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Role of primary care in early diagnosis and effective management of COPD
International Journal of Clinical Practice
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a common multi-component disease that imposes an enormous burden on the patient, the healthcare professional and the society in terms of morbidity, mortality, healthcare resource utilisation and cost. Despite the availability of several comprehensive treatment guidelines, COPD is both under-diagnosed and misdiagnosed. Some of the factors contributing to this are a poor knowledge and low adherence to guideline recommendations, on the part of some healthcare professionals, and a lack of understanding of the significance and severity of the disease, on the part of patients. However, evidence suggests that COPD is both preventable and treatable when it is diagnosed early and treated effectively. Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest that the key to early diagnosis is the recognition of the clinical features of persistent cough, chronic sputum production, breathlessness on exertion and a history of exposure to tobacco smoke. Primary care clinicians can play a crucial role in early diagnosis of at-risk subjects. They can educate patients to recognise the early symptoms of COPD, avoid the risk factors, such as smoking, and encourage early presentation to a primary care professional. Similarly, evidence suggests that effective implementation of non-pharmacological and pharmacological interventions can improve the management of COPD patients at the primary care level.
Objectives: The aim of this review is to discuss the role of the primary care team in the early diagnosis and effective management of COPD, and to outline education initiatives and management strategies that can be implemented in primary care.
... Airflow limitation in the lungs can be partially reversed, and treatment of COPD may improve patient symptoms, quality of life, exercise capacity and health status as well as preventing exacerbations. Early diagnosis and treatment, therefore, result in reduced mortality, morbidity and health care expenditures related to the disease (Bellamy & Smith, 2007;Hill et al., 2010). Hence, it is essential to diagnose and treat the disease as early as possible (GOLD, 2016;Radin & Cote, 2008). ...
... A spirometry test is required both to diagnose the disease and to categorise it into grades of severity. Greater screening of at-risk individuals in primary health care is necessary to counterbalance under-diagnosis (Bellamy & Smith, 2007;Hill et al., 2010;Radin & Cote, 2008). ...
... If participants recognised the symptoms, they did not necessarily put them into the context of COPD. This has been described in previous research for patients both in initial (Ansari et al., 2014;Arne et al., 2007;Lindgren et al., 2014) and advanced stages (Bellamy & Smith, 2007;Pols, 2013) of the disease, which can lead to a prolonged diagnostic process. To get a diagnosis was essential for most patients in this study to be able to do something about their health and the situation they found themselves in Arne et al. (2007). ...
Aims and objectives:
To gain insight into the lived experience of learning about having Chronic Obstructive Pulmonary Disease (COPD) for patients and their families.
Background:
COPD often progresses for years. Adjustment to declining health is gradual and the disease may have developed considerably when health care is sought and people are diagnosed. Reaching patients at early stages is necessary to delay progression of the disease.
Design:
Interpretive phenomenology.
Methods:
Data were collected in four family focus group interviews (N=37) and a subsample of eight family-dyad interviews. Patients were eight men and 14 women aged 51 to 68 years. Majority of the patients (n=19) were at GOLD grades II and III, with three at grade IV. The family members were eight men and seven women aged 29 to 73 years. Data were collected between June and November 2012.
Results:
Five, not mutually exclusive themes, revealed a long and arduous process of learning about and becoming diagnosed with COPD and how unaware participants were of the imminent threat that the disease imposes on life. The themes were: Burden of shame and self-blame, enclosed in addiction, living in parallel worlds, realising the existence of the disease and a cry for empathy.
Conclusions:
Learning about and realising the existence of COPD and what it entails at present time and in the future was bleak for the participants. The patients tended to put aside the thought of being a person with COPD and defer actions that might halter progression of the disease, particularly to quit smoking. This article is protected by copyright. All rights reserved.
... In the USA it is estimated that only 50% of individuals with COPD have been diagnosed. 3 In a large survey in the USA and Europe only 23% of individuals presenting with COPD were accurately diagnosed. 4 If these findings are extrapolated to the South African context it can be assumed that we too have a large number of either undiagnosed or misdiagnosed individuals with COPD. ...
... The development of dyspnoea is insidious and may be compensated for by a modified lifestyle and attributed to the process of ageing. 3 It is therefore necessary for the general practitioner to actively enquire about symptoms that may suggest early COPD in all individuals exposed to risk factors for COPD. In a study in GP practices in the Netherlands, 27% of smokers over the age of 35 years who admitted to having a cough on questioning were found to have evidence of airway obstruction (FEV 1 <80% predicted ). ...
... Dyspnoea is the most common reason why individuals with COPD seek medical attention. 3 Dyspnoea in COPD is characteristically persistent and progressive. Individuals with COPD experience dyspnoea at lower levels of activity than unaffected people of the same age even on 'a good day' . ...
... This disease is unique among the major non-malignant diseases in Western societies in that prevalence, illness burden and death rates due to COPD continue to rise . COPD represents substantial and increasing economic and social burdens in terms of morbidity and mortality (Bellamy & Smith, 2007). The WHO Global Burden of Disease Project estimated that COPD was the fifth leading cause of death worldwide in 2001 and is expected to be the third leading cause by 2020 . ...
... Of the six leading major causes of death in the USA, COPD is the only one to increase steadily over the last 30 years (Jemal, Ward, Hao, & Thun, 2005). COPD is presently the 4 th leading cause of death in Canada and will cause more than 20,000 deaths COPD is often not diagnosed until it is moderately advanced (Bellamy & Smith, 2007). Two of the most prevalent reasons for the delay in diagnosis include the fact that many patients and caregivers fail to appreciate that COPD is a life threatening illness, and the highly unpredictable trajectory of COPD itself (Rocker et al., 2007). ...
... Many people experiencing COPD, therefore, receive inadequate or insufficient health care until they reach a moderately or severely advanced stage. Even after diagnosis, symptom burden is often not addressed sufficiently (Bellamy & Smith, 2007;Edmonds et al., 2001;L. Walke et al., 2007). ...
... Bellamy et al. 23 in their study, calculated that the mean cost of a visit to a chest physician was $20, the mean cost of an ED service visit was $98, the mean hospitalization cost per day was $313, and the mean cost of hospitalization in the intensive care unit was $1092. 23 In the study of Wilson et al., 24 In our study, 74% of the patients applied to step 2 hospitals, and the step 3 hospitals covered the remaining 26% of them. ...
... Bellamy et al. 23 in their study, calculated that the mean cost of a visit to a chest physician was $20, the mean cost of an ED service visit was $98, the mean hospitalization cost per day was $313, and the mean cost of hospitalization in the intensive care unit was $1092. 23 In the study of Wilson et al., 24 In our study, 74% of the patients applied to step 2 hospitals, and the step 3 hospitals covered the remaining 26% of them. ...
Objective:
Chronic obstructive pulmonary disease (COPD) is one of the major causes of mortality and morbidity worldwide. The aim of this study was to reveal the trend in direct costs related to COPD between 2012 and 2016, and to evaluate hospital costs in 2016, together with their subcomponents.
Material and methods:
A population-based descriptive study was conducted using administrative healthcare data in Turkey. The total direct cost of COPD diagnosis-treatment for each year from 2012 to 2016, was calculated. The distribution of the hospital's COPDrelated costs for the year 2016 was also examined, together with morbidity data.
Results:
The direct costs of the patients who were admitted to step 1, step 2, and step 3 health care centers between 2012 and 2016 increased by 41% [895 041 403TL ($496 930 501) in 2012 to 1 263 288 269TL ($417 834 197) in 2016]; the increase was 60% and 24%, for inpatient and outpatient groups respectively. In the year 2016, the direct total cost was 1003TL ($332) per patient. In 2016, mean specialist consultations per patient with mean cost per specialist consultation, and mean emergency visits per patient with mean cost per emergency visit, were 1.7, 42 TL ($14), and 0.4, 71TL ($23) respectively. For the inpatient group, the mean number of hospitalizations per patient, mean number of hospitalization days, and the mean cost per hospitalization were 0.4, 6.5, and 1926TL ($637), respectively.
Conclusion:
When the readmissions of patients with COPD were evaluated together with the costs, and compared with the statistics from other countries, it was found that the costs per patient were lower in Turkey. However, the reasons for the significant rise in inpatient costs compared to outpatient costs should be investigated. Further investigations are required regarding pulmonary rehabilitation, home health care services, preventive measures for infections, management of comorbidities, and treatment optimization, which may reduce hospitalizations.
... Importance of QoL in COPD patients has received prompt attention by the scientific community, since it has already been included in patient classification 1 . Apart from the obvious priorities of the primary health care team, i.e. early diagnosis of population at risk, special focus should be given on training patients to recognize the early COPD-related symptoms, avoid risk factors, such as smoking, and encourage visits to a primary health care unit for raising awareness towards protective factors and healthy lifestyle [6][7][8]28 . Towards this direction, primary health care could prioritize implementation of non-pharmacological interventions that could enhance COPD patients' self-efficacy, enhance coherence and wellbeing and monitor them at a primary health care level 28 . ...
... Apart from the obvious priorities of the primary health care team, i.e. early diagnosis of population at risk, special focus should be given on training patients to recognize the early COPD-related symptoms, avoid risk factors, such as smoking, and encourage visits to a primary health care unit for raising awareness towards protective factors and healthy lifestyle [6][7][8]28 . Towards this direction, primary health care could prioritize implementation of non-pharmacological interventions that could enhance COPD patients' self-efficacy, enhance coherence and wellbeing and monitor them at a primary health care level 28 . Oginska-Bulik suggested coherence, self-efficacy/selfmanagement and dispositional optimism could be used as personal resources for the prevention of adverse health outcomes or models that focus on individual responsibility for own health 29 . ...
Sense of coherence and self-efficacy has been found to affect health-related quality of life in chronic diseases. However, research on respiratory diseases is limited. Here we report findings on quality of life (QoL) of COPD patients and the associations with coherence and self-efficacy. This study consists of the Greek national branch of the UNLOCK study, with a sample of 257 COPD patients. Coherence and self-efficacy are positively inter-correlated (Pearson rho = 0.590, p < 0.001). They are negatively correlated with the quality of life (CAT) [Pearson rho: coherence = −0.29, p < 0.001; self-efficacy = −0.29, p < 0.001) and mMRC (coherence = −0.37, p < 0.001; self-efficacy rho = −0.32, p < 0.001)]. Coherence is inversely associated with (Global Initiative for Chronic Obstructive Lung Disease) GOLD 2018—CAT and GOLD 2018—mMRC classification and “having at least one exacerbation in the past year”. Findings are stressing the need for their incorporation in primary health care and COPD guidance as it maybe that enhancing coherence and self-efficacy will improve QoL.
... Additionally most COPD patients from the prevalence studies were classifi ed as mild or moderate. Th us, there is a large opportunity for preventive and treatment interventions that could slow or halt progression of disease (54)(55)(56). Increasing awareness of COPD, and implementing eff ective screening programs in primary care could signifi cantly improve management of the disease (54,57). Primary care physician and patient education may lead to early diagnosis and interventions to curb disease progression or prevent complications. ...
... Th us, there is a large opportunity for preventive and treatment interventions that could slow or halt progression of disease (54)(55)(56). Increasing awareness of COPD, and implementing eff ective screening programs in primary care could signifi cantly improve management of the disease (54,57). Primary care physician and patient education may lead to early diagnosis and interventions to curb disease progression or prevent complications. ...
Unlabelled:
Abstract Background: In the developing world, COPD continues to be an under studied, diagnosed and treated disorder. In the present study, we analyzed the prevalence, mortality and resource utilization of COPD in Latin America and the Caribbean (LAC) in order to guide future research and public policies.
Methods:
A systematic review and meta-analysis was performed following MOOSE and PRISMA guidance. We searched CENTRAL, MEDLINE, EMBASE, LILACS, countries' Ministries of Health, proceedings, and doctoral theses from January 1990 to October 2012. We included studies with a validated definition of COPD that assessed the incidence, prevalence, use of health care resources or costs since 1985. Using EROS, a web-based software, pairs of reviewers independently selected, performed quality assessment (using a STROBE-based checklist) and extracted the study data. Discrepancies were resolved by consensus. Arcsine transformations and random-effects model were used for proportion meta-analyses.
Results:
26 articles met entry criteria. The pooled COPD prevalence defined by GOLD criteria (11 cities, 6 countries) was 13.4% (95%CI, 10.1-17.1). Most patients suffer mild or moderate COPD and were undertreated according to international guidelines. The prevalence increased by age and was 1.75 times higher in men than women. 35 of every 1,000 hospitalizations were due to COPD, most of high economic cost, and the COPD in-hospital mortality ranged from 6.7% to 29.5%.
Conclusions:
COPD burden in LAC is high, especially for men and older persons; however few persons had severe disease. COPD patients often received inappropriate treatment and had high exacerbation and hospitalization rates leading to high economic costs.
... Efforts to improve the quality and efficiency of health care have thus been given high priority by governments and health-care organizations. Chronic diseases often coexist and associated morbidity, mortality, health-care resource utilization and costs impose an enormous burden on patients, medical professionals and societies [2]. The multiple and often complex needs of populations affected by the chronic-illness epidemic require approaches that include collaboration among health-care professionals from various organizations, and extend beyond traditional acute episodic health care and the services of any single organization [3][4][5]. ...
... Disease management is considered an effective approach to improving the delivery of primary care [3,14]. Because chronic-illness care is performed largely within a primary-care setting, primary-care professionals are at the forefront of chronic-disease diagnosis and management [2]. Synergy is the degree to which the partnership combines the complementary strengths, perspectives, values and resources of all partners in the search for better solutions [15, p. 5] and is generally regarded as the product of a partnership [16]. ...
This study explored associations among disease-management partnership functioning, synergy and effectiveness in the delivery of chronic-illness care.
This study had a cross-sectional design.
The study sample consists of 218 professionals (out of 393) participating in 22 disease-management partnerships in various regions of the Netherlands.
We assessed the relationships among partnership functioning, synergy and effectiveness in the delivery of chronic-illness care. Partnership functioning was assessed through leadership, resources, administration and efficiency. Synergy was considered the proximal outcome of partnership functioning, which, in turn, influenced the effectiveness of disease-management partnerships [measured with the Assessment of Chronic Illness Care (ACIC) survey instrument].
Overall ACIC scores ranged from 3 to 10, indicating basic/intermediate to optimal/comprehensive delivery of chronic-illness care. The results of the regression analysis demonstrate that partnership effectiveness was positively associated with leadership (β = 0.25; P≤ 0.01), and resources (β = 0.31; P≤ 0.001). No significant relationship was found between administration, efficiency and partnership effectiveness. Partnership synergy acted as a mediator for partnership functioning and was statistically significantly associated with partnership effectiveness (β = 0.25; P≤ 0.001).
Disease-management partnerships seemed better able to deliver higher levels of chronic-illness care when synergy is created between partners. Synergy was more likely to emerge with boundary-spanning leaders who understood and appreciated partners' different perspectives, could bridge their diverse cultures and were comfortable sharing ideas, resources and power. In addition, the acknowledgement of and ability to use members' resources are valuable in engaging partners' involvement and achieving synergy in disease-management partnerships.
... Chronic diseases are the main cause of death and disability worldwide, and as the population ages, prevalence of chronic conditions will increase [1]. Chronic obstructive pulmonary disease (COPD) is a common multicomponent disease that imposes an enormous burden on the patient, medical professionals and society in terms of morbidity, mortality, health care resource utilization and cost [2] . Already highly prevalent , COPD is projected to become the third most common cause of death by 2020 [1]. ...
... A growing body of literature argues that improving the delivery of primary care is an effective approach to implement disease management [5, 6], as chronic illness care is largely performed within a primary care setting. Primary care professionals are therefore at the forefront of COPD diagnosis and management [2]. Their motivation to redesign care is one of the keys to successful disease management [7]. ...
The aim of this exploratory study was to investigate to what extent primary care professionals are able to change their systems for delivering care to chronic obstructive pulmonary disease (COPD) patients and what professional and organizational factors are associated with the degree of process implementation.
Quasi-experimental design with 1 year follow-up after intervention.
Three regional COPD management programmes in the Netherlands, in which general practices cooperated with regional hospitals.
All participating primary care professionals (n = 52).
COPD management programme.
Professional commitment, organizational context and degree of process implementation.
Professionals significantly changed their systems for delivering care to COPD patients, namely self-management support, decision support, delivery system design and clinical information systems. Associations were found between organizational factors, professional commitment and changes in processes of care. Group culture and professional commitment appeared to be, to a moderate degree, predictors of process implementation.
