subjects were obstructed according to both FEV1/FVC cut-off points. 173 (4.3%) subjects were obstructed according to the fixed cut-off point, but not according to the LLN cut-off point ("discordant" subjects). Mean±SE post-bronchodilator FEV1 decline was 41.8±2.0 mL·year(-1) in nonobstructed subjects, 43.8±3.8 mL·year(-1) in discordant subjects and 53.5±0.9 mL·year(-1) in obstructed subjects (p<0.001). Our study showed that FEV1 decline in subjects deemed obstructed according to a fixed criterion (FEV1/FVC <0.70), but non-obstructed by a sex- and age-specific criterion (LLN) closely resembles FEV1 decline in subjects designated as non-obstructed by both criteria. Sex and age should be taken into account when assessing airflow obstruction in middle-aged smokers.

Prevalence and incidence density rates of chronic comorbidity in type 2 diabetes patients: an exploratory cohort study

BACKGROUND

Evidence-based diabetes guidelines generally neglect comorbidity, which may interfere with diabetes management. The prevalence of comorbidity described in patients with type 2 diabetes (T2D) shows a wide range depending on the population selected and the comorbid diseases studied. This exploratory study aimed to establish comorbidity rates in an unselected primary-care population of patients with T2D.

METHODS

This was a cohort study of 714 adult patients with newly diagnosed T2D within the study period (1985-2007) in a practice-based research network in the Netherlands. The main outcome measures were prevalence and incidence density rates of chronic comorbid diseases and disease clusters. All chronic disease episodes registered in the practice-based research network were considered as comorbidities. We categorised comorbidity into 'concordant' (that is, shared aetiology, risk factors, and management plans with diabetes) and 'discordant' comorbidity. Prevalence and incidence density were assessed for both categories of comorbidity.

RESULTS

The mean observation period was 17.3 years. At the time of diabetes diagnosis, 84.6% of the patients had one or more chronic comorbid disease of 'any type', 70.6% had one or more discordant comorbid disease, and 48.6% and 27.2% had three or more chronic comorbid diseases of 'any type' or of 'discordant only', respectively. A quarter of those without any comorbid disease at the time of their diabetes diagnosis developed at least one comorbid disease in the first year afterwards. Cardiovascular diseases (considered concordant comorbidity) were the most common, but there were also high rates of musculoskeletal and mental disease. Discordant comorbid diseases outnumbered concordant diseases.

CONCLUSIONS

We found high prevalence and incidence density rates for both concordant and discordant comorbidity. The latter may interfere with diabetes management, thus future research and clinical practice should take discordant comorbidity in patients with T2D into account.

PELICAN: A quality of life instrument for childhood asthma: study protocol of two randomized controlled trials in primary and specialized care in the Netherlands

Background

Asthma is one of the major chronic health problems in children in the Netherlands. The Pelican is a paediatric asthma-related quality of life instrument for children with asthma from 6–11 years old, which is suitable for clinical practice in primary and specialized care. Based on this instrument, we developed a self-management treatment to improve asthma-related quality of life. The Pelican intervention will be investigated in different health care settings. Results of intervention studies are often extrapolated to other health care settings than originally investigated. Because of differences in organization, disease severity, patient characteristics and care provision between health care settings, extrapolating research results could lead to unnecessary health costs without the desired health care achievements. Therefore, interventions have to be investigated in different health care settings when possible. This study is an example of an intervention study in different health care settings. In this article, we will present the study protocol of the Pelican study in primary and specialized care.

Method/design

This study consists of two randomized controlled trials to assess the effectiveness of the Pelican intervention in primary and specialized care. The trial in primary care is a multilevel design with 170 children with asthma in 16 general practices. All children in one general practices are allocated to the same treatment group. The trial in specialized care is a multicentre trial with 100 children with asthma. Children in one outpatient clinic are randomly allocated to the intervention or usual care group. In both trials, children will visit the care provider four times during a follow-up of nine months. This study is registered and ethically approved.

Discussion

This article describes the study protocol of the Pelican study in different health care settings. If the Pelican intervention proves to be effective and efficient, implementation in primary and specialized care for paediatric asthma in the Netherlands will be recommended.

Trial registration

This study is registered by clinicaltrial.gov (NCT01109745)

Management of rhinosinusitis in Dutch general practice

AIMS

To determine whether general practitioners (GPs) distinguish between the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS), especially with regard to prescription of antibiotics and nasal steroids.

