Chronic Obstructive Pulmonary Disease In Primary Care Research Articles

Exploring the causes of COPD misdiagnosis in primary care: A mixed methods study.

Within primary care there exists a cohort of patients misdiagnosed with Chronic Obstructive Pulmonary Disease (COPD). Misdiagnosis can have a detrimental impact on healthcare finances and patient health and so understanding the factors leading to misdiagnosis is crucial in order to reduce misdiagnosis in the future. The objective of this study is to understand and explore the perceived causes of COPD misdiagnosis in primary care. A sequential mixed methods study, quantifying prevalence and features of patients misdiagnosed with COPD in primary care followed by a qualitative analysis to explore perceived causes of misdiagnosis. Quantitative data was collected for 206 patients identified as misdiagnosed with COPD within the INTEGR COPD study (NCT03482700). Qualitative data collected from 21 healthcare professionals involved in providing COPD care and 8 misdiagnosed patients who were recruited using a maximum variation purposive sampling. Misinterpretation of spirometry results was the prevailing factor leading to patients initially being misdiagnosed with COPD, affecting 59% of misdiagnosed patients in this cohort. Of the 99 patients who were investigated for their underlying diagnosis; 41% had normal spirometry and 40% had asthma. Further investigation through qualitative methodology uncovered reluctance to challenge historical misdiagnoses and challenges in differential diagnosis as the underlying explanations for COPD misdiagnosis in this cohort. Patients historically diagnosed with COPD without spirometric evidence are at risk of remaining labelled and treated for COPD despite non-obstructive respiratory physiology, leading to a persistent cohort of patients misdiagnosed with COPD in primary care. The lack of spirometry services during and after the COVID19 pandemic in primary care risks adding to the cohort of misdiagnosed patients. Support from respiratory specialists can potentially help to reduce the prevalence of COPD misdiagnosis in primary care. NCT03482700.

Assessment of Obstructive Sleep Apnea Among Patients With Chronic Obstructive Pulmonary Disease in Primary Care.

Observational studies link untreated obstructive sleep apnea (OSA) with adverse outcomes in chronic obstructive pulmonary disease (COPD). The first step in addressing OSA is a clinical assessment. However, given competing demands and a lack of high-quality evidence, it is unclear how often such assessments occur. We explored the documentation of OSA assessment among patients with COPD in primary care, and the patient and provider characteristics associated with these assessments. We conducted a cross-sectional study of patients with clinically diagnosed COPD at 2 primary care practices. We abstracted charts to determine whether providers assessed OSA, defined as documentation of symptoms, treatment, or a referral to sleep medicine. We performed multivariable mixed-effects logistic regression to assess the associations of patient and provider characteristics with OSA assessment. Among 641 patients with clinically diagnosed COPD, 146 (23%) had OSA assessed over a 1-year period. Positive associations with OSA assessment included body mass index ≥ 30 (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-7.0), pulmonary subspecialist visits (OR 3.9, 95%CI 2.4-6.3), and a prior sleep study demonstrating OSA documented within the electronic medical record (OR 18.0, 95%CI 9.0-35.8). Notably, patients identifying as Black were less likely to have OSA assessed than those identifying as White (OR 0.5, 95%CI 0.2-0.9). Providers document an assessment of OSA among a quarter of patients with COPD. Our findings highlight the importance of future work to rigorously test the impact of assessment on important health outcomes. Our findings also reinforce that additional strategies are needed to improve the equitable delivery of care.

Diagnostic yield of a proactive strategy for early detection of cardiovascular disease versus usual care in adults with type 2 diabetes or chronic obstructive pulmonary disease in primary care in the Netherlands (RED-CVD): a multicentre, pragmatic, cluster-randomised, controlled trial