COPD management was effective; all processes improved significantly. Moreover, theoretically expected associations between organizational context and professional factors with the implementation of COPD management were indeed confirmed to some extent. Group culture and professional commitment are important facilitators.
... However, early COPD patients are easy to be ignored because of asymptomatic and mild symptoms [5,6]. Most patients are often diagnosed with moderate to severe, which seriously affects the quality of life, and the cost of treatment has risen sharply [7]. Consequently, early identification and staging are important to reduce the risk of exacerbations, fewer concurrent health issues, and decreased healthcare expenses [8]. ...
Background
Chronic obstructive pulmonary disease (COPD) is a prevalent and debilitating respiratory condition that imposes a significant healthcare burden worldwide. Accurate staging of COPD severity is crucial for patient management and treatment planning.
Methods
The retrospective study included 530 hospital patients. A lobe-based radiomics method was proposed to classify COPD severity using computed tomography (CT) images. First, we segmented the lung lobes with a convolutional neural network model. Secondly, the radiomic features of each lung lobe are extracted from CT images, the features of the five lung lobes are merged, and the selection of features is accomplished through the utilization of a variance threshold, t-Test, least absolute shrinkage and selection operator (LASSO). Finally, the COPD severity was classified by a support vector machine (SVM) classifier.
Results
104 features were selected for staging COPD according to the Global initiative for chronic Obstructive Lung Disease (GOLD). The SVM classifier showed remarkable performance with an accuracy of 0.63. Moreover, an additional set of 132 features were selected to distinguish between milder (GOLD I + GOLD II) and more severe instances (GOLD III + GOLD IV) of COPD. The accuracy for SVM stood at 0.87.
Conclusions
The proposed method proved that the novel lobe-based radiomics method can significantly contribute to the refinement of COPD severity staging. By combining radiomic features from each lung lobe, it can obtain a more comprehensive and rich set of features and better capture the CT radiomic features of the lung than simply observing the lung as a whole.
... Primary prevention is of great importance in improving community health outcomes. This includes reducing mortality through early interventions for common chronic diseases (Bellamy & Smith, 2007;Hung et al., 2007). Effective primary prevention is associated with reduced mortality, increased life expectancy, and more equitable health outcomes (Engström, Foldevi, & Borgquist, 2009;Starfield, Shi, & Macinko, 2005). ...
... In adolescents, it focusses on prevention of addictions (89), suicide (90) and intimate violence (91). In adults, primary prevention focusses on intimate partner violence (92), early detection of essential hypertension (93), diabetes mellitus (94) and chronic obstructive pulmonary disease (COPD) (95). In elderly patients, it aims at screening for frailty in order to prevent disability (96). ...
The general purpose of this thesis was the study of tools to enhance health behaviour with patients in primary care waiting rooms. The time patients spent in the waiting room was used as an opportunity for a moment of health education. A systematic review on educative efficiency of audio-visual aids in primary care waiting rooms learned that audio-visual aids broadcasting messages using screens (TVs, computers, tablets, smartphones with Bluetooth® pairing) probably enhance patients’ knowledge, but a change in health behaviour remains controversial. In a second phase the thesis focused on the annual advertisement campaign by posters and pamphlets in general practice (GP) waiting rooms to promote seasonal influenza vaccination as a paradigm to measure the efficacy of posters and pamphlets with a randomized controlled trial (RCT). It is notable that the validity of studies in the field of changes in health behaviour is often invalidated by experimental artefacts, in particular, the so-called Hawthorne effect (HE), related to behavioural changes in patients and in investigators caused by the experimental environment. The thesis sought to update and refine the definition of the HE in medical research and more specifically in primary care. Following our refined definition, the probability of a HE in the RCT was scarce, but no indisputable evidence was strengthening our conclusions. We redesigned our RCT bypassing the limitations of the first and followed over two years our research cohort to obtain an insight of the natural evolution of seasonal influenza vaccination uptake in GPs’ customer base.
Health promotion and patients’ health education are an important part of a GP’s commitments as patients’ health behaviours are crucial factors in life expectancy and good health. Most waiting-rooms have therefore been implemented with audio-visual aids (posters, pamphlets or screens) for health promotion purposes. Posters and pamphlets are present in practically all primary care practices. Few studies have assessed the effect of audio-visual aids in primary care.
Our first objectives, as to scan this research field, was to identify, describe and appraise studies that had investigated the effects of audio-visual aids on health promotion in primary health care waiting-rooms and to identify which factors influence their effect through a systematic literature review.
Databases were searched by two independent researchers using predefined keywords. Additional records were extracted from the reference lists of the selected articles. The selection of the reports was performed on the title and abstract, followed by complete reading and assessment. Bias and level of evidence were analysed.
We collected 909 records. Most of them were not in primary care settings. Fourteen peer-reviewed reports fully meeting the inclusion criteria were retained for analysis. Good quality studies were scarce as it appeared difficult to distinguish the specific effect of the aids from the motivation of investigators. Eight of these articles using videos or slideshows on TV screens or tablets indicated effects: three of them showed a significant improvement of patient knowledge with acceptable evidence and three on health behaviour with surrogate endpoints didn’t show a clear association with the studied outcome. Audio-visual aids seemed to be used or noticed by patients and could induce conversations with physicians. The relevant factors that might influence these effects (duration of exposure, conception quality, theme, target population and time spent in the waiting-room) were insufficiently investigated. Finally, if audio-visual aids broadcasting messages using screens might enhance patients’ knowledge, no effect of posters and pamphlets in waiting rooms was demonstrated. A change in health behaviour remained controversial.
As most GPs use advertising with posters and pamphlets in their waiting rooms for patient’s education purposes without clear evidence of their use, we sought to demonstrate the effect of an advertising campaign using these two media. Patients vaccinated against seasonal influenza have been gradually lessening between 2009 and 2014, and mandatory health insurance companies have implemented in France an advertising campaign using posters and pamphlets displayed in primary care waiting rooms to promote seasonal influenza vaccination uptake, together with incentives in mass-media.
We designed a trial with the objective of assessing the effect of this advertising campaign for influenza vaccination using posters and pamphlets in GPs’ waiting rooms.
This registry based 2/1 cluster randomized controlled trial (RCT), a cluster gathering the enlisted patients aged over 16 years, of 75 GPs, run during the 2014-2015 influenza vaccination campaign. It compared patient’s awareness in 50 GPs’ standard waiting rooms exposed to a lot of information (control group) versus that of patients, spending their time in waiting rooms from 25 GPs, who had received and displayed (in addition to mandatory information) only those pamphlets and one poster about the influenza vaccination campaign (intervention group). The main outcome was the number of vaccination units delivered in community pharmacies. Data were extracted from the SIAM-ERASME claim database of the main mandatory Health Insurance Fund of Lille-Douai (France). The association between the intervention (yes/no) and the main outcome was assessed through a generalized estimating equation.
Seventy-five GPs enrolled 10,597 patients of 65 years and over, or of 16 years and over suffering from long lasting diseases (intervention/control as of 3781/6816 patients) from October 15, 2014 to February 28, 2015. No difference was found regarding the number of influenza vaccination units delivered in community pharmacies (Relative Risk =1.01; 95% Confidence interval: 0.97 to 1.05; p=0.561). A vaccination performed on the previous year increased revaccination probability (RR=5.63; 95%CI: [5.21 to 6.10] p<0.001). Effects of the monothematic campaign promoting vaccination against influenza using a poster and pamphlets displayed in GPs’ waiting rooms could not be demonstrated.
Unexpected, vaccination uptake rose by 3% in both arms of the RCT whereas public health data based on the “generalist sample of beneficiaries” and the SNIIRAM warehouse database indicated a simultaneous decrease of 2%. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear. In medical sciences, the meaning of the HE was drifting towards the interaction of artefacts in an experimental environment. In social sciences, and mainly in psychology, it was more closely bound to the Hawthorne experiments conducted from 1924 to 1933 and the definition given in 1953 by Festinger; for these reasons, its existence was disputed.
Our objectives were 1) to refine a definition of the HE in medical sciences and for primary care and 2) to evaluate its size and to draw consequences for primary care research.
We designed a PRISMA 2020 review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analysed to evaluate odds ratios (OR) in primary care and close circumstances.
The search led to 180 records, reduced after review on title and abstract and on full reading of the remaining reports to 74 on definition and 15 on quantification. Our refined definition of HE is “an aware or unconscious complex behaviour change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias”. Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect and regression towards the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13;1.75]; I²=97%), but the significance of the HE disappears in well-designed studies.
We concluded that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research. Its size can considerably be reduced by refining study designs, for instance by the submission of research projects to registry platforms. Further, the chance that the increase of the vaccination uptake in both arms of the RCT was related to a HE appeared to be negligible.
As noted above, to conduct our RCT, we used a different database than the SNIIRAM warehouse claim database to collect our data. The SNIIRAM warehouse database merges data from all different mandatory French Health Insurance regimes and is used for public health surveys. By the time of the trial, there was a sufficient number of GPs left on our randomisation list to recruit 100 more GPs that were naïve to the RCT, and thus completely exempt of influence that might lead to a HE. Searching for an explanation of the rise in influenza vaccination uptake, it was possible to follow our trial cohort during three years using the SNIIRAM warehouse database and to constitute a posteriori a second control group, naïve to the trial, as described by Zelen in 1979.
So, in 2019 we deepened the investigations explaining the increased uptake, conducting a registry-based 4/2/1 cluster RCT designed by Zelen with two extra years of follow-up of the study cohort. The study population included 23,024 patients, registered with 175 GPs, eligible to benefit from a free influenza vaccination, that is, aged 65 years and over or 16 years and over with a chronic condition. The main outcome remained the number of vaccination units delivered in community pharmacies per study group. Data were extracted from the SNIIRAM warehouse claim database for the Lille-Douai district (Northern France).
No difference in vaccination uptake was found in the Zelen versus the control group of the initial RCT, closing the debate about the usefulness of posters and pamphlets as health promotion vectors in primary care waiting rooms. Overall, the proportion of vaccinated patients increased in the cohort from 51.4% to 70.4% over the three years. Being vaccinated the previous year was a strong predictor of being vaccinated in a subsequent year. The increase in vaccination uptake can be explained by a cohort effect, especially among people of 65 years and older, reaching 75% of influenza vaccination coverage as determined by the WHO. Health promotion and the promotion of primary health care may play an important role in this increase. However, if promoting health behaviour of patients matches with the commitment and congruence, and conformity and social desirability expected from general practitioners and primary care teams, to reach their objectives these teams also have to meet the expectations of patients who feel concerned by their health outcomes, like sexagenarians regarding the prevention of influenza.
The limitation of this health promotion approach in primary care is the population, mainly represented by persons with a low level of health literacy, whose life priorities don’t meet their health outcomes. This population, roughly representing one quarter of the global population, is difficult to reach by primary health teams, generally shares a low life expectancy in good health, is barely participating in primary healthcare research projects and not represented in routine collected databases (claim databases or databases collecting data in primary care electronic medical records), constituting a research blind spot. One of the most important challenges for the next years in primary healthcare practice and research will be to reach these populations and integrate them in health pathways meeting their expectations: deprived communities, patients at risk of developing chronic conditions or their complications, prefrail or frail aging persons, or young persons not in education, employment or training (NEET).
... Birincil koruma toplumun sağlık çıktılarının geliştirilmesinde büyük öneme sahiptir. Yaygın kronik hastalıklara yapılacak erken müdahaleler vasıtasıyla mortalitenin azaltılması bu kapsamda değerlendirilebilir [22,23]. Etkili birincil koruma; azalmış mortalite, artmış yaşam süresi ve daha adil sağlık çıktılarıyla birliktelik gösterir [24,25]. ...
Abstract
Background/aim: The relationship between COVID-19 fatality and quality health care in OECD countries was aimed to be examined, considering the effectiveness of primary health care, the effectiveness of secondary health care. Materials and methods: Data from OECD countries were collected from open-access websites. Dependent variable is COVID-19 fatality, independent variables are effectiveness of primary health care, the effectiveness of secondary health care, gross domestic product, median age, number of hospital beds, number of intensive care unit beds, number of doctors and nurses, number of computed tomography scanners, educational status and air pollution. Spearman Rho correlation and partial correlation were used in the analysis of the data, and generalized linear regression analysis was performed. Results: A statistically significant relationship was found between case fatality rates and the effectiveness of secondary health care (p<0,05). The relationships between case fatality rates and other health, demographic indicators are not statistically significant. In Generalized Linear Model (GLM-Logit Model) analysis results, only the effectiveness of secondary health care (p< 0,01) and the number of hospital beds (p<0,05) were found to be statistically significant. Conclusion: Satisfaction with quality health care is not associated with COVID-19 fatality. As the effectiveness of secondary health care increases, the fatality of COVID-19 decreases. The effectiveness of primary health care has no effect on COVID-19 fatality.
... To prevent severe conditions and complications and to lower respiratory mortality, COPD should be detected at an early stage, managed 29 , and prioritized groups should be selected. Age, gender, and education are the most important factors related to COPD 10,13 . ...
This study aimed to investigate national-level prevalence of COPD, proportion of patients diagnosed with and without COPD. We performed pulmonary function test (PFT) in 24,454 adults aged > 40 years for 8 years (2010–2017). The annual COPD prevalence increased from 13.1% in 2010 to 14.6% in 2012, followed by 13.3% in 2017. However, patients diagnosed with COPD ranged between 0.5 and 1.0% in the last 8 years, which means that only 5% of all COPD patients were diagnosed with COPD by doctors. We defined potential high-risk individuals as those with a FEV1/FVC ratio of < 0.70, who have not been diagnosed with COPD and other respiratory diseases tuberculosis, asthma, lung cancer. The proportion of this group was 80.8% in 2010 and 78.1% in 2017. The older age group, women, low-educated group, and current smokers who have been smoking for a long time are more likely to be in the high-risk group having a higher possibility to develop COPD but are not diagnosed with COPD appropriately. Although COPD prevalence was high in the ever, current, and heavy smokers, only the diagnosis rate of COPD in ever smokers was 2.38 times higher than never smokers, indicating that a system is needed to screen and intervention for these groups.
... In recent years, the status of disease assessment in COPD patient management is becoming more and more important. At present, pulmonary function grading, COPD assessment test score, dyspnea index score, and history of acute exacerbation are mainly used for comprehensive evaluation [7,8]. However, the above evaluation indexes are highly subjective and require high cooperation degrees of patients, while biological markers are not subject to subjective infuence and detection is convenient. ...
Objective:
To evaluate the level of cardiometabolic index (CMI) to predict the risk of acute exacerbation in patients with stable chronic obstructive pulmonary disease (COPD), and to provide a basis for early identification and intervention of high-risk patients in clinical nursing work.
Methods:
Patients with stable chronic obstructive pulmonary disease who were admitted to the outpatient department of respiratory medicine in a tertiary hospital or followed up after discharge from January to December 2021 were retrospectively selected. CMI was measured and statistical analysis was performed to determine the optimal threshold for predicting acute exacerbation of chronic obstructive pulmonary disease.
Results:
A total of 63 patients with chronic obstructive pulmonary disease were enrolled. The median number of episodes in the previous year was 1.00; 44 patients had ≥1 acute exacerbation. The CMI was positively correlated with the frequency of acute exacerbations and the British Medical Research Council (mMRC) score in the previous year, and negatively correlated with the percentage of forced expiratory volume in 1 second to the predicted value (FEV1% PRED). The cut-off point of CMI for predicting acute exacerbations in stable chronic obstructive pulmonary disease patients was 2.05, with a sensitivity of 0.864% and specificity of 0.842%. It is a risk factor for acute exacerbation in COPD patients.
Conclusion:
CMI can be used as a biological index to predict acute exacerbation in stable COPD patients. Clinical nursing needs to evaluate patients' CMI and provide personalized nursing intervention for patients with CMI≥2.05.
... Nevertheless, patients with early COPD can be easily neglected as they have no symptoms or only mild symptoms [2,3]. Most of the patients have often developed into the moderate-to-severe stage when diagnosed, seriously affecting the quality of life, and the cost of treatment also rises sharply [4]. Therefore, early detection of COPD is associated with a lower risk of exacerbations, fewer comorbidities, and lower costs. ...