METHODS

A questionnaire on the management of rhinosinusitis was sent to 1000 GPs in The Netherlands.

RESULTS

Ninety-six percent discriminated between ARS and CRS. However, the definition of ARS and CRS varied. The percentage of GPs prescribing antibiotics rose as rhinosinusitis severity increased. The prescription rate of nasal corticosteroids was highest for CRS (88.6%). Prescribing nasal corticosteroids in ARS was not very common.

CONCLUSIONS

Most GPs discriminate between ARS and CRS and 54% accepted (the EP3OS-defined) 12 weeks as the division between ARS and CRS. Antibiotics and nasal steroids are commonly used agents, but the management of rhinosinusitis is not always consistent with guidelines.

Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma?

BACKGROUND

There is strong evidence that there is a relationship between allergic rhinitis (AR) and asthma, but it is unclear whether there is a causal relation between AR and asthma. The aim of this study was to assess prospectively whether AR is a risk factor for the diagnosis of asthma in a large primary care population.

METHODS

We performed a historic cohort study of life-time morbidity that had been recorded prospectively since 1967 in four general practices. Two groups of subjects were selected: (i) patients with diagnosis of AR, (ii) a control group matched using propensity scores. We assessed the risk of physician-diagnosed asthma in patients with physician-diagnosed AR compared to subjects without a diagnosis of AR (controls).

RESULTS

The study population consisted of 6491 subjects (n = 2081 patients with AR). Average study follow-up was 8.4 years. In patients with AR, the frequency of newly diagnosed asthma was 7.6% (n = 158) compared to 1.6% (n = 70) in controls (P < 0.001). After adjusting the effect of AR on asthma diagnosis for registration time, age, gender, eczema and socioeconomic status, having AR was a statistically significant risk factor for asthma (hazard ratio: 4.86, P < 0.001, 95% confidence interval: 3.50-6.73, controls as reference).

CONCLUSION

A diagnosis of AR was an independent risk factor for asthma in our primary care study population. Having physician-diagnosed AR increased the risk almost fivefold for a future asthma diagnosis.

Spirometry and impulse oscillometry (IOS) for detection of respiratory abnormalities in metropolitan firefighters

BACKGROUND AND OBJECTIVE

As firefighters are at increased risk of adverse health effects, periodic examination of their respiratory health is important. The objective of this study was to establish whether the use of impulse oscillometry (IOS) reveals respiratory abnormalities in metropolitan firefighters that go undetected during routine respiratory health screening by spirometry and assessment of respiratory symptoms.

METHODS

This was a cross-sectional analysis of spirometry, IOS and questionnaire data from 488 male firefighters. Abnormal spirometry was defined as FEV(1), FEV(1)/FVC and/or FEF(50) below the lower limit of normal. Abnormal IOS was defined as resistance at 5 Hz (R5), frequency dependence of resistance (DeltaR5-R20) and/or reactance area (AX) above the upper limit of normal. Respiratory symptoms, smoking history, exposures and medical history were assessed. Data were analysed using logistic and linear regression models.

RESULTS

The mean age of the firefighters was 43.8 (SD 8.4) years. There were 123 (25%) former smokers and 50 (10%) current smokers. Abnormal spirometry was detected in 12%, abnormal IOS in 9% and respiratory symptoms in 20% of firefighters. Current smoking was associated with all IOS parameters (OR for R5 = 3.1, OR for DeltaR5-R20 = 7.7, OR for AX = 4.3), and with FEF(50) (OR = 9.1), chronic productive cough (OR = 4.0) and breathlessness (OR = 5.4) (P < 0.05 for all). Exposure during firefighting duties was associated with chronic productive cough (OR = 2.6), but not with spirometry or IOS parameters. Interaction terms in the linear regression models indicated associations between smoking and DeltaR5-R20, and also between smoking and AX, in the lowest and second lowest quartiles of spirometry parameters.

CONCLUSIONS

Application of IOS for the assessment of respiratory health in firefighters identified airways dysfunction in some individuals, even when spirometry values were within the normal range and there were no respiratory symptoms.

Dynamic hyperinflation after metronome-paced hyperventilation in COPD--a 2 year follow-up

In contrast to the decline in FEV(1), the behavior of dynamic hyperinflation (DH) over time is unknown in patients with COPD. Metronome-paced hyperventilation (MPH) is a simple applicable surrogate for exercise to detect DH.