Progressive cardiovascular diseases (eg, heart failure, atrial fibrillation, and coronary artery disease) are often diagnosed late in high-risk individuals with common comorbidities that might mimic or mask symptoms, such as chronic obstructive pulmonary disease (COPD) and type 2 diabetes. We aimed to assess whether a proactive diagnostic strategy consisting of a symptom and risk factor questionnaire and low-cost and accessible tests could increase diagnosis of progressive cardiovascular diseases in patients with COPD or type 2 diabetes in primary care. In this multicentre, pragmatic, cluster-randomised, controlled trial (RED-CVD), 25 primary care practices in the Netherlands were randomly assigned to usual care or a proactive diagnostic strategy conducted during routine consultations and consisting of a validated symptom questionnaire, followed by physical examination, N-terminal-pro-B-type natriuretic peptide measurement, and electrocardiography. We included adults (≥18 years) with type 2 diabetes, COPD, or both, who participated in a disease management programme. Patients with an established triple diagnosis of heart failure, atrial fibrillation, and coronary artery disease were excluded. In the case of abnormal findings, further work-up or treatment was done at the discretion of the general practitioner. The primary endpoint was the number of newly diagnosed cases of heart failure, atrial fibrillation, and coronary artery disease, adjudicated by an expert clinical outcome committee using international guidelines, at 1-year follow-up, in the intention-to-treat population. Between Jan 31, 2019, and Oct 7, 2021, we randomly assigned 25 primary care centres: 11 to usual care and 14 to the intervention. We included patients between June 21, 2019, and Jan 31, 2022. Following exclusion of ineligible patients and those who did not give informed consent, 1216 participants were included: 624 (51%) in the intervention group and 592 (49%) in the usual care group. The mean age of participants was 68·4 years (SD 9·4), 482 (40%) participants were female, and 734 (60%) were male. During 1 year of follow-up, 50 (8%) of 624 participants in the intervention group and 18 (3%) of 592 in the control group were newly diagnosed with heart failure, atrial fibrillation, or coronary artery disease (adjusted odds ratio 2·97 [95% CI 1·66-5·33]). This trial is registered with the Netherlands Trial Registry, NTR7360, and was completed on Jan 31, 2023. An easy-to-use, proactive, diagnostic strategy more than doubled the number of new diagnoses of heart failure, atrial fibrillation, and coronary artery disease in patients with type 2 diabetes or COPD in primary care compared with usual care. Although the effect on patient outcomes remains to be studied, our diagnostic strategy might contribute to improved early detection and timely initiation of treatment in individuals with cardiovascular disease. Dutch Heart Foundation.

The Influence of Social Support in PROMs of Patients with COPD in Primary Care: A Scoping Review.

Chronic obstructive pulmonary disease (COPD) is a prevalent and multidimensional disease with symptoms that greatly influence patients' health. Healthcare professionals utilize patient-reported outcome measures (PROMs) to classify and better manage the disease. Despite the value of PROMs, they inadequately represent some important dimensions of COPD, like social support and healthcare access/utilization. This is important, especially for social support, since it can positively influence PROMs results and the overall health of patients with COPD. Therefore, a scoping review was conducted to determine how social support affects PROMs of patients with COPD in primary care. The PRISMA-Scoping approach was adopted, and we sought articles published in MEDLINE and COHRANE. We screened 2038 articles for inclusion and finally included a total of 10 articles. Most of the articles were conducted in the U.S. and Norway. Social support had a strong positive impact on PROMs. Additionally, different types of social support were observed. Moreover, higher levels of social support were linked to better quality of life, mental health, self-care behaviors, self-management, functionality, and less severe COPD. Consequently, this scoping review highlights the value of social support in patients with COPD and its underrepresentation and misrepresentation in PROMs literature.

Acceptability and barriers of a GP-physiotherapist partnership in the diagnosis and management of COPD in primary care: A qualitative study.