Chronic obstructive pulmonary disease (COPD) is a common disease with high morbidity and mortality, where early detection benefits the population. However, the early diagnosis rate of COPD is low due to the absence or slight early symptoms. In this paper, a novel method based on graph convolution network (GCN) for early detection of COPD is proposed, which uses small and weakly labeled chest computed tomography image data from the publicly available Danish Lung Cancer Screening Trial database. The key idea is to construct a graph using regions of interest randomly selected from the segmented lung parenchyma and then input it into the GCN model for COPD detection. In this way, the model can not only extract the feature information of each region of interest but also the topological structure information between regions of interest, that is, graph structure information. The proposed GCN model achieves an acceptable performance with an accuracy of 0.77 and an area under a curve of 0.81, which is higher than the previous studies on the same dataset. GCN model also outperforms several state-of-the-art methods trained at the same time. As far as we know, it is also the first time using the GCN model on this dataset for COPD detection.
... Primary care physicians have a vital role to play in the diagnosis of COPD, where earlier diagnosis might reduce morbidity and prevent or delay hospital admission, reducing then financial costs associated with the management of COPD [29]. Effective early diagnosis requires both patient education in order to encourage earlier presentation and case-finding using spirometry in the symptomatic patients and possibly screening of at-risk subjects [30,31]. ...
... Primary care physicians have a vital role to play in the diagnosis of COPD, where earlier diagnosis might reduce morbidity and prevent or delay hospital admission, reducing then financial costs associated with the management of COPD [29]. Effective early diagnosis requires both patient education in order to encourage earlier presentation and case-finding using spirometry in the symptomatic patients and possibly screening of at-risk subjects [30,31]. ...
This study aimed to investigate the underdiagnosis of COPD and its determinants based on the Tunisian Burden of Obstructive Lung Disease study. We collected information on respiratory history symptoms and risk factors for COPD. Post-bronchodilator (Post-BD) FEV 1 /FVC < the lower limit of normal (LLN) was used to define COPD. Undiagnosed COPD was considered when participants had post-BD FEV 1 /FVC < LLN but were not given a diagnosis of emphysema, chronic bronchitis or COPD. 730 adults aged P40 years selected from the general population were interviewed, 661 completed spirometry, 35 (5.3%) had COPD and 28 (80%) were undiagnosed with the highest prevalence in women (100%). When compared with patients with an established COPD diagnosis, undiagnosed subjects had a lower education level, milder airway obstruction (Post-BD FEV 1 z-score À2.2 vs. À3.7, p < 0.001), fewer occurrence of wheezing (42.9% vs. 100%, p ¼ 0.009), less previous lung function test (3.6% vs. 42.8%, p ¼ 0.019) and less visits to the physician (32.1% vs. 85.7%, p ¼ 0.020) in the past year. Multivaried analysis showed that the probability of COPD underdiagno-sis was higher in subjects who had mild to moderate COPD and in those who did not visit a clin-ician and did not perform a spirometry in the last year. Collectively, our results highlight the need to improve the diagnosis of COPD in Tunisia. Wider use of spirometry should reduce the incidence of undiagnosed COPD. Spirometry should also predominately be performed not only in elderly male smokers but also in younger women in whom the prevalence of underdiagnosis is the highest. ARTICLE HISTORY
... Primary care physicians have a vital role to play in the diagnosis of COPD, where earlier diagnosis might reduce morbidity and prevent or delay hospital admission, reducing then financial costs associated with the management of COPD [29]. Effective early diagnosis requires both patient education in order to encourage earlier presentation and case-finding using spirometry in the symptomatic patients and possibly screening of at-risk subjects [30,31]. ...
This study aimed to investigate the underdiagnosis of COPD and its determinants based on the Tunisian Burden of Obstructive Lung Disease study. We collected information on respiratory history symptoms and risk factors for COPD. Post-bronchodilator (Post-BD) FEV 1 /FVC < the lower limit of normal (LLN) was used to define COPD. Undiagnosed COPD was considered when participants had post-BD FEV 1 /FVC < LLN but were not given a diagnosis of emphysema, chronic bronchitis or COPD. 730 adults aged P40 years selected from the general population were interviewed, 661 completed spirometry, 35 (5.3%) had COPD and 28 (80%) were undiagnosed with the highest prevalence in women (100%). When compared with patients with an established COPD diagnosis, undiagnosed subjects had a lower education level, milder airway obstruction (Post-BD FEV 1 z-score À2.2 vs. À3.7, p < 0.001), fewer occurrence of wheezing (42.9% vs. 100%, p ¼ 0.009), less previous lung function test (3.6% vs. 42.8%, p ¼ 0.019) and less visits to the physician (32.1% vs. 85.7%, p ¼ 0.020) in the past year. Multivaried analysis showed that the probability of COPD underdiagno-sis was higher in subjects who had mild to moderate COPD and in those who did not visit a clin-ician and did not perform a spirometry in the last year. Collectively, our results highlight the need to improve the diagnosis of COPD in Tunisia. Wider use of spirometry should reduce the incidence of undiagnosed COPD. Spirometry should also predominately be performed not only in elderly male smokers but also in younger women in whom the prevalence of underdiagnosis is the highest. ARTICLE HISTORY
... Therefore, active COPD nding is recommended in patients with respiratory symptoms and/or risk factors. [30] To prevent severe conditions and complications and to lower respiratory mortality, COPD should be detected at an early stage, managed, [31] and prioritized groups should be selected. Age, gender, and education are the most important factors related to COPD. ...
Background: There is public health risk due to COPD underdiagnosis. To decrease the rate of underdiagnosed COPD and to plan strategies for efficient screening for disease management, we investigated the national-level prevalence of COPD by airflow obstruction.
Methods: We performed pulmonary function test (PFT) in 24,454 adults aged >40 years, based on 8 years (2010-2017) of data. FEV1/FVC ratio of <0.70 was defined as COPD. We performed multivariate logistic regression analysis by adjusting dependent variable to determine if each factor was related to COPD.
Results: The annual COPD prevalence increased from 13.1% in 2010 to 14.6% in 2012 followed by 13.3% in 2017. The proportion of potential high-risk group that was not diagnosed with COPD and other respiratory diseases was 80.8% in 2010 and 78.1% in 2017 ranging between 73.0% and 86.2%. Multivariate logistic regression showed that ever smokers in the COPD diagnosed patient group had a 2.38 times higher rate of diagnosis than never smokers. Furthermore, the group with PY of 4Q had a 2.81 times higher diagnosis rate than that of 1Q. Regarding the potential high-risk group, the ever smokers, current smokers, and heavy smokers had a higher prevalence than never smokers.
Conclusion: Although COPD prevalence was high in the ever, current, and heavy smokers, only the diagnosis rate of COPD in ever smokers was 2.38 times higher than never smokers, indicating that smoking is the most important cause of COPD.
... However, limitations in early detection and the ability of radiographic studies to visualize COPD sub-types have made CT a recent focus in the diagnosis and categorization of COPD. COPD is often misdiagnosed in early stages because of the similarity of initial symptoms to common illnesses, and lack of significant symptoms until the advanced stage [3]. The shortcomings in the diagnosis are addressed using computer-aided detection (CAD). ...
Chronic obstructive pulmonary disease (COPD) is a lung disease that is not fully reversible and one of the leading causes of morbidity and mortality in the world. Early detection and diagnosis of COPD can increase the survival rate and reduce the risk of COPD progression in patients. Currently, the primary examination tool to diagnose COPD is spirometry. However, computed tomography (CT) is used for detecting symptoms and sub-type classification of COPD. Using different imaging modalities is a difficult and tedious task even for physicians and is subjective to inter-and intra-observer variations. Hence, developing methods that can automatically classify COPD versus healthy patients is of great interest. In this paper, we propose a 3D deep learning approach to classify COPD and emphysema using volume-wise annotations only. We also demonstrate the impact of transfer learning on the classification of emphysema using knowledge transfer from a pre-trained COPD classification model.
... However, limitations in early detection and the ability of radiographic studies to visualize COPD sub-types have made CT a recent focus in the diagnosis and categorization of COPD. COPD is often misdiagnosed in early stages because of the similarity of initial symptoms to common illnesses, and lack of significant symptoms until the advanced stage [3]. The shortcomings in the diagnosis are addressed using computer-aided detection (CAD). ...
Chronic obstructive pulmonary disease (COPD) is a lung disease that is not fully reversible and one of the leading causes of morbidity and mortality in the world. Early detection and diagnosis of COPD can increase the survival rate and reduce the risk of COPD progression in patients. Currently, the primary examination tool to diagnose COPD is spirometry. However, computed tomography (CT) is used for detecting symptoms and sub-type classification of COPD. Using different imaging modalities is a difficult and tedious task even for physicians and is subjective to inter-and intra-observer variations. Hence, developing methods that can automatically classify COPD versus healthy patients is of great interest. In this paper, we propose a 3D deep learning approach to classify COPD and emphysema using volume-wise annotations only. We also demonstrate the impact of transfer learning on the classification of emphysema using knowledge transfer from a pre-trained COPD classification model.
... However, various studies have suggested that there is a poor adherence to these recommendations both in primary care and in specialty setting in Italy [17][18][19] that lead to a significant imbalance between guideline-defined treatment and actual care provided. Patients also sometimes underestimate the severity of disease, contributing further to non-adherence to guideline recommendations and adequate treatment [20]. ...
Background:
Several documents and guidelines provide recommendations for effective management of COPD patients. However, there is often a significant imbalance between recommended treatment of COPD patients and the actual care provided both in primary care and specialty setting. This imbalance could result in a significant negative impact on patients' health status and quality of life, leading to increased hospitalisations and health resource utilisation in COPD patients METHODS: MISTRAL was an observational, longitudinal, prospective cohort study, designed to assess the overall pharmacological approach of COPD in routine clinical practice in Italy. Eligible patients were divided into two cohorts based on their exacerbation history in the year prior to the enrolment, frequent exacerbators (FEs; ≥2 exacerbations), and non-frequent exacerbators (NFEs; ≤1 exacerbation). The primary objective was to assess adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 treatment recommendations in FEs and NFEs at baseline and follow-up visits RESULTS: Of the 1489 enrolled patients, 1468 (98.6%; FEs, 526; NFEs, 942) were considered evaluable for analyses. At baseline, 57.8% of patients were treated according to GOLD 2011 recommendations; a greater proportion of FEs were treated according to GOLD recommendations, compared with NFEs patients at baseline (77.1% versus 46.7%; P < 0.0001), and all study visits. At baseline, GOLD group D patients were the most adherent (81.2%) to treatment recommendations, while group A patients were the least adherent (30.3%) at baseline, attributed mainly to overuse of inhaled corticosteroids in less severe GOLD groups. Triple therapy with long-acting muscarinic antagonist (LAMA) + long-acting β2-agonist/inhaled corticosteroid (LABA/ICS) was the most frequent prescribed treatment at all study visits, irrespective of patient's exacerbation history. Changes in treatment were more frequent in FEs versus NFEs CONCLUSIONS: The Mistral study reports a scarce adherence to the GOLD 2011 treatment recommendations in routine clinical practice in Italy. The adherence was particularly low in less severe, non-frequent exacerbating patients mostly for ICS overuse, and was higher in high-risk, frequent exacerbating COPD patients.
... COPD shows high prevalence in smokers and many authors agree it is paramount to anticipate and improve diagnosis from primary care [6,8,9,21]. In our study, a percentage of 11.2% individuals affected by COPD were obtained within smoking participants, none of whom had been previously diagnosed with respiratory disease. ...
... PCPs can educate patients to recognize COPD symptoms, avoid risk factors, and provide early referral to a Pulmonologist. 46 Our findings are comparable to the BREATHE study, in which 66% of patients were notified of their diagnosis by a physician, 66% followed their physician's advice, 59% were at least "adequately informed" about their COPD, but over 90% felt there was some need for improved education. 47 Patient self-management of COPD correlates directly with education by the PCP about COPD and its management which may be improved by directly educating PCPs. ...
Chronic Obstructive Pulmonary Disease (COPD) is a common disorder of Veterans that causes significant morbidity and mortality. To measure Veterans' perceptions about COPD, the effect of COPD on their lives and health, and their needs for improved health, we performed a postal survey.
3263 Veterans with a diagnosis of COPD who received care at the Cincinnati Veterans Affairs Medical Center in 2008 were stratified into quintiles by Veterans Health Administration-associated COPD healthcare cost and uniformly sampled.
493 of 1000 surveys (49%) were completed and returned. COPD had different effects on respondents in top and bottom quintiles (highest and lowest COPD-related cost) for: knowledge of COPD diagnosis (89% vs 73%, p = 0.03); activities affected by breathing, including work (69% vs 45%), recreation (85% vs 62%), change in living arrangements (36% vs 16%), and increased need for help (54% vs 25%) (p < 0.05 for all comparisons); emotional effect of respiratory symptoms, including depression (53% vs 30%), fear (41% vs 15%), and helplessness (49% vs 24%) (p < 0.05 for all comparisons). 91% of Veterans were prescribed inhalers and one-quarter had difficulties using them. 25% of Veterans did nothing when they had symptoms of an exacerbation.
COPD has profound effects on Veterans' breathing related activities and generates many negative emotions. Primary care providers are critical in conveying the diagnosis of COPD and providing information about the disease and its management. Veterans with COPD adhere poorly to their medications, and report little instruction about COPD or its management.
... 19 The chronic airflow obstruction in COPD is a mixture of small airway disease (obstructive bronchiolitis) and parenchymal destruction (emphysema). 20 The panel of 82 selected phage-expressed antigens used in our study comprises previously identified cancer-associated antigens. One-third of these antigens was identified in previous SEREX (serological identification of antigens by recombinant expression cloning) screenings from 3 squamous cell lung cancer libraries. ...
Serum-based diagnosis offers the prospect of early lung carcinoma detection and of differentiation between benign and malignant nodules identified by CT. One major challenge toward a future blood-based diagnostic consists in showing that seroreactivity patterns allow for discriminating lung cancer patients not only from normal controls but also from patients with non-tumor lung pathologies. We addressed this question for squamous cell lung cancer, one of the most common lung tumor types. Using a panel of 82 phage-peptide clones, which express potential autoantigens, we performed serological spot assay. We screened 108 sera, including 39 sera from squamous cell lung cancer patients, 29 sera from patients with other non-tumor lung pathologies, and 40 sera from volunteers without known disease. To classify the serum groups, we employed the standard Naïve Bayesian method combined with a subset selection approach. We were able to separate squamous cell lung carcinoma and normal sera with an accuracy of 93%. Low-grade squamous cell lung carcinoma were separated from normal sera with an accuracy of 92.9%. We were able to distinguish squamous cell lung carcinoma from non-tumor lung pathologies with an accuracy of 83%. Three phage-peptide clones with sequence homology to ROCK1, PRKCB1 and KIAA0376 reacted with more than 15% of the cancer sera, but neither with normal nor with non-tumor lung pathology sera. Our study demonstrates that seroreactivity profiles combined with statistical classification methods have great potential for discriminating patients with squamous cell lung carcinoma not only from normal controls but also from patients with non-tumor lung pathologies.
... As a result, COPD remains difficult to diagnose and manage. 6 Furthermore, diagnosis tends to occur at a late stage in the disease process, limiting the opportunity to prevent deterioration. 7 In addition to COPD, smoking can also cause or influence the severity of many other diseases. ...
In the Western world, chronic obstructive pulmonary disease (COPD) is predominantly caused by long-term smoking, which results in pulmonary inflammation that is often associated with systemic inflammation. A number of co-morbid conditions, such as cardiovascular disease, muscle wasting, type 2 diabetes and asthma, may coexist with COPD; these and other co-morbidities not directly related to COPD are major causes of excess morbidity and mortality.
This review sets out to explore the most frequent co-morbidities in COPD and their implications for treatment.
Review of the literature on co-morbidities of COPD.
Co-morbidities are frequent, but often remain undiagnosed in the COPD patient. In order to provide the best possible care for people with COPD, the physician should be aware of all potential co-morbidities that may arise, and the critical role that effective management of these co-morbidities can play in improving patient outcomes.
Increased awareness of the potential co-morbidities of COPD, although potentially adding to the general practitioner's work burden, may provide insights into this difficult disease state and possibly improve each individual's prospects for effective management.
Objective:
To determine the extent of chronic obstructive pulmonary disease (COPD) hospitalization in easily identifiable high-risk subgroups within a typical primary care practice.
Design:
Prospective cohort analysis of administrative claims data.
Setting:
British Columbia.
Participants:
British Columbia residents who were 50 years or older on December 31, 2014, and received a physician diagnosis of COPD between 1996 and 2014.
