Utilization in COPD: patient characteristics and diagnostic evaluation

Design of the Reducing Diagnostic Error to Improve Patient Safety (REDEfINE) in COPD and asthma study: A cluster randomized comparative effectiveness trial

Although spirometry is a simple, portable test and recommended for the diagnosis of asthma and chronic obstructive pulmonary disease (COPD), it is not routinely used in the primary care setting. Minorities and underserved populations are less likely to have spirometry assessment, leading to both over and misdiagnosis of asthma and COPD. Because dyspnea is a common symptom across multiple diseases, use of spirometry as a diagnostic tool is important. Missed, delayed, or misdiagnosis of asthma and COPD, which are considered diagnostic errors (DE), can lead to poor quality of care, increased morbidity and mortality, and increased costs to patients and health systems. Barriers to the use of spirometry have been identified at clinician/clinic and health systems levels. The REDEFINE program is designed to overcome identified barriers to spirometry use in primary care by utilizing health promoters (HPs) who perform spirometry within primary care clinics and work collaboratively with clinicians to incorporate the results at the point of care without interrupting clinic workflow. The REDEFINE trial is a comparative effectiveness study comparing outcomes of the REDEFINE program with usual care (UC) in primary care patients determined to be at increased risk of DE for asthma and COPD. The primary outcome will be all-cause hospitalizations. The secondary outcomes will be the proportion of accurate diagnosis of COPD, asthma, or asthma-COPD overlap based on initial diagnosis and spirometry and all cause and respiratory-related acute outpatient care and emergency department visits. In this report, we describe the design and methods for the REDEFINE trial. Trial registration: NCT03137303https://clinicaltrials.gov/ct2/show/NCT03137303?term=REDEFINE&draw=2&rank=1.

Sputum and salivary protein biomarkers and point-of-care biosensors for the management of COPD

Chronic obstructive pulmonary disease (COPD) has become one of the most fatal diseases of the century considering mortality and morbidity levels worldwide. This disease is an inflammatory response to environmental stress and tobacco smoking. Although spirometry is the gold-standard diagnostic test administrated in primary and secondary care, it often exhibits low accuracy in cases of predicting disease worsening and possible bias due to the operator, patient, and conditions. Recent developments in proteomics research suggest that the presence of protein biomarkers can aid in the accurate diagnosis and prediction of disease outcomes. This review presents the cutting-edge research progress in the area of protein biomarkers towards the management of COPD. The literature review was confined to protein biomarkers in saliva and sputum because testing these bodily fluids shows great promise for point-of-care (POC) testing due to its practicality, non-invasiveness and inexpensive handling and sampling. Although it is conclusive that more studies on sputum and saliva are needed, this review studies the promising clinical value of interleukin (IL)-6 and IL-8, matrix metalloproteinase (MMP)-8 and MMP-9, C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), and neutrophil elastase (NE). Following the critical analysis of salivary and sputum biomarkers, the recent development of POC biosensors for the multiplexed detection of biomarkers is also reported. Overall, the review aims to explore the possibility for the future development of POC sensors for chronic lung disease management utilizing clinically relevant biomarkers in saliva and sputum.

Electrochemical methods for detection of biomarkers of Chronic Obstructive Pulmonary Disease in serum and saliva

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death nowadays, and its underdiagnosis is still a great challenge. More effective diagnosis method is in urgent need since the traditional spirometry has many limitations in the practical application. The electrochemical (EC) detection methods have their unique advantages of high accuracy, short response time and easy integration of the system. In this review, recent works on the EC methods for COPD biomarkers including interleukin 6 (IL-6), interleukin 8 (IL-8) and C-reactive protein (CRP) are summarized. Five types of EC methods are highlighted in this study, as enzyme-labelled immunosensors, nanoparticle-labelled immunosensors, capacitive or impedimetric immunosensors, magnetoimmunosensors, and field effect transistor (FET) immunosensors. To date, EC immunosensors have been exhibiting high analytical performance with a detection limit that can achieve several pg/mL or even lower. The simplicity of EC immunosensors makes them a perfect solution for a future point-of-care device to use in settings for COPD diagnosis and follow-up. Nevertheless, more efforts need to be paid on the simultaneous detection of multiple biomarkers, a demand for the clinical diagnosis, and processes of assay simplification towards achieving one-step detection.