Chronic obstructive pulmonary disease (COPD) is commonly diagnosed and managed in primary care but there is evidence that this has been suboptimal, with low confidence expressed in providing interventions requiring behaviour change. The aim of this study was to determine the acceptability of a general practitioner (GP)-physiotherapist partnership in the diagnosis and management of COPD in primary care and to explore the experiences of participants during the implementation of the model. Semi-structured interviews were conducted with physiotherapists (n = 3), GPs (n = 2), practice nurses (PNs) (n = 2) and patients (n = 12) who had participated in the InNovaTivE Gp-physiotheRapist pArTnErship for copD (INTEGRATED) trial. We sought to explore participants' views about their experiences and perceived benefits, barriers and facilitators to the implementation of this model of care. Interviews were transcribed, coded and thematically analysed. Synthesis of the data was guided by the Theoretical Domains Framework for clinician interviews and the health belief model for patient interviews. All clinicians felt that this integrated model helped to optimise care for patients with COPD by facilitating evidence-based practice. GPs and PNs valued the physiotherapist's knowledge and skills relating to diagnosis and management, which was reported to complement their own management and improve patient outcomes. Patients reported a sense of empowerment following their appointments and acknowledged improved self-management skills. However, physiotherapists reported many patients were already engaging in positive health behaviours. Responses were mixed on the effectiveness of the model in facilitating teamwork between clinicians with different perspectives concerning management, communication pathways and logistical issues, such as time and room availability, being cited as barriers. An experienced cardiorespiratory physiotherapist embedded into a small number of primary care practices to work in partnership with GPs for COPD diagnosis and management was acceptable and viewed as beneficial for patients. Barriers relating to logistics and resources remain, which must be addressed to optimise implementation. Patient input was obtained from qualitative feedback from a prior study conducted by two authors and was used to refine the model of care to determine the added value of a physiotherapist integrated into the primary care team. This feedback was also used to refine the interview guides utilised in this study determine the acceptability of this model of care. We had health service involvement from the rehabilitation service of the local health district who were directly involved in determining study aims and establishing the project around the priorities for their chronic disease integration service. For example, this project aimed to engage with a less severe patient population in primary care who would benefit from pulmonary rehabilitation. The findings from this study will be used to further tailor the model of care to the needs of the public and patients. ACTRN12619001127190.

Overcoming the Digital Divide for Older Patients With Respiratory Disease: Focus Group Study.

The need for and adoption of eHealth programs are growing worldwide. However, access can be limited among patients with low socioeconomic backgrounds, often resulting in a so-called "digital divide" due to a mismatch between eHealth and target populations that can gain benefit. This digital divide can result in unsuccessful eHealth implementations, which is of critical importance to health care. This study evaluated the opinions of elderly patients with asthma and chronic obstructive pulmonary disease (COPD) about an existing pharmacy-based personalized patient web portal that provides medication overview and information on associated diagnoses. The aim was to obtain insights on the common barriers of elderly people when using health-related websites, which can help to improve accessibility. This was a cross-sectional qualitative study of a patient panel of the Groningen Research Institute for Asthma and COPD in primary care. Participants were required to be older than 55 years, be Dutch speaking, have no prior experience with the study website, and be diagnosed with a chronic respiratory illness. Two focus groups were created, and they completed a 45-minute session for testing the website and a 120-minute session for semistructured interviews. The focus group sessions were recorded, transcribed verbatim, and analyzed by content analysis. We enrolled 11 patients (9 women) with a mean age of 66 (SD 9) years. Of these, 5 had asthma, 3 had COPD, 2 had asthma-COPD overlap syndrome, and 1 had bronchiectasis. Participants were generally positive about the website, especially the areas providing disease-related information and the medication overview. They appreciated that the website would enable them to share this information with other health care providers. However, some difficulties were reported with navigation, such as opening a new tab, and others reported that the layout of the website was difficult either because of visual impairments or problems with navigation. It was also felt that monitoring would only be relevant if it is also checked by health care professionals as part of a treatment plan. Participants mentioned few privacy or safety concerns. It is feasible to develop websites for elderly patients; however, developers must take the specific needs and limitations of elderly people into account (eg, navigation problems, poor vision, or poor hand-eye coordination). The provision of information appears to be the most important aspect of the website, and as such, we should endeavor to ensure that the layout and navigation remain basic and accessible. Patients are only motivated to use self-management applications if they are an integrated part of their treatment. The usability of the website can be improved by including older people during development and by implementing design features that can improve accessibility in this group.

The effects of an innovative GP-physiotherapist partnership in improving COPD management in primary care