Main outcome measures:
Rate of acute exacerbation of COPD (AECOPD) or pneumonia hospitalization in 2015, broken down by risk identifiers including previous AECOPD admission, 2 or more community respirologist consultations, nursing home residence, or none of these.
Results:
Of the 242,509 identified COPD patients (12.9% of British Columbia residents ≥50 years), 2.8% were hospitalized for AECOPD in 2015 (0.038 AECOPD hospitalizations per patient-year). The 12.0% with prior AECOPD hospitalization accounted for 57.7% of new AECOPD hospitalizations (0.183 hospitalizations per patient-year); the 7.7% with respirologist involvement accounted for 20.4% (0.102 hospitalizations per patient-year); and the 2.2% in nursing homes accounted for 3.6% (0.061 hospitalizations per patient-year). Those with any of the 3 risk identifiers accounted for only 1.5% more COPD hospitalizations (59.2%) than those with prior AECOPD hospitalization, suggesting prior AECOPD hospitalization is the most important indication of risk. A typical primary care practice held a median of 23 (interquartile range=4 to 65) COPD patients, of whom roughly 20 (86.4%) had none of these risk identifiers. This low-risk majority had only 0.018 AECOPD hospitalizations per patient-year.
Conclusion:
Most AECOPD hospitalizations occur in patients with previous such admissions. When time and resources are limited, COPD initiatives targeting primary care practices should focus more on the 2 to 3 patients with prior AECOPD hospitalization or more symptomatic disease, and less on the low-risk majority.
Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease with high morbidity and mortality. The early diagnosis of COPD is vital for clinical treatment, which helps patients to have a better quality of life. Because COPD can be ascribed to chronic bronchitis and emphysema, lesions in a computed tomography (CT) image can present anywhere inside the lung with different types, shapes and sizes. Multiple instance learning (MIL) is an effective tool for solving COPD discrimination. In this study, a novel graph convolutional MIL with the adaptive additive margin loss (GCMIL-AAMS) approach is proposed to diagnose COPD by CT. Specifically, for those early stage patients, the selected instance-level features can be more discriminative if they were learned by our proposed graph convolution and pooling with self-attention mechanism. The AAMS loss can utilize the information of COPD severity on a hypersphere manifold by adaptively setting the angular margins to improve the performance, as the severity can be quantified as four grades by pulmonary function test. The results show that our proposed GCMIL-AAMS method provides superior discrimination and generalization abilities in COPD discrimination, with areas under a receiver operating characteristic curve (AUCs) of 0.960
$\pm$
0.014 and 0.862
$\pm$
0.010 in the test set and external testing set, respectively, in 5-fold stratified cross validation; moreover, it demonstrates that graph learning is applicable to MIL and suggests that MIL may be adaptable to graph learning.
Nighttime symptoms are important indicators of impairment for many diseases and particularly for respiratory diseases such as chronic obstructive pulmonary disease (COPD). The use of wearable sensors to assess sleep in COPD has mainly been limited to the monitoring of limb motions or the duration and continuity of sleep. In this paper we present an approach to concisely describe sleep patterns in subjects with and without COPD. The methodology converts multimodal sleep data into a text representation and uses topic modeling to identify patterns across the dataset composed of more than 6000 assessed nights. This approach enables the discovery of higher level features resembling unique sleep characteristics that are then used to discriminate between healthy subjects and those with COPD and to evaluate patients’ disease severity and dyspnea level. Compared to standard features, the discovered latent structures in nighttime data seem to capture important aspects of subjects sleeping behavior related to the effects of COPD and dyspnea.
Objective
The chronic obstructive pulmonary disease (COPD) integrated care pathway (ICP) programme was designed and implemented to ensure that the care for patients with COPD is comprehensive and integrated across different care settings from primary care to acute hospital and home. We evaluated the effectiveness of the ICP programme for patients with COPD.
Design, setting and participants
A retrospective propensity score matched cohort study was conducted comparing differences between programme enrolees and propensity-matched non-enrolees in a Regional Health System in Singapore. Data on patients diagnosed with COPD who enrolled in the programme (n=95) and patients who did not enrol (n=6330) were extracted from the COPD registry and hospital administrative databases. Enrolees and non-enrolees were propensity score matched.
Outcome measures
The risk of COPD hospitalisations and COPD hospital bed days savings were compared between the groups using a difference-in-difference strategy and generalised estimating equation approach. Adherence with recommended care elements for the COPD-ICP group was measured quarterly at baseline and during a 2-year follow-up period.
Results
Compared with non-enrolees, COPD hospitalisation risk for ICP programme enrolees was significantly lower in year 2 (incidence rate ratio (IRR): 0.73; 95% CI 0.54 to 1.00). Similarly, COPD hospital bed days was significantly lower for enrolees in year 2 (IRR: 0.78; 95% CI 0.64 to 0.95). ICP programme patients had sustained improvements in compliance with all recommended care elements for patients with COPD. The overall all-or-none care bundle compliance rate had improved from 28% to 54%.
Conclusion
The study concluded that the COPD-ICP programme was associated with reductions in COPD hospitalisation risk and COPD health utilisation in a 2-year follow-up period.
Chronic Obstructive Pulmonary Disease (COPD), a major cause of morbidity and mortality worldwide, is preventable and treatable. Comprehensive COPD management can improve many aspects of patient functioning, but adherence tends to be poor. Barriers to adherence may be socioeconomic, patient, therapy, disease, or healthcare systems/provider-related (Sabaté, 2003). This chapter describes potential barriers to participation in COPD management, including screening and assessment questions and tools. It then outlines a stepped-care approach to brief interventions to increase adherence across all aspects of COPD treatment and provides resources for patients and providers.
Background:
Introduced in 2004, the UK's Quality and Outcomes Framework (QOF) is the world's largest primary care pay-for-performance programme. We tested whether the QOF was associated with reduced population mortality.
Methods:
We used population-level mortality statistics between 1994 and 2010 for the UK and other high-income countries that were not exposed to pay-for-performance. The primary outcome was age-adjusted and sex-adjusted mortality per 100 000 people for a composite outcome of chronic disorders that were targeted by the QOF. Secondary outcomes were age-adjusted and sex-adjusted mortality for ischaemic heart disease, cancer, and a composite of all non-targeted conditions. For each study outcome, we created a so-called synthetic UK as a weighted combination of comparison countries. We then estimated difference-in-differences models to test whether mortality fell more in the UK than in the synthetic UK after the QOF.
Findings:
Introduction of the QOF was not significantly associated with changes in population mortality for the composite outcome (-3·68 per 100 000 population [95% CI -8·16 to 0·80]; p=0·107), ischaemic heart disease (-2·21 per 100 000 [-6·86 to 2·44]; p=0·357), cancer (0·28 per 100 000 [-0·99 to 1·55]; p=0·679), or all non-targeted conditions (11·60 per 100 000 [-3·91 to 27·11]; p=0·143).
Interpretation:
Although we noted small mortality reductions for a composite outcome of targeted disorders, the QOF was not associated with significant changes in mortality. Our findings have implications for the probable effects of similar programmes on population health outcomes. The relation between incentives and mortality needs to be assessed in specific disease domains.
Funding:
None.
The use of integrated syndromic guidelines (ISG) aims to improve the quality of care for patients with respiratory diseases. The impact of such ISG in clinical practice can be potentially significant in primary health care (PHC) settings. We report the impact of the use by general practitioners (GPs) of a Tunisian ISG for respiratory diseases in management of respiratory patients in PHC.
The short-term impact was assessed through the results of the feasibility study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG. The same 73 GPs practicing within 28 PHCs were involved in the two surveys at an interval of 6 weeks. Information on each patient mentioned gender, age, underlying conditions, symptoms, referral, diagnosis and drug prescription details.
During the periods of the baseline and impact surveys, 36.0 and 31.1% of PHC attendees, respectively, sought care for respiratory symptoms. Acute respiratory infection (ARI) cases accounted for more than 85% of patients with respiratory disease. In the impact survey, chronic respiratory disease (CRD) diagnosis increased by approximately 50%. In the same way, the proportion of tuberculosis suspects increased 5.5 times. The number of drugs prescribed per patient decreased by 18.8%, and the proportion of patients who were prescribed antibiotics decreased by 19.0%. The prescription of steroids also significantly decreased while inhaled β-agonist prescription increased. The average cost of drug prescription was reduced by 19%.
Training on ISG for respiratory diseases improved the diagnosis of CRD and tuberculosis, and lead to a more rational use of drugs for ARIs in PHCs.
© 2015 John Wiley & Sons, Ltd.
To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.
Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA).
32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.
8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.
National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.
All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.
All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.
Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.
© Kontopantelis et al 2015.
The goals for management of stable chronic obstructive pulmonary disease (COPD) as per the latest Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013 revision include reducing both symptoms (modified medical research council dyspnea score and/or COPD assessment tool) and future risk (severity of airflow limitation and/or exacerbation history in the previous year). Bronchodilators remain central to the management of COPD; a combination of long-acting bronchodilators from different pharmacological classes is recommended to achieve maximal bronchodilation in patients not controlled with monotherapy alone. Presently, several issues related to COPD management remain unaddressed, perhaps due to the paucity of evidence - when should bronchodilator therapy be stepped up, what is the value of early diagnosis and treatment of COPD; how appropriate is long-acting bronchodilator therapy in early disease, and what is the role of inhaled corticosteroids in COPD? The intent of this review is to address the issues highlighted above using a pragmatic and evidence-based approach that can be utilized by both primary and specialty care providers.
Background: The sudden natural death is defined as: Death occurs within 24 hours from the onset of symptoms. The disclosing of the causes of sudden natural death is important for prevention and improving outcome. The objectives of this study were to determine the causes of sudden natural death in Khartoum Mortuary Methods Descriptive, cross-sectional study of natural sudden death in Khartoum Mortuary, which was located in Khartoum Teaching Hospital and offers services to the state. The autopsy records of 2007, which were 150, were considered. Data were collected by a structured check list, and analysis was done by the SPSS soft ware. Results: The most important systems involved in sudden natural deaths were respiratory (49.3%), cardiovascular (24%), gastro intestinal (15.3%) and cerebral (4%), while the leading causes of sudden natural death were pneumonia (20%), myocardial infarction (17.3%) and tuberculosis (14%). Sudden natural death occurred in slightly higher ratio in the age group 40 years and below (50.1%), males were dominating (83%). Conclusion: The commonest causes of sudden natural death, which were pneumonia, myocardial infarction and tuberculosis, were different from the literature in which the commonest causes were myocardial infarction followed by pulmonary embolism. The study highlighted the importance of respiratory diseases besides myocardial infarction as leading causes of sudden natural death, and the need for further researches in this issue. Key words: pneumonia, myocardial infarction and tuberculosis, postmortem ccording to WHO, the sudden natural death is defined as "Death occurs within 24 hours from the onset of symptoms". In forensic practice sudden death occurs within minutes or even seconds after the onset of symptoms 1 .
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and, although it is a preventable and treatable disease, it often remains undiagnosed in patients with mild disease. It is now evident that pathologic changes and physiologic impairment start early in disease progression, and even patients with mild airflow limitation have impairment in the form of exertional dyspnea, general fatigue, and exercise intolerance. Primary care physicians are optimally positioned to recognize these progressive activity restrictions in their patients, usually involving little more than a detailed patient history and a simple symptom questionnaire. Once a patient with persistent activity-related dyspnea has been diagnosed with COPD, bronchodilators can effectively address expiratory airflow limitation and lung hyperinflation that underlie symptoms. These pharmacologic interventions work in conjunction with nonpharmacologic interventions, including smoking cessation, exercise training, and pulmonary rehabilitation. Although the benefits of exercise intervention are well established in patients with more severe COPD, a small amount of new data is emerging that supports the benefits of both pharmacologic treatment and exercise training for improving exercise endurance in patients with mild-to-moderate COPD. This review examines the growing body of data that suggests that early identification-most likely by primary care physicians-and appropriate intervention can favorably impact the symptoms, exercise tolerance, health status, quality of life, hospitalizations, and economic costs of COPD.
Taking and interpreting spirometry tests has proven difficult in primary care practice. This may lead to mis- or underdiagnosis of pulmonary diseases, among others chronic obstructive pulmonary disease. Telespirometry and telepulmonology consultation (TPC) may play a role in monitoring and improving the quality of the spirometry tests, supporting GPs in interpreting spirometry test results and reducing the number of physical referrals to the pulmonologist. In telespirometry up to 10% of spirometry results uploaded by GPs were randomly sent to a pulmonologist. Both the GP or practice nurse and the pulmonologist interpreted the spirometry results and gave their diagnostic findings. Additionally the pulmonologist assessed the quality of the test. In TPC a GP could digitally consult a pulmonologist for advice or referral of patients. On sending and closing the TPC consult the GP was presented a number of questions. Based on these questions the percentage of prevented physical referrals and the educational effect experienced by the GPs were determined. Almost a third of the 227 telespirometry tests was of Moderate or Bad quality. The Kappa of the interobserver agreement on diagnostic findings between GP and pulmonologist was 0.38. Between April 2009 and January 2014, GPS sent 4.488 TPCs to pulmonologists. Sixty-nine percent of the TPCs were sent to gain advice, the others were sent in order to prevent a physical referral. Overall telepulmonology reduced the number of physical referrals by 22%. In 90% of the TPCs the GPs indicated they had learned from the consult.
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, but it often remains undetected in its mild and moderate forms. Patients frequently remain undiagnosed and untreated until the disease has become severe and debilitating, greatly impacting their quality of life. Primary care physicians (PCPs) are most often the first point of contact, and therefore they are in the best position to identify patients at risk of COPD in the early stages. Consequently, they play a critical role in the management of the disease, particularly smoking cessation. One of the earliest symptoms is activity-related dyspnea and subsequent exercise intolerance, often compensated for by reduction in physical activity. This review addresses the approaches used to identify COPD in the primary care setting, including simple tools such as handheld spirometers and questionnaires. A recent study demonstrated that, compared with usual care, use of the COPD Population Screener questionnaire alone and in combination with the copd-6 handheld spirometer significantly improved the odds of referral of patients with suspected COPD for pulmonary function testing or to a pulmonologist. Identification of patients suspected of having the disease and differentiation of COPD from asthma are important in order that treatment can be initiated in the mild stages to slow or prevent disease progression and reduce the risk of exacerbations. The review also discusses the evidence to date on pharmacologic treatment using short-acting and long-acting anticholinergics and β2-agonists, and nonpharmacologic interventions, such as smoking cessation, pulmonary rehabilitation, and influenza and pneumococcal vaccination in patients with mild and moderate COPD.
In this research paper, we used a novel approach to pre-process the heart sound signals by altering the electrical signal in a similar way as is done by human cochlea before they go to Artificial Intelligence (AI) for murmur detection/classification. Cochlea-like pre-processing changes the spectral contents of the heart sounds to enhance the murmur information which can then be detected/classified more accurately by AI circuitry. We designed a heart murmur detection/classification system based upon this approach and tested this system using simulated sounds of various murmur types. Our test results show that this approach significantly improves heart murmur detection/classification accuracy.
Interpreting spirometry results has proven challenging in primary care practice, among others potentially leading to under- and misdiagnosis of COPD. In telepulmonology a general practitioner (GP) digitally consults a pulmonologist to support the interpretation of spirometry results. This study assessed the effect of telepulmonology on quality and efficiency of care.
Quality of care was measured by five indicators, among others the percentage of TelePulmonology Consultations (TPCs) sent by GPs for advice, percentage of those TPCs resulting in a physical referral, and educational effect of telepulmonology as experienced by GPs. Efficiency was defined as the percentage of prevented unnecessary physical referrals of patients to the pulmonologist.
Between April 2009 and November 2012 1.958 TPCs were sent by 158 GPs to 32 pulmonologists. Sixty-nine percent of the TPCs were sent for advice. Based on the advice of the pulmonologist 18% of these TPCs led to a physical referral of patients who would not have been referred without telepulmonology. Thirty-one percent of the TPCs were intended to prevent a physical referral, 68% of these actually prevented a physical referral to a pulmonologist.
The results show telepulmonology can contribute to quality of care by supporting GPs and can additionally prevent unnecessary physical referrals.
Chronic obstructive pulmonary disease (COPD) is quickly becoming one of the leading causes of morbidity and mortality. The purpose of this article is to present an overview of the clinical presentation, spirometry, and pharmacologic management of COPD, as well as the results of a survey examining nurse practitioners' (NPs) knowledge about COPD and its management.