OBJECTIVE

To evaluate changes in MPH-induced DH during two years follow-up in mild-to-severe COPD patients. Additionally, influence of smoking status on DH and the relation between DH and other lung function parameters were assessed.

METHODS

Patients were recruited from a randomized controlled trial conducted in general practice. Measurements of lung function and DH were performed at baseline and after 12 and 24 months. DH was assessed by MPH with breathing frequency set at twice the baseline rate. Change in inspiratory capacity after MPH was used to reflect change in end-expiratory lung volume and therefore DH, presuming constant total lung capacity.

RESULTS

During follow-up, 68 patients completed all measurements. DH increased by 0.23±0.06L (p≤0.001). No significant changes in FEV(1) %pred were seen. Smokers had lower FEV(1) and a more rapid decline than non-smokers. DH in smokers increased more over time compared to non-smokers. The amount of DH correlated positively with resting inspiratory capacity.

CONCLUSION

After two years, a significant increase in MPH-induced DH in COPD patients was demonstrated, which was not accompanied by a decline in FEV(1). It might be that DH is a sensitive measure to track consequences of changes in airflow obstruction.

How does asthma influence the daily life of children? Results of focus group interviews

Background

Health-related quality of life (HRQL) brings together various aspects of an individual's subjective experience that relate both directly and indirectly to health, disease, disability, and impairment. Although asthma is the most common chronic disease in childhood, information on pediatric patients' views on asthma-specific HRQL has not been described before. The aim of this study was to establish the components of asthma-specific HRQL, as experienced by primary school-aged asthmatic children. The generated components will be used to develop an individualized HRQL instrument for childhood asthma.

Methods

Primary school-aged asthmatic children were invited to participate in three consecutive focus group sessions. A total of five focus groups were formed. Two reviewers independently 1) identified trends in the statements and relations between HRQL components, 2) clustered the components into a small number of domains and, 3) made a model on asthma-specific HRQL based on the transcribed statements of the children. The results were compared between the two reviewers and resulted in a final model.

Results

Asthma influenced the life of the children physically, emotionally and socially. The most important components of HRQL were the effects on, and consequences of asthma on peer relationships (e.g., being bullied), the dependence on medication, shortness of breath, cough, limitations in activities and limitations due to the response on cigarette smoke exposure.

Conclusion

The outcome of the focus group meetings indicates that asthma influences the life of children in various ways. Not all essential components of HRQL, according to the children, are part of existing asthma-specific HRQL instruments.

Pulse oximetry in family practice: indications and clinical observations in patients with COPD

PURPOSE

To establish situations in which family physicians (FPs) consider pulse oximetry a valuable addition to their clinical patient assessment; to explore pulse oximetry results (SpO(2)) when used by FPs in patients with chronic obstructive pulmonary disease (COPD); to explore associations between SpO(2) and other markers of COPD severity.

METHODS

We performed three separate studies: (i) interviews plus a Delphi consensus procedure with FPs experienced in using pulse oximetry to elucidate indications for pulse oximetry; (ii) analysis of SpO(2) and clinical data in COPD patients who presented to FPs with deteriorating symptoms and (iii) analysis of SpO(2), spirometry and clinical data in patients with stable COPD.

RESULTS

Interviewed FPs (n = 11) used their pulse oximeter for a range of acute (14) and non-acute (11) indications but valued it highest in acute (worsening of) dyspnoea, in suspected respiratory insufficiency/failure and in patients with COPD. In 88 patients with deteriorating COPD, 22% showed SpO(2) <or=92%. Correlation between baseline forced expiratory volume in 1 second % predicted and SpO(2) in patients presenting with acute COPD exacerbations was r = 0.55 (P = 0.001). In 207 patients with stable COPD, 6.3% showed SpO(2) values <or=92%. SpO(2) values were associated with Medical Research Council dyspnoea scores (P = 0.019).

CONCLUSIONS

FPs report a wide range of indications for pulse oximetry in acute as well as non-acute situations. In COPD, pulse oximetry appears to be especially useful in patients with severe disease and worsening of symptoms. Pulse oximetry may have a role in the monitoring of patients with COPD with exercise-related dyspnoea.

Diagnostic accuracy of spirometry in primary care

BACKGROUND

To evaluate the sensitivity, specificity and predictive values of spirometry for the diagnosis of chronic obstructive pulmonary disease (COPD) and asthma in patients suspected of suffering from an obstructive airway disease (OAD) in primary care.