BackgroundEvidence suggests that management of people with Chronic Obstructive Pulmonary Disease (COPD) in primary care has been suboptimal, in particular, with low referral rates to pulmonary rehabilitation (PR). The aim of this study was to evaluate the effectiveness of a GP-physiotherapist partnership in optimising management of COPD in primary care.MethodsA pragmatic, pilot, before and after study was conducted in four general practices in Australia. A senior cardiorespiratory physiotherapist was partnered with each general practice. Adults with a history of smoking and/or COPD, aged ≥ 40 years with ≥ 2 practice visits in the previous year were recruited following spirometric confirmation of COPD. Intervention was provided by the physiotherapist at the general practice and included PR referral, physical activity and smoking cessation advice, provision of a pedometer and review of inhaler technique. Intervention occurred at baseline, one month and three months. Main outcomes included PR referral and attendance. Secondary clinical outcomes included changes in COPD Assessment Test (CAT) score, dyspnoea, health activation and pedometer step count. Process outcomes included count of initiation of smoking cessation interventions and review of inhaler technique.ResultsA total of 148 participants attended a baseline appointment where pre/post bronchodilator spirometry was performed. 31 participants with airflow obstruction on post-bronchodilator spirometry (mean age 75yrs (SD 9.3), mean FEV1% pred = 75% (SD 18.6), 61% female) received the intervention. At three months, 78% (21/27) were referred to PR and 38% (8/21) had attended PR. No significant improvements were seen in CAT scores, dyspnoea or health activation. There was no significant change in average daily step count at three months compared to baseline (mean difference (95% CI) -266 steps (-956 to 423), p = 0.43). Where indicated, all participants had smoking cessation interventions initiated and inhaler technique reviewed.ConclusionThe results of this study suggest that this model was able to increase referrals to PR from primary care and was successful in implementing some aspects of COPD management, however, was insufficient to improve symptom scores and physical activity levels in people with COPD.Trial registrationANZCTR, ACTRN12619001127190. Registered 12 August 2019 – Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx.

Efficacy and safety of oral corticosteroids to treat outpatients with acute exacerbations of COPD in primary care: a multicentre pragmatic randomised controlled study.

To compare prednisone and placebo for the treatment of outpatients treated for acute exacerbations of chronic obstructive pulmonary disease (COPD) in a primary care setting. A multicentre, parallel, double-blind, pragmatic randomised controlled trial was performed in France. A total of 66 general practitioners included patients aged ≥40 years with cumulative smoking of ≥10 pack-years and a diagnosis of certain or likely acute exacerbation of COPD. Oral prednisone (40 mg) or placebo were administered daily for 5 days. The main outcome was treatment failure at 8 weeks, defined as a composite criterion based on the occurrence of at least one of the following: unplanned visit to an emergency department or to a practitioner in the ambulatory setting, hospital admission or death. The planned sample size was 202 patients per group. 175 patients were included from February 2015 to May 2017 (43% of the planned sample). All-cause 8-week treatment failure rate was 42.0% in the prednisone group and 34.5% in the placebo group (relative risk 1.22, 95% CI 0.87-1.69, p=0.25). Respiratory-related 8-week treatment failure rate was 27.6% in the prednisone group and 13.6% in the placebo group (relative risk 2.00, 95% CI 1.15-3.57, p=0.015). Although the planned sample size was not achieved, the study does not suggest that oral corticosteroids are more effective than placebo for the treatment of an acute exacerbation of COPD in a primary care setting.

Cause-specific mortality in COPD subpopulations: a cohort study of 339 647 people in England

BackgroundIdentifying correlates of cause-specific mortality in patients with chronic obstructive pulmonary disease (COPD) may aid the targeting of therapies to reduce mortality. We determined factors associated with causes of death...

Implementierung einer elektronischen Entscheidungshilfe zur Unterstützung der Behandlungsqualität der COPD in der Hausarztmedizin