Introduction:
Computed tomography (CT) has been approved for diagnosing chronic obstructive pulmonary disease (COPD). The diagnostic accuracy, however, has never been examined in a systematic review. Therefore, we conducted a meta-analysis to evaluate the accuracy of CT in diagnosing COPD.
Methods:
Articles reporting diagnostic accuracy of CT for COPD were searched from seven electronic databases and hand searching. Two reviewers independently extracted data and assessed methodological quality. Sensitivity (SEN), specificity (SPE), positive and negative likelihood ratios (LR+ and LR-, respectively), and diagnostic odds ratios (DOR) were pooled using a bivariate model. The diagnostic performance of overall test also was assessed using the visual power of the ROC plot to present the bivariate model. Potential between-study heterogeneity was explored using subgroup analyses.
Results:
Data were extracted from 8 studies that met the inclusion criteria. All summary measures were grossly heterogeneous and therefore would not be appropriately summarized. These studies were further stratified by type of imaging technique and test index. The summary estimates of CT for COPD were as follows: SEN, 0.83(95% CI, 0.73-0.89); SPE, 0.87(95% CI, 0.70-0.95); LR+, 6.2(95% CI, 2.5-15.5); LR-, 0.20(95% CI, 0.12-0.34); and DOR, 31(95% CI, 8-116). The five summary estimates of CT on the lung density were 0.80 (95% CI, 0.74-0.84), 0.77(95% CI, 0.58-0.89), 3.5(95% CI, 1.8-6.9), 0.26(95% CI, 0.20-0.34) and 13(95% CI, 6-32), respectively.
Conclusions:
The current meta-analyses suggest that quantitative measures of CT may be useful to diagnose COPD. Developed CT technology may improve the accuracy of diagnosis. Further studies assessed diagnostic performance of CT are needed.
To evaluate the implementation of three regional disease-management programmes on chronic obstructive pulmonary disease (COPD) based on bottlenecks experienced in professional practice.
The authors performed a multisite comparison of three Dutch regional disease-management programmes combining patient-related, professional-directed and organisational interventions. Process (Assessing Chronic Illness Care survey) and outcome (disease specific quality of life (clinical COPD questionnaire (CCQ); chronic respiratory questionnaire (CRQ)), Medical Research Council dyspnoea and patients' experiences) data were collected for 370 COPD patients and their care providers.
Bottlenecks in region A were mostly related to patient involvement, in region B to organisational issues and in region C to both. Selected interventions related to identified bottlenecks were implemented in all programmes, except for patient-related interventions in programme A. Within programmes, significant improvements were found on dyspnoea and patients' experiences with practice nurses. Outcomes on quality of life differed between programmes: programme A did not show any significant improvements; programme B did show any significant improvements on CCQ total (p<0.001), functional (p=0.011) and symptom (p<0.001), CRQ fatigue (p<0.001) and emotional scales (p<0.001); in programme C, CCQ symptom (p<0.001) improved significantly, whereas CCQ mental score (p<0.001) deteriorated significantly. Regression analyses showed that programmes with better implementation of selected interventions resulted in relatively larger improvements in quality of life (CCQ).
Bottom-up implementation of COPD disease-management programmes is a feasible approach, which in multiple settings leads to significant improvements in outcomes of care. Programmes with a better fit between implemented interventions and bottlenecks showed more positive changes in outcomes.
Chronic obstructive pulmonary disease (COPD) is a common cause of acute medical hospital admission, and the prevalence of undiagnosed COPD in the community is high. The impact of undiagnosed COPD on presentation to secondary care services is not currently known. We therefore set out to characterise patients at first admission with an acute exacerbation of COPD, and to identify potential areas for improvement in earlier diagnosis and further management. A retrospective case review of patients first admitted to a district teaching hospital with an acute exacerbation of COPD over a 1-year period was carried out. Forty-one patients with a first admission with an acute exacerbation of COPD were identified, 14 (34%) of whom had not been previously diagnosed and were diagnosed with COPD as a result of the admission. At presentation, this group of patients had severe disease, with mean (SD) FEV(1) 1.02 (0.32) L, and a respiratory acidosis in eight (20%) patients, even though this was their first admission for an acute exacerbation of COPD. Missed potential opportunities to intervene in community and inpatient management were identified, including earlier diagnosis, pre-hospital corticosteroid therapy, inpatient respiratory team input, provision of smoking cessation advice and consideration of pulmonary rehabilitation. Patients with a first hospital admission with an acute exacerbation of COPD frequently have severe disease at presentation. Despite having severe disease, a diagnosis of COPD had not been made in the community prior to admission in one-third of patients. Future work should be directed at earlier identification of patients who are symptomatic from COPD and ensuring that the interventions of proven benefit in COPD are systematically offered to patients in both primary and secondary care.
Using a general practice research database with general practitioner (GP) clinical records, it has been observed that among the 617,280 subjects registered with 400 Italian GPs, 15,229 (2.47%) patients were suffering from chronic obstructive pulmonary disease (COPD). Of these, 67.7% had a chest radiograph at least once in a period of 10 years (1997-2006), while in the same period only 31.9% had a spirometry, 29.9% had a visit to a specialist, and 0.94% had a visit to an allergologist. From 1997 to 2006, 7.5% of patients with COPD, especially the oldest ones, were hospitalized at least once for the disease, although 44.0% of all patients with COPD were hospitalized for other pathologies. With regard to treatment, in 2006, 10,936 (71.1%) of COPD patients received at least one drug for their disease (drugs classified within the R03 therapeutic pharmacological subgroup of the Anatomical Therapeutic Chemical Classification). In particular, salmeterol/fluticasone was prescribed 6441 times, tiotropium 4962, theophylline 3142, beclomethasone 2853, salbutamol 2256, formoterol 2191, salbutamol/beclomethasone 2129, oxitropium 1802 and formoterol/budesonide 1741 times. Based on these findings, the level of COPD management in Italy seems to fall short of recommended international COPD guidelines. In particular, it appears that GPs usually prescribe treatment without the use of spirometry, and/or without taking into account the severity of airway obstruction. It must also be noted that, in general, patients with COPD are undertreated.
This summary presents an overview of the entire document or the health practitioner, which is readily available online (www.copd-ats-ers, www.ersnet.org and www.thoracic.org). This summary does not include any reference to the patient document, which, due to its inherent characteristics, cannot be presented in a conventional format. The readers are encouraged to visit the website to access both full documents. The committee that developed this document fully understands that the field is rapidly changing and that individual components of this document need to be updated periodically as the need arises. However, the modular and flexible design allows for this to occur easier than ever before. The challenge for the future is to develop mechanisms to permit the updated flow of valid scientific information to reach all who need it.
To determine the effect of long term inhaled corticosteroids on lung function, exacerbations, and health status in patients with moderate to severe chronic obstructive pulmonary disease.
Double blind, placebo controlled study.
Eighteen UK hospitals. Participants: 751 men and women aged between 40 and 75 years with mean forced expiratory volume in one second (FEV(1)) 50% of predicted normal. Interventions: Inhaled fluticasone propionate 500 microgram twice daily from a metered dose inhaler or identical placebo. Main outcome measures: Efficacy measures: rate of decline in FEV(1) after the bronchodilator and in health status, frequency of exacerbations, respiratory withdrawals. Safety measures: morning serum cortisol concentration, incidence of adverse events.
There was no significant difference in the annual rate of decline in FEV(1 )(P=0.16). Mean FEV(1) after bronchodilator remained significantly higher throughout the study with fluticasone propionate compared with placebo (P<0.001). Median exacerbation rate was reduced by 25% from 1.32 a year on placebo to 0.99 a year on with fluticasone propionate (P=0.026). Health status deteriorated by 3.2 units a year on placebo and 2.0 units a year on fluticasone propionate (P=0.0043). Withdrawals because of respiratory disease not related to malignancy were higher in the placebo group (25% v 19%, P=0.034).
Fluticasone propionate 500 microgram twice daily did not affect the rate of decline in FEV(1) but did produce a small increase in FEV(1). Patients on fluticasone propionate had fewer exacerbations and a slower decline in health status. These improvements in clinical outcomes support the use of this treatment in patients with moderate to severe chronic obstructive pulmonary disease.
This paper updates the evidence base and key recommendations of the Health Education Authority (HEA) smoking cessation guidelines for health professionals published in Thorax in 1998. The strategy for updating the evidence base makes use of updated Cochrane reviews supplemented by individual studies where appropriate. This update contains additional detail concerning the effectiveness of interventions as well as comments on issues relating to implementation. The recommendations include clarification of some important issues addressed only in general terms in the original guidelines. The conclusion that smoking cessation interventions delivered through the National Health Service are an extremely cost effective way of preserving life and reducing ill health remains unchanged. The strategy recommended by the guidelines involves: (1) GPs opportunistically advising smokers to stop during routine consultations, giving advice on and/or prescribing effective medications to help them and referring them to specialist cessation services; (2) specialist smokers' services providing behavioural support (in groups or individually) for smokers who want help with stopping and using effective medications wherever possible; (3) specialist cessation counsellors providing behavioural support for hospital patients and pregnant smokers who want help with stopping; (4) all health professionals involved in smoking cessation encouraging and assisting smokers in use of nicotine replacement therapies (NRT) or bupropion where appropriate. The key points of clarification of the previous guidelines include: (1) primary health care teams and hospitals should create and maintain readily accessible records on the current smoking status of patients; (2) GPs should aim to advise smokers to stop, and record having done so, at least once a year; (3) inpatient, outpatient, and pregnant smokers should be advised to stop as early as possible and the advice recorded in the notes in a readily accessible form; (4) there is currently little scientific basis for matching individual smokers to particular forms of NRT; (5) NHS specialist smokers' clinics should be the first point of referral for smokers wanting help beyond what can be provided through brief advice from the GP; (6) help from trained health care professionals specialising in smoking cessation such as practice nurses should be available for smokers who do not have access to specialist clinics; (7) the provision of specialist NHS smokers' clinics should be commensurate with demand; this is currently one or two full time clinics or their equivalent per average sized health authority, but demand may rise as publicity surrounding the services increases.
To date, no international surveys estimating the burden of chronic obstructive pulmonary disease (COPD) in the general population have been published. The Confronting COPD International Survey aimed to quantify morbidity and burden in COPD subjects in 2000. From a total of 201,921 households screened by random-digit dialling in the USA, Canada, France, Italy, Germany, The Netherlands, Spain and the UK, 3,265 subjects with a diagnosis of COPD, chronic bronchitis or emphysema, or with symptoms of chronic bronchitis, were identified. The mean age of the subjects was 63.3 yrs and 44.2% were female. Subjects with COPD in North America and Europe appear to underestimate their morbidity, as shown by the high proportion of subjects with limitations to their basic daily life activities, frequent work loss (45.3% of COPD subjects of <65 yrs reported work loss in the past year) and frequent use of health services (13.8% of subjects required emergency care in the last year), and may be undertreated. There was a significant disparity between subjects' perception of disease severity and the degree of severity indicated by an objective breathlessness scale. Of those with the most severe breathlessness (too breathless to leave the house), 35.8% described their condition as mild or moderate, as did 60.3% of those with the next most severe degree of breathlessness (breathless after walking a few minutes on level ground). This international survey confirmed the great burden to society and high individual morbidity associated with chronic obstructive pulmonary disease in subjects in North America and Europe.
The efficacy and safety of budesonide/formoterol in a single inhaler compared with placebo, budesonide and formoterol were evaluated in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). In a 12-month, randomised, double-blind, placebo-controlled, parallel-group study in 812 adults (mean age 64 yrs, mean forced expiratory volume in one second (FEV1) 36% predicted normal), patients received two inhalations twice daily of either budesonide/formoterol (Symbicort) 160/4.5 microg (delivered dose), budesonide 200 microg (metered dose), formoterol 4.5 microg or placebo. Severe exacerbations and FEV1 (primary variables), peak expiratory flow (PEF), COPD symptoms, health-related quality of life (HRQL), mild exacerbations, use of reliever beta2-agonist and safety variables were recorded. Budesonide/formoterol reduced the mean number of severe exacerbations per patient per year by 24% versus placebo and 23% versus formoterol. FEV1 increased by 15% versus placebo and 9% versus budesonide. Morning PEF improved significantly on day 1 versus placebo and budesonide; after 1 week, morning PEF was improved versus placebo, budesonide and formoterol. Improvements in morning and evening PEF versus comparators were maintained over 12 months. Budesonide/formoterol decreased all symptom scores and use of reliever beta2-agonists significantly versus placebo and budesonide, and improved HRQL versus placebo. All treatments were well tolerated. These results suggest a role for budesonide/formoterol in the long-term management of moderate-to-severe chronic obstructive pulmonary disease.
Lung function in chronic obstructive pulmonary disease (COPD) can be improved acutely by oral corticosteroids and bronchodilators. Whether clinical improvement can be maintained by subsequent inhaled therapy is unknown. COPD patients (n=1,022, mean prebronchodilator forced expiratory volume in one second (FEV1) 36% predicted) initially received formoterol (9 microg b.i.d.) and oral prednisolone (30 mg o.d.) for 2 weeks. After this time, patients were randomised to b.i.d. inhaled budesonide/formoterol 320/9 microg, budesonide 400 microg, formoterol 9 microg or placebo for 12 months. Postmedication FEV1 improved by 0.21 L and health-related quality of life using the St George's Respiratory Questionnaire (SGRQ) by 4.5 units after run-in. Fewer patients receiving budesonide/formoterol withdrew from the study than those receiving budesonide, formoterol or placebo. Budesonide/formoterol patients had a prolonged time to first exacerbation (254 versus 96 days) and maintained higher FEV1 (99% versus 87% of baseline), both primary variables versus placebo. They had fewer exacerbations (1.38 versus 1.80 exacerbations per patient per year), had higher prebronchodilator peak expiratory flow, and showed clinically relevant improvements in SGRQ versus placebo (-7.5 units). Budesonide/formoterol was more effective than either monocomponent in both primary variables. Budesonide/formoterol in a single inhaler (Symbicort) maintains the benefit of treatment optimisation, stabilising lung function and delaying exacerbations more effectively than either component drug alone or placebo.
Chronic obstructive pulmonary disease (COPD) is a major public health problem associated with long-term exposure to toxic gases and particles. We examined the evolution of the pathological effects of airway obstruction in patients with COPD.
The small airways were assessed in surgically resected lung tissue from 159 patients--39 with stage 0 (at risk), 39 with stage 1, 22 with stage 2, 16 with stage 3, and 43 with stage 4 (very severe) COPD, according to the classification of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).
The progression of COPD was strongly associated with an increase in the volume of tissue in the wall (P<0.001) and the accumulation of inflammatory mucous exudates in the lumen (P<0.001) of the small airways. The percentage of the airways that contained polymorphonuclear neutrophils (P<0.001), macrophages (P<0.001), CD4 cells (P=0.02), CD8 cells (P=0.038), B cells (P<0.001), and lymphoid aggregates containing follicles (P=0.003) and the absolute volume of B cells (P=0.03) and CD8 cells (P=0.02) also increased as COPD progressed.
Progression of COPD is associated with the accumulation of inflammatory mucous exudates in the lumen and infiltration of the wall by innate and adaptive inflammatory immune cells that form lymphoid follicles. These changes are coupled to a repair or remodeling process that thickens the walls of these airways.
Individuals with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular diseases, osteoporosis, and muscle wasting. Systemic inflammation may be involved in the pathogenesis of these disorders. A study was undertaken to determine whether systemic inflammation is present in stable COPD.
A systematic review was conducted of studies which reported on the relationship between COPD, forced expiratory volume in 1 second (FEV(1)) or forced vital capacity (FVC), and levels of various systemic inflammatory markers: C-reactive protein (CRP), fibrinogen, leucocytes, tumour necrosis factor-alpha (TNF-alpha), and interleukins 6 and 8. Where possible the results were pooled together to produce a summary estimate using a random or fixed effects model.
Fourteen original studies were identified. Overall, the standardised mean difference in the CRP level between COPD and control subjects was 0.53 units (95% confidence interval (CI) 0.34 to 0.72). The standardised mean difference in the fibrinogen level was 0.47 units (95% CI 0.29 to 0.65). Circulating leucocytes were also higher in COPD than in control subjects (standardised mean difference 0.44 units (95% CI 0.20 to 0.67)), as were serum TNF-alpha levels (standardised mean difference 0.59 units (95% CI 0.29 to 0.89)).
Reduced lung function is associated with increased levels of systemic inflammatory markers which may have important pathophysiological and therapeutic implications for subjects with stable COPD.