METHODS

Cross sectional diagnostic study of 219 adult patients attending 10 general practices for the first time with complaints suspicious for OAD. All patients underwent spirometry and structured medical histories were documented. All patients received whole-body plethysmography (WBP) in a lung function laboratory. The reference standard was the Tiffeneau ratio (FEV1/VC) received by the spirometric maneuver during examination with WBP. In the event of inconclusive results, bronchial provocation was performed to determine bronchial hyper-responsiveness (BHR). Asthma was defined as a PC20 fall after inhaling methacholine concentration < or = 16 mg/ml.

RESULTS

90 (41.1%) patients suffered from asthma, 50 (22.8%) suffered from COPD, 79 (36.1%) had no OAD. The sensitivity for diagnosing airway obstruction in COPD was 92% (95%CI 80-97); specificity was 84% (95%CI 77-89). The positive predictive value (PPV) was 63% (95%CI 51-73); negative predictive value (NPV) was 97% (95%CI 93-99). The sensitivity for diagnosing airway obstruction in asthma was 29% (95%CI 21-39); specificity was 90% (95%CI 81-95). PPV was 77% (95%CI 60-88); NPV was 53% (95%CI 45-61).

CONCLUSION

COPD can be estimated with high diagnostic accuracy using spirometry. It is also possible to rule in asthma with spirometry. However, asthma can not be ruled out only using spirometry. This diagnostic uncertainty leads to an overestimation of asthma presence. Patients with inconclusive spirometric results should be referred for nitric oxide (NO) - measurement and/or bronchial provocation if possible to guarantee accurate diagnosis.

Improving initial management of lower urinary tract symptoms in primary care: Costs and patient outcomes

OBJECTIVE

Guidelines for primary care management of lower urinary tract symptoms in older men recommend shared decision making regarding the choice of treatment. In this study we aimed to determine the costs and patient outcomes of an implementation strategy designed to enhance uptake of these guidelines.

MATERIAL AND METHODS

The intervention comprised a distance learning programme for general practitioners, comprising evidence-based information, assessment of learning needs, a knowledge test and patient education materials. The control group only received the written guidelines. A cluster randomized trial in 187 older male patients compared costs and outcomes in the two study groups. A healthcare perspective was taken in the economic evaluation, with a 3-month time horizon. The primary health outcome was patient-reported urinary symptoms at 3 months. Costs relating to the distance learning package and the healthcare provided were considered, using undiscounted standardized prices.

RESULTS

Patient-reported urinary symptoms at 3 months did not differ between the study groups: 66% and 61% with moderate symptoms and 7% and 11% with severe symptoms in the intervention and control groups, respectively. The mean total costs per patient were euro28.15 lower in the intervention group (euro93.11) compared to the control group (euro121.26), mainly because of a lower number of referrals to the urologist. A bootstrap analysis showed an incremental cost-effectiveness ratio of euro111.98 (95% CI -euro423 to +euro329).

CONCLUSIONS

The distance learning programme did not change health outcomes, but it reduced costs in the first 3 months after an initial consultation compared to written guidelines. Studies with a longer follow-up period are needed.

Do family physicians' records fit guideline diagnosed COPD?

BACKGROUND

In family practice, chronic obstructive pulmonary disease (COPD) is usually not diagnosed until clinically apparent and of moderately advanced severity.

OBJECTIVE

To analyse the diagnostic process from early development onwards and to assess the current state of underpresentation and underdiagnosis of COPD and asthma in primary care in the Netherlands.

METHODS

The population-based study sample consisted of formerly undiagnosed subjects (n = 532) from family practice. Family physicians' (FPs) chronic respiratory disease diagnoses (as recorded over 10 years in their patient records) were compared to a cross-sectional but extensive diagnostic assessment by a chest physician. Logistic regression modelling was used for a retrospective analysis on the relation between respiratory symptoms, practice visit rate and FPs' diagnosis of COPD.

RESULTS

After 10 years, the chest physician diagnosed 26% of subjects as COPD and 16% as (late-onset) asthma. Underpresentation of these patients in family practice was 46%, whereas underdiagnosis occurred in 37% of patients. A chest physician diagnosis of COPD was associated with the presence of chronic cough [odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.1-4.6], a FP diagnosis of COPD with chronic phlegm (OR = 10.6, 95% CI 1.3-83.6). Repeated practice visits (OR = 1.8) and presence of wheeze and breathlessness (OR = 5.5) appeared to trigger the diagnostic process in family practice.