BackgroundElectronic clinical decision aids (eCDAs) have the potential to improve the quality of chronic disease management (CDM) and, therefore, patient relevant outcomes. However, eCDAs are only sparsely implemented in primary care for chronic obstructive pulmonary disease (COPD). The aim of this pilot study was to develop and implement of an eCDA for COPD primary care in two Swiss primary care practices. MethodTwo primary care practices, each with five primary care physicians and their assistants, participated in the study. The eCDA was developed in collaboration with one of the two GP practices (Practice 1) following a development cycle encompassing alpha- and beta-testing stages. Long-term testing for one year was conducted in both practices. The implementation of the eCDA was evaluated according to the RE-AIM framework counting occurrences as follows: Reach: the number of patients included in the CDM using the eCDA. Effectiveness: the number of treatment processes initiated per patient. Adoption: practice utilization of the diverse functions featured in the eCDA. Implementation and Maintenance: health care professionals’ attitudes towards the impact of the eCDA on the quality of care and their willingness to continue using the eCDA after long-term testing. Data were collected by the eCDA itself, which was programmed to track user data, and from practice staff using questionnaires. ResultsReach: After the long-term test, the number of patients recorded in the eCDA was 28 in practice 1, and 12 in practice 2. Effectiveness: The number of evidence-based treatment processes per patient was 14 (IQR 6 to 22) in Practice 1 and 6 (IQR 5 to 8) in Practice 2. Adoption: The utilization profiles of the eCDA differed greatly between practices. Implementation and Maintenance: After the long-term test, respondents were more critical of the quality of the CDM for patients with COPD, and attitudes consistent with interprofessional care were more prevalent compared to baseline. Respondents were optimistic regarding both the potential of the eCDA to improve the quality of CDM and their motivation to continue using the eCDA after long-term testing. ConclusionThis pilot study is a roadmap for future projects aiming to develop and implement eCDAs for the CDM of COPD in primary care. Future larger implementation studies in this domain should place greater emphasis on the measurement of structural practice characteristics as potential determinants of patient-relevant outcomes. The modifiable determinants should then be tested for their effects on patient-relevant outcomes in a randomized controlled design.

Characteristics of New Users of Single- and Multiple-Inhaler Triple Therapy for COPD in Primary Care in England.

PurposeInhaled triple therapy is recommended for patients with chronic obstructive pulmonary disease (COPD) who have poorly controlled symptoms and to reduce the risk of exacerbations. This study assessed the clinical characteristics of new users of single- and multiple-inhaler triple therapy (SITT and MITT) treated in a primary care setting in England.Patients and MethodsThis cross-sectional, observational study used data from an electronic health record database (CPRD Aurum) of COPD patients registered with a primary care practice in England, with linkage to a secondary care database. Patients were required to have initiated a new triple therapy (index) between November 2017 and November 2018 and have ≥12 months of available medical history prior to the index date.ResultsIn total, 3536 patients initiated fluticasone furoate, umeclidinium, and vilanterol (FF/UMEC/VI) SITT for the first time: 65% had a Medical Research Council (MRC) dyspnea score ≥3, 45% had forced expiratory volume in 1 second (FEV1)% predicted <50%, and 64% had a moderate or severe exacerbation in the previous 12 months. The majority (83%) of new FF/UMEC/VI users had a history of MITT use. Immediately prior to FF/UMEC/VI initiation, 46% received MITT, 25% received an inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA), 12% received long-acting muscarinic antagonist (LAMA)/LABA, and 14% stepped up directly from LAMA monotherapy. A second cohort of 6540 patients initiated triple therapy (SITT or MITT) for the first time. COPD severity (airflow limitation, exacerbation history) was worse among patients initiating SITT versus MITT. In the 12 months before triple-therapy initiation, ICS/LABA was the most common treatment; a step up from LAMA/LABA was more common among patients initiating FF/UMEC/VI (34%) or beclomethasone/formoterol/glycopyrronium bromide SITT (25%) than MITT (14%).ConclusionFirst-time triple therapy was frequently initiated in patients with COPD inadequately controlled on maintenance therapy. General practitioners in England generally identify appropriate patients who require initiation of triple therapy.

Development and validation of a multivariable mortality risk prediction model for COPD in primary care

Risk stratification of chronic obstructive pulmonary disease (COPD) patients is important to enable targeted management. Existing disease severity classification systems, such as GOLD staging, do not take co-morbidities into account despite their high prevalence in COPD patients. We sought to develop and validate a prognostic model to predict 10-year mortality in patients with diagnosed COPD. We constructed a longitudinal cohort of 37,485 COPD patients (149,196 person-years) from a UK-wide primary care database. The risk factors included in the model pertained to demographic and behavioural characteristics, co-morbidities, and COPD severity. The outcome of interest was all-cause mortality. We fitted an extended Cox-regression model to estimate hazard ratios (HR) with 95% confidence intervals (CI), used machine learning-based data modelling approaches including k-fold cross-validation to validate the prognostic model, and assessed model fitting and discrimination. The inter-quartile ranges of the three metrics on the validation set suggested good performance: 0.90–1.06 for model fit, 0.80–0.83 for Harrel’s c-index, and 0.40–0.46 for Royston and Saurebrei’s R_D^2 with a strong overlap of these metrics on the training dataset. According to the validated prognostic model, the two most important risk factors of mortality were heart failure (HR 1.92; 95% CI 1.87–1.96) and current smoking (HR 1.68; 95% CI 1.66–1.71). We have developed and validated a national, population-based prognostic model to predict 10-year mortality of patients diagnosed with COPD. This model could be used to detect high-risk patients and modify risk factors such as optimising heart failure management and offering effective smoking cessation interventions.