Guidelines recommend inhaled corticosteroids (ICS) as maintenance treatment for patients with chronic obstructive pulmonary disease (COPD) with a post-bronchodilator forced expiratory volume in 1 second (FEV1) <50% predicted and frequent exacerbations, although they have only a small preventive effect on the accelerated decline in lung function. Combined treatment with ICS and long acting beta2 agonists (LABA) may provide benefit to the stability of COPD, but it is unknown if withdrawal of ICS will result in disease deterioration.
The effects of 1 year withdrawal of the ICS fluticasone propionate (FP) after a 3 month run-in treatment period with FP combined with the LABA salmeterol (S) (500 microg FP + 50 microg S twice daily; SFC) were investigated in patients with COPD in a randomised, double blind study. 497 patients were enrolled from 39 centres throughout the Netherlands; 373 were randomised and 293 completed the study.
The drop out rate after randomisation was similar in the two groups. Withdrawal of FP resulted in a sustained decrease in FEV1: mean (SE) change from baseline -4.4 (0.9)% (S) v -0.1 (0.9)% (SFC); adjusted difference 4.1 (95% CI 1.6 to 6.6) percentage points (p<0.001). Corresponding figures for the FEV1/FVC ratio were -3.7 (0.8)% (S) v 0.0 (0.8)% (SFC) (p = 0.002). The annual moderate to severe exacerbation rate was 1.6 and 1.3 in the S and SFC groups, respectively (adjusted rate ratio 1.2; 95% CI 0.9 to 1.5; p = 0.15). The mean annual incidence rate of mild exacerbations was 1.3 (S) v 0.6 (SFC), p = 0.020. An immediate and sustained increase in dyspnoea score (scale 0-4; mean difference between groups 0.17 (0.04), p<0.001) and in the percentage of disturbed nights (6 (2) percentage points, p<0.001) occurred after withdrawal of fluticasone.
Withdrawal of FP in COPD patients using SFC resulted in acute and persistent deterioration in lung function and dyspnoea and in an increase in mild exacerbations and percentage of disturbed nights. This study clearly indicates a key role for ICS in the management of COPD as their discontinuation leads to disease deterioration, even under treatment with a LABA.
The Smoking cessation guidelines for Australian general practice is based on published evidence, review of overseas guidelines, existing general practice programs, and a process of stakeholder consultation. It was distributed to Australian general practitioners in 2004.
This article describes the development and content of the guidelines.
The guidelines provide an evidence based approach to smoking cessation advice in general practice using the 5 As framework (Ask, Assess, Advise, Assist, Arrange). The intervention approach (modelled on the Smokescreen Program) makes use of stage of change assessment and motivational interviewing. The guidelines are consistent with the Smoking, Nutrition and Physical activity (SNAP) framework for intervention on behavioural risk factors, and integrate GP advice with Quitline services.
C-reactive protein (CRP) is often used as a clinical marker of acute systemic inflammation. Since low grade inflammation is evident in chronic diseases such as chronic obstructive pulmonary disease (COPD), new methods have been developed to enhance the sensitivity of CRP assays in the lower range. A study was undertaken to investigate the discriminative value of high sensitivity CRP in COPD with respect to markers of local and systemic impairment, disability, and handicap.
Plasma CRP levels, interleukin 6 (IL-6) levels, body composition, resting energy expenditure (REE), exercise capacity, health status, and lung function were determined in 102 patients with clinically stable COPD (GOLD stage II-IV). The cut off point for normal versus raised CRP levels was 4.21 mg/l.
CRP levels were raised in 48 of 102 patients. In these patients, IL-6 (p<0.001) and REE (adjusted for fat-free mass, p = 0.002) were higher while maximal (p = 0.040) and submaximal exercise capacity (p = 0.017) and 6 minute walking distance (p = 0.014) were lower. The SGRQ symptom score (p = 0.003) was lower in patients with raised CRP levels, as were post-bronchodilator FEV1 (p = 0.031) and reversibility (p = 0.001). Regression analysis also showed that, when adjusted for FEV1, age and sex, CRP was a significant predictor for body mass index (p = 0.044) and fat mass index (p = 0.016).
High sensitivity CRP is a marker for impaired energy metabolism, functional capacity, and distress due to respiratory symptoms in COPD.
The aim of the present study was to analyse the risk of rehospitalisation in patients with chronic obstructive pulmonary disease and associated risk factors. This prospective study included 416 patients from a university hospital in each of the five Nordic countries. Data included demographic information, spirometry, comorbidity and 12 month follow-up for 406 patients. The hospital anxiety and depression scale and St. George's Respiratory Questionnaire (SGRQ) were applied to all patients. The number of patients that had a re-admission within 12 months was 246 (60.6%). Patients that had a re-admission had lower lung function and health status. A low forced expiratory volume in one second (FEV1) and health status were independent predictors for re-admission. Hazard ratio (HR; 95% CI) was 0.82 (0.74-0.90) per 10% increase of the predicted FEV1 and 1.06 (1.02-1.10) per 4 units increase in total SGRQ score. The risk of rehospitalisation was also increased in subjects with anxiety (HR 1.76 (1.16-2.68)) and in subjects with low health status (total SGRQ score >60 units). When comparing the different subscales in the SGRQ, the closest relation between the risk of rehospitalisation was seen with the activity scale (HR 1.07 (1.03-1.11) per 4 unit increase). In patients with low health status, anxiety is an important risk factor for rehospitalisation. This may be important for patient treatment and warrants further studies.
Background:
Chronic obstructive pulmonary disease (COPD) results from a progressive decline in lung function, which is thought to be the consequence of airway inflammation. We hypothesized that antiinflammatory therapy with inhaled corticosteroids would slow this decline.
Methods:
We enrolled 1116 persons with COPD whose forced expiratory volume in one second (FEV1) was 30 to 90 percent of the predicted value in a 10-center, placebo-controlled, randomized trial of inhaled triamcinolone acetonide administered at a dose of 600 microg twice daily. The primary outcome measure was the rate of decline in FEV1 after the administration of a bronchodilator. The secondary outcome measures included respiratory symptoms, use of health care services, and airway reactivity. In a substudy of 412 participants, we measured bone density in the lumbar spine and femur at base line and one and three years after the beginning of treatment.
Results:
The mean duration of follow-up was 40 months. The rate of decline in the FEV1 after bronchodilator use was similar in the 559 participants in the triamcinolone group and the 557 participants in the placebo group (44.2+/-2.9 vs. 47.0+/-3.0 ml per year, P= 0.50). Members of the triamcinolone group had fewer respiratory symptoms during the course of the study (21.1 per 100 person-years vs. 28.2 per 100 person-years, P=0.005) and had fewer visits to a physician because of a respiratory illness (1.2 per 100 person-years vs. 2.1 per 100 person-years, P=0.03). Those taking triamcinolone also had lower airway reactivity in response to methacholine challenge at 9 months and 33 months (P=0.02 for both comparisons). After three years, the bone density of the lumbar spine and the femur was significantly lower in the triamcinolone group (P < or = 0.007).
Conclusions:
Inhaled triamcinolone does not slow the rate of decline in lung function in people with COPD, but it improves airway reactivity and respiratory symptoms and decreases the use of health care services for respiratory problems. These benefits should be weighed against the potential long-term adverse effects of triamcinolone on bone mineral density.
Study objective:
We compared the long-term safety and efficacy of the combination ipratropium bromide (IB) and albuterol sulfate (ALB) inhalation solution with that of each separate component using three-times-daily administration.
Design:
Using a parallel design, we randomized patients to receive 3.0 mg ALB, 0.5 mg IB, or the combination by small-volume nebulizer (SVN) for 85 days. Subjects were allowed to use up to two extra doses of study medication daily for control of symptoms on an as-needed basis. The main efficacy evaluation was the acute pulmonary function response to an aerosol of the maintenance study medication over the course of the investigation. Physician global evaluation, subject quality of life assessments, COPD symptom scores, and twice-daily peak expiratory flow rate (PEFR) were also assessed over the study period.
Setting:
Twenty-five centers participated in the investigation.
Patients:
We studied 652 patients with moderate to severe COPD.
Measurements and results:
Over the course of the study, the acute spirometric response and evening PEFR values with the SVN combination of IB plus ALB were statistically significantly better compared to ALB or IB alone. The quality of life scores, physician global evaluations, symptom scores, and morning PEFR scores were unchanged over the duration of the study in all treatment groups. There was no significant difference in adverse events in the three treatment groups.
Conclusions:
In patients with COPD, maintenance SVN therapy with IB and ALB provides better bronchodilation than either therapy alone without increasing side effects.
Objectives: To investigate the effectiveness of case finding of patients at risk of developing chronic obstructive pulmonary disease, whether the method is suitable for use in general practice, how patients should be selected, and the time required. Design: Cross sectional study. Setting: Two semirural general practices in the Netherlands. Participants: 651 smokers aged 35 to 70 years. Main outcome measures: Short standardised questionnaire on bronchial symptoms for current smokers, lung function with a spirometer, and the quality of the spirometric curve. Results: Of the 201 smokers not taking drugs for a pulmonary condition, 169 produced an acceptable curve (fulfilling American Thoracic Society criteria). Of these, 30 (18%, 95% confidence interval 12% to 24%) had a forced expiratory volume in one second (FEV 1 ) 1 v 2.50 (1.14 to 5.52)). Age was also a good predictor of obstruction; smokers over 60 with cough had a 48% chance of having an obstruction. The mean time needed for spirometry was four minutes. Detecting one smoker with an FEV 1 Conclusions: Trained practice assistants could check all patients who smoke for chronic obstructive pulmonary disease at little cost to the practice. Cough and age are the most important predictors of the disease. By testing one smoker a day, an average practice could identify one patient at risk a week.
The current paradigm for the pathogenesis of chronic obstructive pulmonary disease is that chronic airflow limitation results from an abnormal inflammatory response to inhaled particles and gases in the lung. Airspace inflammation appears to be different in susceptible smokers and involves a predominance of CDS+ T lymphocytes, neutrophils, and macrophages. Studies have characterized inflammation in the peripheral airspaces in different stages of disease severity. Two other processes have received considerable research attention. The first is a protease-antiprotease imbalance, which has been linked to the pathogenesis of emphysema. However, the hypothesis of an increased protease burden associated with functional inhibition of antiproteases has been difficult to prove and is now considered an oversimplification. The second process, oxidative stress, has a role in many of the pathogenic processes of chronic obstructive pulmonary disease and may be one mechanism that enhances the inflammatory response. In addition, it has been proposed that the development of emphysema may involve alveolar cell loss through apoptosis. This mechanism may involve the vascular endothelial growth factor pathway and oxidative stress.
Objectives: To evaluate primary care physicians’ knowledge of guidelines for the management of COPD.Method: Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital.Results: Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians.Conclusions: This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs.
This paper updates the evidence base and key recommendations of the Health Education Authority (HEA) smoking cessation guidelines for health professionals published in Thorax in 1998. The strategy for updating the evidence base makes use of updated Cochrane reviews supplemented by individual studies where appropriate. This update contains additional detail concerning the effectiveness of interventions as well as comments on issues relating to implementation. The recommendations include clarification of some important issues addressed only in general terms in the original guidelines. The conclusion that smoking cessation interventions delivered through the National Health Service are an extremely cost effective way of preserving life and reducing ill health remains unchanged. The strategy recommended by the guidelines involves: (1) GPs opportunistically advising smokers to stop during routine consultations, giving advice on and/or prescribing effective medications to help them and referring them to specialist cessation services; (2) specialist smokers' services providing behavioural support (in groups or individually) for smokers who want help with stopping and using effective medications wherever possible; (3) specialist cessation counsellors providing behavioural support for hospital patients and pregnant smokers who want help with stopping; (4) all health professionals involved in smoking cessation encouraging and assisting smokers in use of nicotine replacement therapies (NRT) or bupropion where appropriate. The key points of clarification of the previous guidelines include: (1) primary health care teams and hospitals should create and maintain readily accessible records on the current smoking status of patients; (2) GPs should aim to advise smokers to stop, and record having done so, at least once a year; (3) inpatient, outpatient, and pregnant smokers should be advised to stop as early as possible and the advice recorded in the notes in a readily accessible form; (4) there is currently little scientific basis for matching individual smokers to particular forms of NRT; (5) NHS specialist smokers' clinics should be the first point of referral for smokers wanting help beyond what can be provided through brief advice from the GP; (6) help from trained health care professionals specialising in smoking cessation such as practice nurses should be available for smokers who do not have access to specialist clinics; (7) the provision of specialist NHS smokers' clinics should be commensurate with demand; this is currently one or two full time clinics or their equivalent per average sized health authority, but demand may rise as publicity surrounding the services increases.
Objective
This study attempted to determine the total direct costs derived from the management of chronic bronchitis and COPD in an ambulatory setting through a prospective, 1-year, follow-up study.
Method
A total of 1,510 patients with chronic bronchitis and COPD were recruited from 268 general practices located throughout Spain. Patients were followed up for 1 year. All direct medical costs incurred by the cohort and related to their respiratory disease were quantified. Costs were calculated for patients with confirmed COPD according to the degree of severity of airflow obstruction.
Results
The global mean direct yearly cost of chronic bronchitis and COPD was $1,876. The cost generated by patients with COPD was $1,760, but the cost of severe COPD ($2,911) was almost double that of mild COPD ($1,484). Hospitalization costs represented 43.8% of costs, drug acquisition costs were 40.8%, and clinic visits and diagnostic tests represented only 15.4% of costs.
Conclusion
This is the first prospective follow-up study on a large cohort of patients with chronic bronchitis and COPD aimed at quantifying direct medical costs under usual clinical practice in the community. Costs of chronic bronchitis and COPD were almost twofold those reported for asthma. Patterns of COPD management in the community differ from those recommended in guidelines. COPD represents a great health-care burden in developed countries, and aging of the population and continuing smoking habits predict that it will continue to do so in the future.
COPD is a category of heterogeneous diseases with varying pathophysiologic basis and varying degrees of airflow obstruction and hyperinflation. Standard therapy has consisted of medical management and individualized exercise training. Multiple surgical attempts have ensued over the years to treat disabling dyspnea in these patients. These techniques have included attempts to improve thoracic mobility, decrease thoracic distention, stabilize dynamic airway collapse and achieve thoracic denervation. The most widely applied and potentially useful techniques have been surgical attempts to decrease pulmonary hyperinflation. Initial techniques removed giant bullous lesions with short and long-term relief of symptoms and improved physiology in carefully selected patients. Recently, similar lung volume reduction surgical techniques have been applied to patients with bullous disease but without discrete, giant bullae. Although the data are limited, early results in selected patients seem promising. This discussion compares the short-term and long-term results of classic giant bullectomy with lung volume reduction in the absence of giant bullae. Data are also reviewed which contrast selection criteria advocated for surgical consideration in both clinical scenarios.
Plausible projections of future mortality and disability are a useful aid in decisions on priorities for health research, capital investment, and training. Rates and patterns of ill health are determined by factors such as socioeconomic development, educational attainment, technological developments, and their dispersion among populations, as well as exposure to hazards such as tobacco. As part of the Global Burden of Disease Study (GBD), we developed three scenarios of future mortality and disability for different age-sex groups, causes, and regions.
We used the most important disease and injury trends since 1950 in nine cause-of-death clusters. Regression equations for mortality rates for each cluster by region were developed from gross domestic product per person (in international dollars), average number of years of education, time (in years, as a surrogate for technological change), and smoking intensity, which shows the cumulative effects based on data for 47 countries in 1950-90. Optimistic, pessimistic, and baseline projections of the independent variables were made. We related mortality from detailed causes to mortality from a cause cluster to project more detailed causes. Based on projected numbers of deaths by cause, years of life lived with disability (YLDs) were projected from different relation models of YLDs to years of life lost (YLLs). Population projections were prepared from World Bank projections of fertility and the projected mortality rates.
Life expectancy at birth for women was projected to increase in all three scenarios; in established market economies to about 90 years by 2020. Far smaller gains in male life expectancy were projected than in females; in formerly socialist economies of Europe, male life expectancy may not increase at all. Worldwide mortality from communicable maternal, perinatal, and nutritional disorders was expected to decline in the baseline scenario from 17.2 million deaths in 1990 to 10.3 million in 2020. We projected that non-communicable disease mortality will increase from 28.1 million deaths in 1990 to 49.7 million in 2020. Deaths from injury may increase from 5.1 million to 8.4 million. Leading causes of disability-adjusted life years (DALYs) predicted by the baseline model were (in descending order): ischaemic heart disease, unipolar major depression, road-traffic accidents, cerebrovascular disease, chronic obstructive pulmonary disease, lower respiratory infections, tuberculosis, war injuries, diarrhoeal diseases, and HIV. Tobacco-attributable mortality is projected to increase from 3.0 million deaths in 1990 to 8.4 million deaths in 2020.