Prescription Status and Clinical Outcomes of Methylxanthines and Leukotriene Receptor Antagonists in Mild-to-Moderate Chronic Obstructive Pulmonary Disease

BACKGROUND

Methylxanthines and leukotriene receptor antagonists (LTRA) are not a first-line medical treatment for chronic obstructive pulmonary disease (COPD) but are frequently prescribed despite limited evidence. We aimed to elucidate the real prescribing status and clinical impacts of these agents in early COPD patients.

METHODS

Patients with mild-to-moderate COPD (FEV₁>50%) were selected from the Korean National Health and Nutrition Examination Survey data between 2007 and 2012. Besides analyzing the prescription status of methylxanthines and LTRA and the contributing factors to the prescription, we evaluated the clinical impacts of these drugs on the exacerbation, hospitalization, and medical costs.

RESULTS

Of 2269 patients with mild-to-moderate COPD, 378 patients (16.7%) were under medical treatments, and the users of methylxanthines and/or LTRA were 279 patients (12.3%); however, only 139 patients (6.1%) were inhaler users. The contributing factors for the prescription of methylxanthines were a comorbidity of asthma or allergic disease, poor lung function, low quality of life, prescribing doctor from the specialty of internal medicine, and an institution type of private hospital. The prescription of LTRA was associated with the comorbidity of allergic disease. The methylxanthine and/or LTRA users had more hospital utilization but did not have significant differences in acute exacerbations and medical cost for hospital utilization, compared with the non-users.

CONCLUSION

Methylxanthines and LTRA were used in a significant proportion of patients with mild-to-moderate COPD in real fields without favorable impacts on the exacerbations, hospitalizations, or medical costs. The use of more effective inhaled medications should be encouraged.

Functional performance in patients with COPD: association with treatment regimen, GOLD group, lung function, and symptom burden in a cross-sectional study

Background

Data suggesting that low physical activity levels are associated with increased mortality and exacerbations in patients with COPD have led to increasing interest in the role of physical activity in COPD. This study evaluated self-reported functional performance, a measure of physical activity impairment, according to current treatment regimen, lung function, symptoms, and Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 groups in a large sample of patients with COPD.

Methods

This multicenter, cross-sectional, observational study (study identifier: D5970R00003) included patients with COPD (≥40 years) in the USA. A self-completion questionnaire captured demographics and patient-reported outcomes, including the Functional Performance Inventory-Short Form (FPI-SF). Diagnosis and treatment history (including spirometry results) were extracted from medical charts. Multiple linear regression was used to determine the relationship between FPI-SF and FEV₁ % predicted, and FPI-SF and COPD assessment test (CAT) score.

Results

Overall, 1,775 patients participated (classified as GOLD 2017 group A, 14.8%; B, 46.6%; C, 2.6%; D, 36.0%). Physical activity impairment affected patients across all treatment regimens and GOLD groups (mean FPI-SF total score: 2.1), with the greatest impairment within FPI-SF observed for domains requiring most physical exertion, “physical exercise” and “maintaining the household” (mean FPI-SF scores: 1.7 and 1.8, respectively). Patients receiving loose triple therapy and those in GOLD group D had the highest impairment (mean FPI-SF total scores: both 1.9), and the lowest FEV₁ % predicted (55.5% and 54.7%, respectively). FPI-SF total score correlated with FEV₁ % predicted and more strongly with CAT score (all P<0.05).

Conclusion

The stronger correlation between FPI-SF and CAT scores compared to FPI-SF and FEV₁ % predicted suggests that symptoms may have a greater impact on patients’ functional performance than lung function. Further longitudinal studies are required to establish a correlation between the effect of treatment on symptoms, lung function, and physical activity.

Chronic Obstructive Pulmonary Disease and the Risk of Stroke

RATIONALE

Chronic obstructive pulmonary disease (COPD) has been identified as a risk factor for cardiovascular diseases such as myocardial infarction. The role of COPD in cerebrovascular disease is, however, less certain. Although earlier studies have suggested that the risk for stroke is also increased in COPD, more recent investigations have generated mixed results.

OBJECTIVES

The primary objective of our review was to quantify the magnitude of the association between COPD and stroke. We also sought to clarify the nature of the relationship between COPD and stroke by investigating whether the risk of stroke in COPD varies with age, sex, smoking history, and/or type of stroke and whether stroke risk is modified in particular COPD phenotypes.