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

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

Improved health status of severe COPD patients after being included in an integrated primary care service: A prospective cohort study

Background Chronic obstructive pulmonary disease (COPD) is a prevalent lung disease. It is assumed that severe patients will receive better treatment in specialised care centres but the prevalence of severe COPD in primary care is high. Integrated primary care services combine input from several sources and advice from pulmonologists to provide general practitioners with support needed to improve diagnosis and treatment of patients with COPD. Objectives To evaluate patient-reported outcomes and costs of managing patients classified as GOLD D in an integrated primary care service over 12 months. Methods Patients were included in this 1-year prospective cohort study if they met the 2014 GOLD D criteria, were aged ≥ 40 years and gave written informed consent for this study. Recruitment took place through the patients’ general practitioners. The primary outcome was health status, assessed with the Clinical COPD Questionnaire (CCQ) and COPD Assessment Test (CAT). Secondary outcomes included self-reported exacerbations, quality-adjusted life years and health(care)-related costs. Results Forty-nine patients were included. At baseline, the mean CAT score was 15.9 and the median CCQ score was 1.7. After 12 months, scores had improved by 2.3 (95% confidence interval, 0.8–3.7) and 0.4 (95% confidence interval, 0.2–0.7), respectively. Percentage of patients with ≥2 exacerbations in the past 12 months also decreased from baseline (77.6%) to 12 months (16.7%). Changes in mean quarterly costs were small. Conclusion An integrated service for COPD based in primary care may improve the health status of patients with a large burden of disease while not increasing health care costs.

Identifying patients with first chronic obstructive pulmonary disease diagnosis in routine databases: a descriptive study

BackgroundThere were about 850 000 people diagnosed with chronic obstructive pulmonary disease (COPD) in England in 2018, and possibly twice as many remain undiagnosed. Starting with the patient's first record of COPD, this study aimed to identify changes in diagnosis, management, and outcomes in COPD over time. MethodsIn this descriptive study, we identified each patient's first record of COPD in primary or secondary care during April 1, 2005, and March 31, 2007 (cohort 1), and during April 1, 2015, and March 31, 2017 (cohort 2). We used the Clinical Practice Research Datalink (CPRD) GOLD database, which contains anonymised patient-level records from a sample of general practices in the UK that use Vision software. General practice records are linked to the Hospital Episode Statistics database, which captures all admissions to English hospitals. The record of COPD was identified with predefined Read and International Classification of Diseases 10 (known as ICD-10) codes. The research protocol was approved by the Independent Scientific Advisory Committee for the Medicines and Healthcare products Regulatory Agency database research (protocol number 19_116). FindingsWe included 37 268 patients with incident COPD (19 266 males and 18 002 female); 57·4% (n=21 392) were from cohort 2. For 24 649 patients (66·1%), the diagnosis was first recorded in secondary care: 40·9% (n=6489 of 15 876) in cohort 1 compared with 84·9% (n=18 160 of 21 392) in cohort 2. However, 14·5% (n=2295) in cohort 1 and 43·0% (n=9207) in cohort 2 transferred out from their general practice before their first COPD record; most of these patients had their first COPD diagnosis in secondary care. More than half of patients with their diagnosis in secondary care had COPD recorded not as a primary diagnosis (51·6% [n=3347] in cohort 1 vs 63·3% [n=11 495] in cohort 2), casting doubt on the diagnosis. For 11 242 patients from cohort 2 with COPD in secondary care, general practices stopped submitting data to CPRD before the COPD diagnosis; consequently, an initial diagnosis could have been made between the time that the practice stopped submitting data and the hospital admission. InterpretationThe background and context of data entry or coding can have an impact on the interpretation of diagnostic data in administrative datasets. When diagnostic codes are used as a starting point for examination of trends in COPD diagnosis and management with CPRD, care is needed to overcome various potentially misleading data artifacts. FundingThis study is funded by the National Institute for Health Research Health Services and Delivery Research stream. The views expressed in this Abstract are those of the authors.