CONCLUSIONS

There is still considerable underpresentation and underdiagnosis of COPD in family practice. As FPs focus on presented symptoms and as detection increases with the frequency of practice visits, diagnostic guidelines should stress the importance of persistent cough and phlegm to support timely diagnosis of COPD in family practice.

Diagnosing asthma in general practice with portable exhaled nitric oxide measurement--results of a prospective diagnostic study: FENO < or = 16 ppb better than FENO < or =12 ppb to rule out mild and moderate to severe asthma [added]

BACKGROUND

To evaluate the sensitivity, specificity and predictive values of fractional exhaled nitric oxide (FENO) for the diagnosis of asthma in general practice.

METHODS

Prospective diagnostic study with 160 patients attending 10 general practices for the first time with complaints suspicious of obstructive airway disease (OAD). Patients were referred to a lung function laboratory for diagnostic investigation. The index test was FENO measured with a portable FENO analyser based on electrochemical sensor. The reference standard was the Tiffeneau ratio (FEV1/VC) as received by spirometric manoeuvre and/or results of bronchial provocation. Bronchial provocation with methacholine was performed to determine bronchial hyper-responsiveness (BHR) in the event of inconclusive spirometric results.

RESULTS

88 (55%) were female; their average age was 43.9 years. 75 (46.9%) patients had asthma, 25 (15.6%) had COPD, 8 (5.0%) had an overlap of COPD and asthma, and 52 (32.5%) had no OAD. At a cut-off level of 46 parts per billion (ppb) (n = 30; 18.8%), sensitivity was 32% (95%CI 23-43%), specificity 93% (95%CI 85-97%), positive predictive value (PPV) 80% (95%CI 63-91%), negative predictive value (NPV) 61% (95%CI 52-69%) when compared with a 20% fall in FEV1 from the baseline value (PC20) after inhaling methacholine concentration

CONCLUSION

Asthma could be ruled in with FENO > 46 ppb. Mild and moderate to severe asthma could be ruled out with FENO Collapse

Key Words Collapse

MESH Headings

• Adult
• Aged
• Asthma/diagnosis
• Asthma/metabolism
• Asthma/physiopathology
• Breath Tests/instrumentation
• Bronchial Hyperreactivity
• Bronchial Provocation Tests
• Bronchoconstrictor Agents
• Electrochemical Techniques/instrumentation
• Equipment Design
• Exhalation
• Family Practice
• Female
• Forced Expiratory Volume
• Germany
• Humans
• Lung/physiopathology
• Male
• Methacholine Chloride
• Middle Aged
• Netherlands
• Nitric Oxide/analysis
• Predictive Value of Tests
• Prospective Studies
• Sensitivity and Specificity
• Severity of Illness Index
• Vital Capacity
• Young Adult

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Grants Collapse

Affiliation(s)

Antonius Schneider Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
Lisa Tilemann Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
Tjard Schermer Department of Primary Care Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
Lena Gindner Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
Gunter Laux Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
Joachim Szecsenyi Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
Franz Joachim Meyer Department of Cardiology, Pulmonology and Angiology, Medical Centre, University of Heidelberg, Heidelberg, Germany

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The risk for depression comorbidity in patients with COPD

INTRODUCTION

Patients with COPD are believed to have a high risk for the development of depression. However, it remains unclear whether or not there is a temporal relation between COPD and depression, and if the higher risk for depression is a result of having a chronic disease, or is specific for COPD. The aim of this study is to compare the risk for physician-diagnosed depression in patients with COPD, patients with diabetes mellitus (DM), and control subjects without chronic conditions.

METHODS

The study was a prospective cohort study based on the Continuous Morbidity Registration database. Cox proportional hazards analysis was used to identify the risk of a first episode of depression in patients with COPD compared to patients with DM and matched control subjects without chronic conditions. The following covariates were added to the model: age, the general practice the patient was listed with, socioeconomic status, comorbidity, and gender. All patients with a diagnosis of depression preceding the date of first diagnosis of COPD or DM (dummy date in control subjects) were excluded.