Health trends in the next 25 years will be determined mainly by the ageing of the world's population, the decline in age-specific mortality rates from communicable, maternal, perinatal, and nutritional disorders, the spread of HIV, and the increase in tobacco-related mortality and disability. Projections, by their nature, are highly uncertain, but we found some robust results with implications for health policy.
Although patients with chronic obstructive pulmonary disease (COPD) should stop smoking, some do not. In a double-blind, placebo-controlled study, we evaluated the effect of the inhaled glucocorticoid budesonide in patients with mild COPD who continued smoking. After a six-month run-in period, we randomly assigned 1277 subjects (mean age, 52 years; mean forced expiratory volume in one second [FEV1], 77 percent of the predicted value; 73 percent men) to twice-daily treatment with 400 microg of budesonide or placebo, inhaled from a dry-powder inhaler, for three years.
Of the 1277 subjects, 912 (71 percent) completed the study. Among these subjects, the median decline in the FEV1 after the use of a bronchodilator over the three-year period was 140 ml in the budesonide group and 180 ml in the placebo group (P=0.05), or 4.3 percent and 5.3 percent of the predicted value, respectively. During the first six months of the study, the FEV1 improved at the rate of 17 ml per year in the budesonide group, as compared with a decline of 81 ml per year in the placebo group (P<0.001). From nine months to the end of treatment, the FEV1 declined at similar rates in the two groups (P=0.39). Ten percent of the subjects in the budesonide group and 4 percent of those in the placebo group had skin bruising (P<0.001). Newly diagnosed hypertension, bone fractures, postcapsular cataracts, myopathy, and diabetes occurred in less than 5 percent of the subjects, and the diagnoses were equally distributed between the groups.
In patients with mild COPD who continue smoking, the use of inhaled budesonide is associated with a small one-time improvement in lung function but does not appreciably affect the long-term progressive decline.
In this study we aimed to estimate direct medical costs of Chronic Obstructive Pulmonary Disease (COPD) by disease type; chronic bronchitis and emphysema. This study estimates direct costs in 1996 dollars using a prevalence approach and both aggregate and microcosting. A societal perspective is taken using prevalence, and multiple national, state and local data sources are used to estimate health-care utilization and costs. Chronic bronchitis and emphysema together account for $14.5 billion in annual direct costs. Inpatient costs are greater than outpatient and emergency costs ($8.3 vs. $7.8 billion) and hospital and medication costs account for most resources spent. The high prevalence of chronic bronchitis accounts for its larger total costs ($11.7 billion) compared with emphysema ($2.8 billion). Emphysema, which is more severe, has higher costs per prevalent case ($1341 vs. $816). Hospital stays account for the highest costs, $6.0 billion for chronic bronchitis and $1.9 billion for emphysema. The hospitalization rate, length of stay and average cost per prevalent case are higher for emphysema than for chronic bronchitis. Medication costs are the second highest cost category ($4.4 billion for chronic bronchitis, $0.693 billion for emphysema). The high hospitalization and low home care costs (0.2% of total) suggest underuse of home care and room to shift from acute to preventive care. More attention to healthcare management of chronic bronchitis and emphysema is suggested, and improving inhaler and anti-smoking compliance might be important targets.
Obstructive lung disease (OLD) is an important cause of morbidity and mortality in the US adult population. Potentially treatable mild cases of OLD often go undetected. This analysis determines the national estimates of reported OLD and low lung function in the US adult population.
We examined data from the Third National Health and Nutrition Examination Survey (NHANES III), a multistage probability representative sample of the US population. A total of 20,050 US adults participated in NHANES III from 1988 to 1994. Our main outcome measures were low lung function (a condition determined to be present if the forced expiratory volume in 1 second-forced vital capacity ratio was less than 0.7 and the forced expiratory volume in 1 second was less than 80% of the predicted value), a physician diagnosis of OLD (chronic bronchitis, asthma, or emphysema), and respiratory symptoms.
Overall a mean (SE) of 6.8% (0.3%) of the population had low lung function, and 8.5% (0.3%) of the population reported OLD. Obstructive lung disease (age-adjusted to study population) was currently reported among 12.5% (0.7%) of current smokers, 9.4% (0.6%) of former smokers, 3.1% (1.1%) of pipe or cigar smokers, and 5.8% (0.4%) of never smokers. Surprisingly, 63.3% (0.2%) of the subjects with documented low lung function had no prior or current reported diagnosis of any OLD.
This study demonstrates that OLD is present in a substantive number of US adults. In addition, many US adults have low lung function but no reported OLD diagnosis, which may indicate the presence of undiagnosed lung disease.
The efficacy and safety of salmeterol alone was compared with the combination of salmeterol plus ipratropium and with placebo during long-term treatment in patients with stable chronic obstructive pulmonary disease. In addition, the single-dose effect in response to the first dose of treatment was studied over 12 h. The patients (n=144; age 64+/-7 yrs, forced expiratory volume in one second (FEV1) 44+/-11% pred) participated in a three-centre double-blind double-placebo parallel group study and were randomized after a run-in period of 2 weeks to receive either salmeterol 50 microg b.i.d., salmeterol 5 microg b.i.d. plus ipratropium 40 microg q.i.d. or placebo for a period of 12 weeks. The single-dose study demonstrated that salmeterol produced a significant increase in FEV1 (peak of 7% pred) and specific airway conductance (sGaw) (maximum of 60% baseline) for > or =12 h. The combination of salmeterol plus ipratropium elicited a greater bronchodilator response (11% and 94% increases respectively) than salmeterol alone during the first 6 h after inhalation. During treatment there were significant improvements in daytime symptom scores and morning peak expiratory flow in both the salmeterol and the salmeterol plus ipratropium groups (p<0.001), with an associated decrease in the use of rescue salbutamol. Improvements in FEV1 and sGaw were greater in the salmeterol plus ipratropium group than in the patients receiving only salmeterol. Thirty-five patients had an exacerbation; 11 (23%) in the salmeterol group (versus placebo NS), six (13%) in the salmeterol plus ipratropium group (versus placebo p<0.01) and 18 (36%) in the placebo group. In conclusion, in patients with severe stable chronic obstructive pulmonary disease, long-term treatment with either salmeterol alone or salmeterol plus ipratropium is safe and effective. There was added benefit from the combination therapy in terms of improvement in airways obstruction, but not for improvement in symptom control or need for rescue salbutamol.
Influenza vaccinations are currently recommended in the care of people with COPD, but these recommendations are based largely on evidence from observational studies with very few randomised controlled trials (RCTs) reported. Influenza infection causes excess morbidity and mortality in COPD patients but there is also the potential for influenza vaccination to cause adverse effects or not to be cost effective.
To evaluate the evidence from RCTs for a treatment effect of influenza vaccination in COPD subjects. Outcomes of interest were exacerbation rates, hospitalisations, mortality, lung function and adverse effects.
We searched the Cochrane Airways Group trials register and reference lists of articles. References were also provided by a number of drug companies we contacted.
RCTs that compared live or inactivated virus vaccines with placebo, either alone or with another vaccine in persons with COPD. Studies of people with asthma were excluded.
Two reviewers extracted data. All entries were double checked. Study authors and drug companies were contacted for missing information.
Nine trials were included but only four of these were specifically performed in COPD patients. The others were conducted on elderly and high-risk individuals, some of whom had chronic lung disease. In one study of inactivated vaccine in COPD patients there was a significant reduction in the total number of exacerbations per vaccinated subject compared with those who received placebo (weighted mean difference (WMD) -0.45, 95% confidence interval -0.75 to -0.15, p = 0.004). This difference was mainly due to the reduction in exacerbations occurring after 3 weeks (WMD -0.44, (95% CI -0.68 to -0.20, p<0.001). The number of patients experiencing late exacerbations was also significantly less (OR= 0.13, 95%CI 0.04 to 0.45, p=0.002). There was no evidence of an effect of intranasal live attenuated virus when this was added to inactivated intramuscular vaccination. In studies in elderly patients (only a minority of whom had COPD), there was a significant increase in the occurrence of local adverse reactions in vaccinees, but the effects were generally mild and transient.
It appears, from the limited number of studies performed, that inactivated vaccine may reduce exacerbations in COPD patients. The size of effect was similar to that seen in large observational studies, and was due to a reduction in exacerbations occurring three or more weeks after vaccination. In elderly, high risk patients there was an increase in adverse effects with vaccination, but these are seen early and are usually mild and transient.
COPD affects millions of people in the United States. The purpose of this study was to describe the medical resource use and costs incurred by persons with COPD in the United States in 1987.
Data for this study were derived from the 1987 National Medical Expenditure Survey. A societal perspective was adopted for this analysis.
All persons > or = 40 years old with resource use or expenditures for chronic bronchitis, emphysema, or nonspecific chronic airway obstruction were included in this study.
Mean per-person direct medical expenditures among persons with COPD were $6,469 (1987 US dollars), about 25% of which was COPD related. Approximately 68% of direct medical expenditures in persons with COPD were for inpatient hospitalization.
COPD causes a large societal burden of illness that is expected to increase. This study provides a valuable foundation and historical measure against which to compare other estimates.
To investigate the effectiveness of case finding of patients at risk of developing chronic obstructive pulmonary disease, whether the method is suitable for use in general practice, how patients should be selected, and the time required.
Cross sectional study.
Two semirural general practices in the Netherlands. Participants: 651 smokers aged 35 to 70 years.
Short standardised questionnaire on bronchial symptoms for current smokers, lung function with a spirometer, and the quality of the spirometric curve.
Of the 201 smokers not taking drugs for a pulmonary condition, 169 produced an acceptable curve (fulfilling American Thoracic Society criteria). Of these, 30 (18%, 95% confidence interval 12% to 24%) had a forced expiratory volume in one second (FEV(1)) <80% of predicted. When smokers were preselected on the basis of chronic cough, the proportion with an FEV(1) <80% of predicted increased to 27% (17 of 64; 12% to 38%). Chronic cough was a better predictor of airflow obstruction than other symptoms, such as wheeze and dyspnoea. The presence of two symptoms was a slightly better predictor than cough only (odds ratio 3.02 (1.37 to 6.64) v 2.50 (1.14 to 5.52)). Age was also a good predictor of obstruction; smokers over 60 with cough had a 48% chance of having an obstruction. The mean time needed for spirometry was four minutes. Detecting one smoker with an FEV(1) <80% of predicted cost 5 pound sterling to 10 pound sterling.
Trained practice assistants could check all patients who smoke for chronic obstructive pulmonary disease at little cost to the practice. Cough and age are the most important predictors of the disease. By testing one smoker a day, an average practice could identify one patient at risk a week.
Although inhaled corticosteroids are commonly used to treat patients with chronic obstructive pulmonary disease (COPD), their effect on clinical outcomes such as exacerbation and mortality is unknown. This systematic review was conducted to determine whether inhaled corticosteroids improve clinical outcomes for patients with stable COPD. All placebo-controlled randomized trials of inhaled corticosteroids given for at least 6 months for stable COPD were identified by searching MEDLINE (1966-2000), EMBASE (1980-2001), CINAHL (1982-2000), SIGLE (1980-2000), the Cochrane Controlled Trial Registry, and the bibliographies of published studies. We independently extracted data from each of the studies using a specified protocol, and determined the summary risk ratios (RRs) and 95% confidence intervals (CIs) for exacerbations and deaths. Nine randomized trials (3976 patients with COPD), including four with a systemic steroid run-in phase, were identified. Use of inhaled corticosteroid therapy reduced the rate of exacerbations (RR = 0.70; 95% CI: 0.58 to 0.84), with similar benefits in those who were and were not pretreated with systemic steroids. Inhaled corticosteroid therapy was also associated with increased rates of oropharyngeal candidiasis (RR = 2.1; 95% CI: 1.5 to 3.1), skin bruising (RR = 2.1; 95% CI: 1.6 to 2.8), and lower mean cortisol levels. No effects were seen on all-cause mortality (RR = 0.84; 95% CI: 0.60 to 1.18) in the five trials that measured this outcome. This systematic review demonstrates a beneficial effect of inhaled corticosteroids in reducing rates of COPD exacerbation. Further research is required to define the long-term effects of these medications and the benefit/risk ratio for patients with COPD.
This randomized controlled trial examined the benefits of combining an inhaled corticosteroid, fluticasone propionate (F), with an inhaled long-acting beta(2)-agonist, salmeterol (S), to treat the inflammatory and bronchoconstrictive components of chronic obstructive pulmonary disease (COPD). A total of 691 patients with COPD received the combination of F and S (FSC), S (50 mcg), F (500 mcg), or placebo twice daily via the Diskus device for 24 weeks. A significantly greater increase in predose FEV(1) at the endpoint was observed after FSC (156 ml) compared with S (107 ml, p = 0.012) and placebo (-4 ml, p < 0.0001). A significantly greater increase in 2-hour postdose FEV(1) at the endpoint was observed after treatment with FSC (261 ml) compared with F (138 ml, p < 0.001) and placebo (28 ml, p < 0.001). There were greater improvements in the Transition Dyspnea Index with FSC (2.1) compared with F (1.3, p = 0.033), S (0.9, p < 0.001), and placebo (0.4, p < 0.0001). The incidence of adverse effects (except for an increase in oral candidiasis with FSC and F) was similar among the treatment groups. We conclude that FSC improved lung function and reduced the severity of dyspnea compared with individual components and placebo.
Despite substantial evidence regarding the benefits of combined use of inhaled corticosteroids and long-acting beta2-agonists in asthma, such evidence remains limited for chronic obstructive pulmonary disease (COPD). Observational data may provide an insight into the expected survival in clinical trials of fluticasone propionate (FP) and salmeterol in COPD. Newly physician-diagnosed COPD patients identified in primary care during 1990-1999 aged > or = 50 yrs, of both sexes and with regular prescriptions of respiratory drugs were identified in the UK General Practice Research Database. Three-year survival in 1,045 COPD patients treated with FP and salmeterol was compared with that in 3,620 COPD patients who regularly used other bronchodilators but not inhaled corticosteroids or long-acting beta2-agonists. Standard methods of survival analysis were used, including adjustment for possible confounders. Survival at year 3 was significantly greater in FP and/or salmeterol users (78.6%) than in the reference group (63.6%). After adjusting for confounders, the survival advantage observed was highest in combined users of FP and salmeterol (hazard ratio (HR) 0.48 (95% confidence interval 0.31-0.73)), followed by users of FP alone (HR 0.62 (0.45-0.85)) and regular users of salmeterol alone (HR 0.79 (0.58-1.07)) versus the reference group. Mortality decreased with increasing number of prescriptions of FP and/or salmeterol. In conclusion, regular use of fluticasone propionate alone or in combination with salmeterol is associated with increased survival of chronic obstructive pulmonary disease patients managed in primary care.
Inhaled long-acting beta2 agonists improve lung function and health status in symptomatic chronic obstructive pulmonary disease (COPD), whereas inhaled corticosteroids reduce the frequency of acute episodes of symptom exacerbation and delay deterioration in health status. We postulated that a combination of these treatments would be better than each component used alone.
1465 patients with COPD were recruited from outpatient departments in 25 countries. They were treated in a randomised, double-blind, parallel-group, placebo-controlled study with either 50 microg salmeterol twice daily (n=372), 500 microg fluticasone twice daily (n=374), 50 microg salmeterol and 500 microg fluticasone twice daily (n=358), or placebo (n=361) for 12 months. The primary outcome was the pretreatment forced expiratory volume in 1s (FEV1) after 12 months treatment' and after patients had abstained from all bronchodilators for at least 6h and from study medication for at least 12h. Secondary outcomes were other lung function measurements, symptoms and rescue treatment use, the number of exacerbations, patient withdrawals, and disease-specific health status. We assessed adverse events, serum cortisol concentrations, skin bruising, and electrocardiograms. Analysis was as predefined in the study protocol.
All active treatments improved lung function, symptoms, and health status and reduced use of rescue medication and frequency of exacerbations. Combination therapy improved pretreatment FEV1 significantly more than did placebo (treatment difference 133 mL, 95% CI 105-161, p<0.0001), salmeterol (73 mL, 46-101, p<0.0001), or fluticasone alone (95 mL, 67-122, p<0.0001). Combination treatment produced a clinically significant improvement in health status and the greatest reduction in daily symptoms. All treatments were well tolerated with no difference in the frequency of adverse events, bruising, or clinically significant falls in serum cortisol concentration.