Impact of PIF, Inhalation Technique and Medication Adherence on Health Status and Exacerbations in COPD: Protocol of a Real-World Observational Study (PIFotal COPD Study).

IntroductionDry powder inhalers (DPIs), a commonly prescribed inhaler type for respiratory diseases, require patients to generate sufficient peak inspiratory flow (PIF) to ensure optimal drug delivery to the airways. Effectiveness of therapy also requires a good inhalation technique and adequate medication adherence. For patients with chronic obstructive pulmonary disease (COPD), recent studies conducted in tertiary care suggest that DPI users with suboptimal PIF have poorer COPD-related health status and increased exacerbation risk versus those with optimal PIF. The PIFotal study will investigate the impact of PIF, inhalation technique and medication adherence on patient-reported outcomes in patients with COPD in primary care using a DPI for their maintenance therapy.Methods and AnalysisThis cross-sectional observational study will assess 1200 patients (aged ≥ 40 years, diagnosed with COPD and using a DPI for COPD maintenance therapy for ≥ 3 months) from the Netherlands, Spain, Portugal, Poland, Greece and Australia. Assessments will consist of (1) PIF measurements (usual patient inhalation manoeuvre, maximal PIF against resistance of own inhaler, and maximal PIF against low resistance); (2) Clinical COPD Questionnaire (CCQ), COPD Assessment Test and Test of Adherence to Inhalers scores; and (3) video recordings of patient inhalation technique. Dependent variables include health status (CCQ score), number of self-reported exacerbations in previous 12 months, and healthcare resource utilisation in previous 6 months. Independent variables include PIF values, inhalation technique errors, medication adherence, and demographic and clinical characteristics. In the primary analysis, the mean difference in CCQ score between patients (1) with optimal/suboptimal PIF, (2) exhibiting/not exhibiting inhalation technique errors, and (3) adhering/not adhering to medication will be examined in a multivariable linear mixed model.EthicsThe study protocol was approved by ethics committees/institutional review boards of all participating sites prior to enrolment; written informed consent was obtained from all study participants.Trial Registration NumberClinicalTrials.gov: NCT04532853.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41030-021-00172-7.

CONQUEST Quality Standards: For the Collaboration on Quality Improvement Initiative for Achieving Excellence in Standards of COPD Care.

BackgroundChronic obstructive pulmonary disease (COPD) are managed predominantly in primary care. However, key opportunities to optimize treatment are often not realized due to unrecognized disease and delayed implementation of appropriate interventions for both diagnosed and undiagnosed individuals. The COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST) is the first-of-its-kind, collaborative, interventional COPD registry. It comprises an integrated quality improvement program focusing on patients (diagnosed and undiagnosed) at a modifiable and higher risk of COPD exacerbations. The first step in CONQUEST was the development of quality standards (QS). The QS will be imbedded in routine primary and secondary care, and are designed to drive patient-centered, targeted, risk-based assessment and management optimization. Our aim is to provide an overview of the CONQUEST QS, including how they were developed, as well as the rationale for, and evidence to support, their inclusion in healthcare systems.MethodsThe QS were developed (between November 2019 and December 2020) by the CONQUEST Global Steering Committee, including 11 internationally recognized experts with a specialty and research focus in COPD. The process included an extensive literature review, generation of QS draft wording, three iterative rounds of review, and consensus.ResultsFour QS were developed: 1) identification of COPD target population, 2) assessment of disease and quantification of future risk, 3) non-pharmacological and pharmacological intervention, and 4) appropriate follow-up. Each QS is followed by a rationale statement and a summary of current guidelines and research evidence relating to the standard and its components.ConclusionThe CONQUEST QS represent an important step in our aim to improve care for patients with COPD in primary and secondary care. They will help to transform the patient journey, by encouraging early intervention to identify, assess, optimally manage and followup COPD patients with modifiable high risk of future exacerbations.

Identifying heart failure in patients with chronic obstructive lung disease through the Canadian Primary Care Sentinel Surveillance Network in British Columbia: a case derivation study.