RESULTS

The hazard ratios for a first episode of depression in the COPD group compared to the DM group and healthy controls subjects were 1.80 (95% confidence interval [CI], 1.16 to 2.81) and 1.68 (95% CI, 1.20 to 2.35), respectively.

DISCUSSION

We found a temporal relation between COPD and physician-diagnosed depression. Patients with COPD are more likely to have depression diagnosed than patients with DM and control subjects without chronic conditions.

Asthma management pocket reference 2008

Asthma is one of the most common chronic airways diseases worldwide, and its prevalence is increasing. Family doctors (sometimes called 'primary care physicians' or 'general practitioners') are frequently an asthma patient's first point of contact with healthcare systems. Disease management that follows evidence-based practice guidelines yields better patient results, but such guidelines are often complicated and may recommend the use of resources not available in the family practice setting. A joint expert panel of the World Organization of Family Doctors (Wonca), International Primary Care Airways Group (IPAG) and the International Primary Care Respiratory Group (IPCRG) offers support to family doctors worldwide by distilling the globally accepted, evidence-based recommendations from the Global Initiative for Asthma (GINA) into this brief reference guide. This guide provides tools intended to supplement a thorough history taking and the clinician's professional judgment in order to provide the best possible care for patients with asthma. Diagnostic Questionnaires developed for children and adults specifically focus the physician's attention on key symptoms and markers of asthma. When questionnaire responses suggest a diagnosis of asthma, Diagnosis Guides then lead the clinician through a series of investigations commonly available in primary care to support the diagnosis. In patients >40 years who smoke, COPD is an important alternative diagnosis, and some key aspects of differential diagnosis are illuminated. According to GINA, the goal of asthma treatment is to achieve and maintain control of the disease symptoms long-term. The physician must first assess the patient's current level of asthma control, then treat asthma in a stepwise manner to achieve and maintain symptom control. Both of these aspects are summarized in figures included in this guide. Finally, the guide also presents a flow chart summarizing management of asthma exacerbations in the acute care setting, and a glossary of asthma medications to assist the clinician in making medication choices for each individual patient. Finally, many patients with asthma also have concomitant allergic rhinitis, and this must be checked. The World Organization of Family Doctors has been delegated by WHO as the group that will be taking primary responsibility for education about chronic respiratory diseases among primary care physicians globally. This document will be a major resource in this educational program.

Allergic rhinitis management pocket reference 2008

Allergic rhinitis is a major chronic respiratory disease because of its prevalence, impacts on quality of life and work/school performance, economic burden, and links with asthma. Family doctors (also known as 'primary care physicians' or 'general practitioners') play a major role in the management of allergic rhinitis as they make the diagnosis, start the treatment, give the relevant information, and monitor most of the patients. Disease management that follows evidence-based practice guidelines yields better patient results, but such guidelines are often complicated and may recommend the use of resources not available in the family practice setting. A joint expert panel of the World Organization of Family Doctors (Wonca), the International Primary Care Airways Group (IPAG) and the International Primary Care Respiratory Group (IPCRG), offers support to family doctors worldwide by distilling the globally accepted, evidence-based recommendations from the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative into this brief reference guide. This guide provides tools intended to supplement a thorough history taking and the clinician's professional judgment in order to provide the best possible care for patients with allergic rhinitis. A diagnostic Questionnaire specifically focuses the physician's attention on key symptoms and markers of the disease. When questionnaire responses suggest a diagnosis of allergic rhinitis, a Diagnosis Guide and a simple flowchart then lead the clinician through a series of investigations commonly available in primary care to support the diagnosis. In addition, key aspects of differential diagnosis are illuminated. According to ARIA, allergic rhinitis may be classified as Intermittent or Persistent, and as Mild or Moderate/Severe. The classification of rhinitis determines the treatment necessary, as set out in an ARIA flowchart included in this guide. The guide also includes information about the strength of evidence for efficacy of certain rhinitis treatments, a brief discussion of pediatric aspects, and a glossary of allergic rhinitis medications to assist the clinician in making medication choices for each individual patient. Finally, many patients with allergic rhinitis also have concomitant asthma, and this must be checked. The World Organization of Family Doctors has been delegated by WHO as the group that will be taking primary responsibility for education about chronic respiratory diseases among primary care physicians globally. This document will be a major resource in this educational program.