Because inhaled long-acting beta2 agonists and corticosteroid combination treatment produces better control of symptoms and lung function, with no greater risk of side-effects than that with use of either component alone, this combination treatment should be considered for patients with COPD.
Recent data suggest that inhaled corticosteroids reduce the number of clinical exacerbations in chronic obstructive pulmonary disease (COPD). It remains unknown whether a dose/response relationship exists. The present study was conducted to evaluate the long-term impact of varying doses of inhaled corticosteroids on COPD mortality. Hospital discharge data were used to identify all patients aged > or = 65 yrs recently hospitalised due to COPD in Alberta, Canada (n = 6,740). The relative risk (RR) for all-cause mortality was compared across different dose categories of inhaled corticosteroids (none and low, medium and high doses) following hospital discharge. Inhaled corticosteroid therapy after discharge was associated with a 25% relative reduction in risk for all-cause mortality (RR 0.75, 95% confidence interval (CI) 0.68-0.82). Patients on medium- or high-dose therapy showed lower risks for mortality than those on low doses (RR 0.77, 95% CI 0.69-0.86 for low dose; RR 0.48, 95% CI 0.37-0.63 for medium dose; and RR 0.55, 95% CI 0.44-0.69 for high dose). Use of inhaled corticosteroids following hospital discharge for chronic obstructive pulmonary disease was associated with a significant reduction in the overall mortality rate. Low- was inferior to medium- or high-dose therapy in protecting against mortality in chronic obstructive pulmonary disease.
This study attempted to determine the total direct costs derived from the management of chronic bronchitis and COPD in an ambulatory setting through a prospective, 1-year, follow-up study.
A total of 1,510 patients with chronic bronchitis and COPD were recruited from 268 general practices located throughout Spain. Patients were followed up for 1 year. All direct medical costs incurred by the cohort and related to their respiratory disease were quantified. Costs were calculated for patients with confirmed COPD according to the degree of severity of airflow obstruction.
The global mean direct yearly cost of chronic bronchitis and COPD was $1,876. The cost generated by patients with COPD was $1,760, but the cost of severe COPD ($2,911) was almost double that of mild COPD ($1,484). Hospitalization costs represented 43.8% of costs, drug acquisition costs were 40.8%, and clinic visits and diagnostic tests represented only 15.4% of costs.
This is the first prospective follow-up study on a large cohort of patients with chronic bronchitis and COPD aimed at quantifying direct medical costs under usual clinical practice in the community. Costs of chronic bronchitis and COPD were almost twofold those reported for asthma. Patterns of COPD management in the community differ from those recommended in guidelines. COPD represents a great health-care burden in developed countries, and aging of the population and continuing smoking habits predict that it will continue to do so in the future.
Lung-volume-reduction surgery has been proposed as a palliative treatment for severe emphysema. Effects on mortality, the magnitude and durability of benefits, and criteria for the selection of patients have not been established.
A total of 1218 patients with severe emphysema underwent pulmonary rehabilitation and were randomly assigned to undergo lung-volume-reduction surgery or to receive continued medical treatment.
Overall mortality was 0.11 death per person-year in both treatment groups (risk ratio for death in the surgery group, 1.01; P=0.90). After 24 months, exercise capacity had improved by more than 10 W in 15 percent of the patients in the surgery group, as compared with 3 percent of patients in the medical-therapy group (P<0.001). With the exclusion of a subgroup of 140 patients at high risk for death from surgery according to an interim analysis, overall mortality in the surgery group was 0.09 death per person-year, as compared with 0.10 death per person-year in the medical-therapy group (risk ratio, 0.89; P=0.31); exercise capacity after 24 months had improved by more than 10 W in 16 percent of patients in the surgery group, as compared with 3 percent of patients in the medical-therapy group (P<0.001). Among patients with predominantly upper-lobe emphysema and low exercise capacity, mortality was lower in the surgery group than in the medical-therapy group (risk ratio for death, 0.47; P=0.005). Among patients with non-upper-lobe emphysema and high exercise capacity, mortality was higher in the surgery group than in the medical-therapy group (risk ratio, 2.06; P=0.02).
Overall, lung-volume-reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity. Patients previously reported to be at high risk and those with non-upper-lobe emphysema and high base-line exercise capacity are poor candidates for lung-volume-reduction surgery, because of increased mortality and negligible functional gain.
The care of patients with chronic obstructive pulmonary disease (COPD) has changed radically over the past 2 decades, and novel therapies can not only improve the health status of patients with COPD but also modify its natural course.
To systematically review the impact of long-acting bronchodilators, inhaled corticosteroids, nocturnal noninvasive mechanical ventilation, pulmonary rehabilitation, domiciliary oxygen therapy, and disease management programs on clinical outcomes in patients with COPD.
MEDLINE and Cochrane databases were searched to identify all randomized controlled trials and systematic reviews from 1980 to May 2002 evaluating interventions in patients with COPD. We also hand searched bibliographies of relevant articles and contacted experts in the field.
We included randomized controlled trials that had follow-up of at least 3 months and contained data on at least 1 of these clinical outcomes: health-related quality of life, exacerbations associated with COPD, or death. For pulmonary rehabilitation, we included studies that had a follow-up of at least 6 weeks. Using standard meta-analytic techniques, the effects of interventions were compared with placebo or with usual care. In secondary analyses, the effects of interventions were compared against each other, where possible.
Long-acting beta2-agonists and anticholinergics (tiotropium) reduced exacerbation rates by approximately 20% to 25% (relative risk [RR] for long-acting beta2-agonists, 0.79; 95% CI, 0.69-0.90; RR for tiotropium, 0.74; 95% CI, 0.62-0.89) in patients with moderate to severe COPD. Inhaled corticosteroids also reduced exacerbation rates by a similar amount (RR, 0.76; 95% CI, 0.72-0.80). The beneficial effects were most pronounced in trials enrolling patients with FEV1 between 1 L and 2 L. Combining a long-acting beta2-agonist with an inhaled corticosteroid resulted in an approximate 30% (RR, 0.70; 95% CI, 0.62-0.78) reduction in exacerbations. Pulmonary rehabilitation improved the health status of patients with moderate to severe disease, but no material effect was observed on long-term survival or hospitalization rates. Domiciliary oxygen therapy improved survival by approximately 40% in patients with PaO2 lower than 60 mm Hg, but not in those without hypoxia at rest. The data on disease management programs were heterogeneous, but overall no effect was observed on survival or risk of hospitalization. Noninvasive mechanical ventilation was not associated with improved outcomes.
A significant body of evidence supports the use of long-acting bronchodilators and inhaled corticosteroids in reducing exacerbations in patients with moderate to severe COPD. Domiciliary oxygen therapy is the only intervention that has been demonstrated to prolong survival, but only in patients with resting hypoxia.
In patients with COPD who have recently been hospitalized for their disease, we examined whether treatment with inhaled corticosteroids without or with long-acting beta-adrenoceptor agonists (beta-agonists) reduced rehospitalization and mortality.
Retrospective cohort analysis in the UK General Practice Research Database.
We compared rehospitalization for a COPD-related medical condition or death within 1 year after first hospitalization, in 3636 COPD patients receiving prescriptions for inhaled corticosteroids or long-acting beta-agonists compared with 627 reference patients with COPD who were prescribed short-acting bronchodilators only.
Rehospitalization within a year occurred in 13.2% of the reference COPD patients, 14.0% of users of long-acting beta-agonists only, 12.3% of users of inhaled corticosteroids only, and 10.4% of users of inhaled corticosteroids and long-acting beta-agonists. Death within a year occurred in 24.3% of the reference COPD patients, 17.3% of users of long-acting beta-agonists only, 17.1% of users of inhaled corticosteroids only, and in 10.5% of users of inhaled corticosteroids and long-acting beta-agonists. In multivariate analyses the risk of rehospitalization or death was reduced by 10% in users of long-acting beta-agonists only (NS), by 16% in users of inhaled corticosteroids only, and by 41% in users of combined inhaled corticosteroids and long-acting beta-agonists (both p < 0.05).
Use of inhaled corticosteroids with/without long-acting beta-agonists was associated with a reduction of rehospitalization or death in COPD patients.
The airflow limitation that defines chronic obstructive pulmonary disease (COPD) is the result of a prolonged time constant for lung emptying, caused by increased resistance of the small conducting airways and increased compliance of the lung as a result of emphysematous destruction. These lesions are associated with a chronic innate and adaptive inflammatory immune response of the host to a lifetime exposure to inhaled toxic gases and particles. Processes contributing to obstruction in the small conducting airways include disruption of the epithelial barrier, interference with mucociliary clearance apparatus that results in accumulation of inflammatory mucous exudates in the small airway lumen, infiltration of the airway walls by inflammatory cells, and deposition of connective tissue in the airway wall. This remodelling and repair thickens the airway walls, reduces lumen calibre, and restricts the normal increase in calibre produced by lung inflation. Emphysematous lung destruction is associated with an infiltration of the same type of inflammatory cells found in the airways. The centrilobular pattern of emphysematous destruction is most closely associated with cigarette smoking, and although it is initially focused on respiratory bronchioles, separate lesions coalesce to destroy large volumes of lung tissue. The panacinar pattern of emphysema is characterised by a more even involvement of the acinus and is associated with alpha1 antitrypsin deficiency. The technology needed to diagnose and quantitate the individual small airway and emphysema phenotypes present in people with COPD is being developed, and should prove helpful in the assessment of therapeutic interventions designed to modify the progress of either phenotype.
Chronic obstructive pulmonary disease (COPD) is a readily diagnosable disorder that responds to treatment. Smoking cessation can reduce symptoms and prevent progression of disease. Bronchodilator therapy is key in improvement of lung function. Three classes of bronchodilators-beta agonists, anticholinergics, and theophylline-are available and can be used individually or in combination. Inhaled glucocorticoids can also improve airflow and can be combined with bronchodilators. Inhaled glucocorticoids, in addition, might reduce exacerbation frequency and severity as might some bronchodilators. Effective use of pharmacotherapy in COPD needs integration with a rehabilitation programme and successful treatment of co-morbidities, including depression and anxiety. Treatment for stable COPD can improve the function and quality of life of many patients, could reduce admissions to hospital, and has been suggested to improve survival.
To evaluate primary care physicians' knowledge of guidelines for the management of COPD.
Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital. Results: Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians.
This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs.
Randomized clinical trials have not yet demonstrated the mortality benefit of smoking cessation.
To assess the long-term effect on mortality of a randomly applied smoking cessation program.
The Lung Health Study was a randomized clinical trial of smoking cessation. Special intervention participants received the smoking intervention program and were compared with usual care participants. Vital status was followed up to 14.5 years.
10 clinical centers in the United States and Canada.
5887 middle-aged volunteers with asymptomatic airway obstruction.
All-cause mortality and mortality due to cardiovascular disease, lung cancer, and other respiratory disease.
The intervention was a 10-week smoking cessation program that included a strong physician message and 12 group sessions using behavior modification and nicotine gum, plus either ipratropium or a placebo inhaler.
At 5 years, 21.7% of special intervention participants had stopped smoking since study entry compared with 5.4% of usual care participants. After up to 14.5 years of follow-up, 731 patients died: 33% of lung cancer, 22% of cardiovascular disease, 7.8% of respiratory disease other than cancer, and 2.3% of unknown causes. All-cause mortality was significantly lower in the special intervention group than in the usual care group (8.83 per 1000 person-years vs. 10.38 per 1000 person-years; P = 0.03). The hazard ratio for mortality in the usual care group compared with the special intervention group was 1.18 (95% CI, 1.02 to 1.37). Differences in death rates for both lung cancer and cardiovascular disease were greater when death rates were analyzed by smoking habit.
Results apply only to individuals with airway obstruction.
Smoking cessation intervention programs can have a substantial effect on subsequent mortality, even when successful in a minority of participants.
Chronic obstructive pulmonary disease (COPD) is a multicomponent disease. These components affect both the lungs and organs outside the lungs (the so-called systemic effects of COPD) and can be of either a structural (including airway remodelling, emphysema, skeletal muscle wasting) or functional nature (inflammation, apoptosis, senescence). Further, these components are interdependent in a closely linked 'vicious cycle'. Accordingly, optimal therapies should therefore aim to address more than one of these components to break such a cycle. This needs to be considered not only in the development of future treatments but also in the current clinical management of patients with COPD. In this paper, evidence that supports the concept that COPD is a multicomponent disease is presented. The effects of currently available therapeutic options, including long-acting anticholinergics and long-acting beta2-agonist/inhaled corticosteroid combination therapies, upon each of these components is reviewed. In addition, potential new avenues for drug development and improved patient care are highlighted. By developing a better understanding of how different therapies impact upon the 'vicious cycle' of COPD, treatment regimens can be optimised to provide the greatest benefits to patients.
Recent cohort studies in chronic obstructive pulmonary disease (COPD) have questioned the validity of previously reported associations between inhaled corticosteroids (ICS) and reductions in mortality and rehospitalization in observational studies. Using time-dependent versions of statistical survival models, these studies have suggested immortal time bias as responsible for the proposed beneficial association.
We explored the extent of this bias in a study of patients with COPD monitored for a year from COPD discharge with two designs free of any immortal time bias in the General Practice Research Database in the United Kingdom.
In Design 1, we used only patients whose treatment status was defined on the same day of discharge to obtain a matched cohort based on propensity scores, which were derived from the patient-level baseline characteristics. In Design 2, we identified all in the study cohort who experienced death or rehospitalization and then matched each case to up to four noncases by randomly sampling from the cohort risk sets without regard to treatment status.
The propensity scores matched cohort analysis of 786 patients without a wait time found a significant risk reduction associated with use of ICS: hazard ratio, 0.69 (95% confidence interval, 0.52-0.93). The matched nested case-control analysis of 2,222 patients, designed without regard to exposure status and hence free of immortal time bias, gave a similar association with exposure to ICS in the last 6-month period: hazard ratio, 0.71 (0.56-0.90).
We conclude that immortal time bias cannot account for the risk reduction associated with ICS exposure in observational studies.
Several observational studies suggest that therapy with inhaled corticosteroids (ICS) is associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD). However, none of these has reported survival data in COPD patients with respiratory insufficiency who require domiciliary oxygen therapy. The present study was conducted to examine the association between ICS and all-cause mortality in patients with severe COPD and chronic hypoxemia.
From a tertiary referral clinic, we identified 145 consecutive COPD patients who met the criteria for long-term oxygen therapy between 1996 and 2002. We compared the hazard ratio (HR) for all-cause mortality over 1 year between patients who were (n=55) and were not treated with ICS (n=90).
In a crude analysis, the use of ICS was associated with a HR of 0.38 (95% confidence interval (CI)=0.18-0.79). After adjustments for age, sex, use of oral steroids, and beta2-agonists, PaO2 and PaCO2, the HR was 0.46 (95% CI=0.21-0.98).
Our findings indicate that ICS may reduce all-cause mortality in patients with severe COPD and chronic hypoxemia, who require long-term domiciliary oxygen therapy. These data suggest that ICS may play an important role in improving clinical outcomes in patients with advanced COPD.
To test questions usable in an ambulatory clinic to identify persons likely to have chronic obstructive pulmonary disease (COPD).
Analyses were performed as part of a study to identify patients with likely COPD in the Glenfield UK primary care clinic. Patients age 40 and older were recruited based on one of the following criteria: (1) respiratory medications in previous 2 years; (2) history of smoking or (3) history of asthma with no current medications based on case notes. Consenting patients reported smoking history, symptoms, and personal and family history of respiratory conditions. Spirometry with reversibility was conducted to ATS standards. Analyses were performed on this database to test questions for identifying patients with COPD from a sample of patients with a positive smoking history. Multivariate logistic regression identified the question set that best discriminated COPD from other conditions using receiver operating characteristic curves. The usefulness of a simple scoring system was assessed.
The study sample included 369 current and former smokers. Patients were diagnosed as: COPD=62 (16.8%); asthma=30 (8.1%); or no obstructive lung disease=277 (75.1%). The best questions for discriminating between persons with and without COPD included items on age, dyspnoea on exertion, and wheeze. This set of questions identified COPD patients with a sensitivity of 77.4--87.1% and specificity of 71.3--76.2%.
A simple questionnaire can facilitate the diagnosis of COPD in a primary care setting.