Background:Heart failure (HF) poses a substantial global health burden, particularly in patients with chronic obstructive pulmonary disease (COPD). The objective of this study was to validate an electronic medical record–based definition of HF in patients with COPD in primary care practices in the province of British Columbia, Canada.Methods:We conducted a cross-sectional retrospective chart review from Sept. 1, 2018, to Dec. 31, 2018, for a cohort of patients from primary care practices in BC whose physicians were recruited through the BC node of the Canadian Primary Care Sentinel Surveillance Network. Heart failure case definitions were developed by combining diagnostic codes, medication information and laboratory values available in primary care electronic medical records. These were compared with HF diagnoses identified through detailed chart review as the gold standard. Sensitivity, specificity, negative (NPV) and positive predictive values (PPV) were calculated for each definition.Results:Charts of 311 patients with COPD were reviewed, of whom 72 (23.2%) had HF. Five categories of definitions were constructed, all of which had appropriate sensitivity, specificity and NPV. The optimal case definition consisted of 1 HF billing code or a specific combination of medications for HF. This definition had an excellent specificity (93.3%, 95% confidence interval [CI] 89.4%–96.1%), sensitivity (90.3%, 95% CI 81.0%–96.0%), PPV (80.2%, 95% CI 69.9%–88.3%) and NPV (97.0%, 95% CI 93.8%–98.8%).Interpretation:This comprehensive case definition improves upon previous primary care HF definitions to include medication codes and laboratory data, along with previously used billing codes. A case definition for HF was derived and validated and can be used with data from electronic medical records to identify HF in patients with COPD in primary care accurately.

The Cost of Chronic Obstructive Pulmonary Disease (COPD) in Compliant Versus Non-Compliant Patients

A literature review conducted, on the cost of Chronic Obstructive Pulmonary Disease (COPD) between patients who are compliant versus non-compliant, reflects on the data for the United States with an emphasis on the areas within the Florida Panhandle. An overview of costs associated with noncompliant COPD patients and strategies for encouraging patients to adhere to treatment and improve healthcare outcomes is provided. A review of recent peer-reviewed articles was performed to determine the additional costs associated with non-compliance. The direct cost of COPD was estimated at $6,246 per patient annually. Nationally projected expenditures for COPD were $49.9 billion in 2010, while costs in Florida were $2.5 billion. Florida’s costs for COPD management ranks much higher than the national average. Potential causes for the differentiation are associated with newer medications and devices that contribute to a higher out-of-pocket expense for patients, patient denial about the seriousness of their illness, and/or inability to understand compliance with treatment. The relationship between the primary care provider and COPD patient is critical for adherence to therapy.

Diagnostic accuracy of screening tools for chronic obstructive pulmonary disease in primary health care: Rapid evidence synthesis.

Background:Chronic obstructive pulmonary disease (COPD) contributed significantly to burden of diseases in India, with missed, incorrect, and delayed diagnosis in primary care. We conducted a rapid evidence synthesis, to summarize the evidence on accuracy of the screening tests for COPD in primary health care on request form State Health Resource Centre, Chhattisgarh.Methods:Considering the rapid nature of decision making, our approach was to first search for existing systematic reviews. We identified one existing systematic review on the topic with the search conducted until 2014. We updated the review by searching in two major databases screened, title/abstracts, and full texts of studies as per eligibility criteria and extracted relevant data. A narrative synthesis was conducted.Results:We retrieved 7,007 and included five new studies, to add to 10 studies of the existing systematic review. Overall, 13 studies assessed diagnostic accuracy of screening questionnaires [e.g., COPD Diagnostic Questionnaire (CDQ)], five assessed handheld flow meters (COPD6 and PICO-6), and four assessed the combination of both the tests. The CDQ questionnaire using a score threshold ≥16.5 or >17 demonstrated comparatively a higher sensitivity both in pooled result for ever-smokers [87.5% (95% CI 83.1--90.9%)] and among the adults >35 years [73.8--93% (95% CI 69--98%)] when compared to a different score threshold of CDQ and other questionnaires. Handheld flow meters reported a pooled high sensitivity of 79.9% (95% CI 74.2--84.7%) in ever-smokers and 87.9% in adults with age >35 years.Conclusions:The need for better diagnosis of COPD in primary healthcare can be addressed by using of COPD Diagnostic Questionnaire alone or in combination with hand-held flow meters. There is scope for more implementation research on the domain.