Primary care spirometry

Primary care spirometry is a uniquely valuable tool in the evaluation of patients with respiratory symptoms, allowing the general practitioner to diagnose or exclude chronic obstructive pulmonary disease (COPD), sometimes to confirm asthma, to determine the efficacy of asthma treatment and to correctly stage patients with COPD. The use of spirometry for case finding in asymptomatic COPD patients might become an option, once early intervention studies have shown it to be beneficial in these patients. The diagnosis of airway obstruction requires accurate and reproducible spirometric measurements, which should comply with the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. Low acceptability of spirometric manoeuvres has been reported in primary care practices. This may hamper the validity of the results and affect clinical decision making. Training and refresher courses may produce and maintain good-quality testing, promote the use of spirometric results in clinical practice and enhance the quality of interpretation. Softening the stringent ATS/ERS criteria could enhance the acceptability rates of spirometry when used in a general practice. However, the implications of potential simplifications on the quality of the data and clinical decision making remain to be investigated. Hand-held office spirometers have been developed in recent years, with a global quality and user-friendliness that makes them acceptable for use in general practices. The precision of the forced vital capacity measurements could be improved in some of the available models.

Are asymptomatic airway hyperresponsiveness and allergy risk factors for asthma? A longitudinal study

Airway hyperresponsiveness (AHR) is a characteristic feature of asthma, but it is unclear whether asymptomatic AHR is associated with a higher risk of asthma. The present study assessed whether there is an association between asymptomatic AHR in adolescence and asthma in adulthood. The association between allergy and development of asthma was also investigated. A follow-up study of a general population cohort of adolescents was performed 14 yrs after baseline. Respiratory status was assessed at baseline in 1989 and at follow-up in 2003-2004 by a respiratory symptoms questionnaire, spirometry and histamine challenge. Allergy status was also assessed. The respiratory status of 199 subjects was assessed twice. In total, 91 (46%) subjects had the same AHR status in combination with respiratory symptoms at follow-up as at baseline. Adjusted for age, sex, allergy, family history of asthma and smoking history, having asymptomatic AHR was not significantly related to having asthma 14 yrs later (odds ratio (OR) 2.15, 95% confidence interval (CI) 0.67-6.83). For subjects with allergy at baseline, the OR for developing asthma was 4.45 (95% CI 1.46-13.54). Screening for asymptomatic airway hyperresponsiveness in adolescence does not identify subjects at risk of developing asthma. Conversely, the presence of allergy in adolescence does seem to be a risk factor for asthma development.

Monitoring of patients with COPD: a review of current guidelines' recommendations

BACKGROUND

The goals for the management of COPD are to delay the process of disease progression and alleviate its manifestations. The follow-up of the patients' physical and mental condition is part of best practice management when monitoring routines results in information that contributes to the achievement of management goals. However, the recommendations on monitoring procedures may differ between guidelines and may not be based on scientific evidence. The aim of this article is to review the current guideline recommendations on monitoring routines for COPD.

METHODS

Clinical practice guidelines on the management of COPD were identified by a Medline search, Internet search and expanded by experts in the respiratory field. Guidelines on the management of COPD were analysed on recommended monitoring routines, recommended frequency of monitoring.

RESULTS

Eighteen clinical practice guidelines on the management of COPD were analysed. The follow-up of lung function indices was the most frequently recommended monitoring routine. Moreover, monitoring of symptoms, exercise tolerance, comorbidity, and smoking habits were recommended regularly. In none of the guidelines, the recommended monitoring routines were evidence based. Only one guideline provides a different set of monitoring parameters for advanced COPD compared to mild and moderate COPD.

CONCLUSION

Some monitoring routines were recommended frequently, especially follow-up of lung function indices. However, evidence to support the guideline recommendations for the monitoring of patients with COPD is missing. The effect of monitoring on care process and outcomes should be assessed.

Prevention and management of chronic obstructive pulmonary disease (COPD) in primary care: position paper of the European Forum for Primary Care

Chronic obstructive pulmonary disease (COPD) is a smoking-related, progressive lung disease that represents a substantial individual, societal and economic burden. Primary care professionals have an important role in healthcare provision for patients with COPD. In this position paper we summarise the current knowledge about, and management of patients with COPD. Next, we describe the role general practitioners and other primary care disciplines (should) have to prevent, diagnose and treat COPD. Finally, we explore differences in the way particular aspects of primary care COPD disease management are available or organised in a number of European countries, in order to identify barriers and provide examples of 'best practices' for optimal primary care management of patients with COPD.