RESULTS

The MEDLINE and EMBASE databases were searched in May 2016 to identify articles that compared stroke outcomes in people with and without COPD. Studies were grouped by study design to distinguish those that reported prevalence of stroke (cross-sectional studies) from those that estimated incidence (cohort or case-control studies). In addition, studies were stratified according to study population characteristics, the nature of COPD case definitions, and adjustment for confounding (smoking). Heterogeneity was assessed using the I² statistic. We identified 5,493 studies, of which 30 met our predefined inclusion criteria. Of the 25 studies that reported prevalence ratios, 11 also estimated prevalence odds ratios. The level of heterogeneity among the included cross-sectional studies did not permit the calculation of pooled ratios, save for a group of four studies that estimated prevalence odds ratios adjusted for smoking (prevalence odds ratio, 1.51; 95% confidence interval, 1.09-2.09; I² = 45%). All 11 studies that estimated relative risk for nonfatal incident stroke reported increased risk in COPD. Adjustment for smoking invariably reduced the magnitude of the associations.

CONCLUSIONS

Although both prevalence and incidence of stroke are increased in people with COPD, the weight of evidence does not support the hypothesis that COPD is an independent risk factor for stroke. The possibility remains that COPD is causal in certain subsets of patients with COPD and for certain stroke subtypes.

The Role of Mitochondria and Oxidative/Antioxidative Imbalance in Pathobiology of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease, characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. The major risk factor of COPD, which has been proven in many studies, is the exposure to cigarette smoke. However, it is 15-20% of all smokers who develop COPD. This is why we should recognize the pathobiology of COPD as involving a complex interaction between several factors, including genetic vulnerability. Oxidant-antioxidant imbalance is recognized as one of the significant factors in COPD pathogenesis. Numerous exogenous and endogenous sources of ROS are present in pathobiology of COPD. One of endogenous sources of ROS is mitochondria. Although leakage of electrons from electron transport chain and forming of ROS are the effect of physiological functioning of mitochondria, there are various intra- and extracellular factors which may increase this amount and significantly contribute to oxidative-antioxidative imbalance. With the coexistence with impaired antioxidant defence, all these issues lead to oxidative and carbonyl stress. Both of these states play a significant role in pathobiology of COPD and may account for development of major comorbidities of this disease.

Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a systemic inflammatory disorder associated with increased comorbid prevalence of cardiovascular diseases. We aimed to quantify the magnitudes of association between overall and specific types of cardiovascular disease, major cardiovascular risk factors, and COPD.

METHODS

We searched Cochrane, Medline, and Embase databases for studies published between Jan 1, 1980, and April 30, 2015, on the prevalence of cardiovascular disease and its risk factors in patients with COPD versus matched controls or random samples from the general public. We assessed associations with random-effects meta-analyses. We studied heterogeneity and biases with random-effects meta-regressions, jackknife sensitivity analyses, assessment of funnel plots, and Egger tests.

FINDINGS

We identified 18,176 unique references and included 29 datasets in the meta-analyses. Compared with the non-COPD population, patients with COPD were more likely to be diagnosed with cardiovascular disease (odds ratio [OR] 2·46; 95% CI 2·02-3·00; p<0·0001), including a two to five times higher risk of ischaemic heart disease, cardiac dysrhythmia, heart failure, diseases of the pulmonary circulation, and diseases of the arteries. Additionally, patients with COPD reported hypertension more often (OR 1·33, 95% CI 1·13-1·56; p=0·0007), diabetes (1·36, 1·21-1·53; p<0·0001], and ever smoking (4·25, 3·23-5·60; p<0·0001). The associations between COPD and these cardiovascular disease types and cardiovascular disease risk factors were consistent and valid across studies. Enrolment period, age, quality of data, and COPD diagnosis partly explained the heterogeneity.

INTERPRETATION

The coexistence of COPD, cardiovascular disease, and major risk factors for cardiovascular disease highlights the crucial need for the development of strategies to screen for and reduce cardiovascular risks associated with COPD.

FUNDING

Canadian Institutes of Health Research.

Underrecognized comorbidities of chronic obstructive pulmonary disease

COPD is associated with different comorbid diseases, and their frequency increases with age. Comorbidities severely impact costs of health care, intensity of symptoms, quality of life and, most importantly, may contribute to life span shortening. Some comorbidities are well acknowledged and established in doctors’ awareness. However, both everyday practice and literature searches provide evidence of other, less recognized diseases, which are frequently associated with COPD. We call them underrecognized comorbidities, and the reason why this is so may be related to their relatively low clinical significance, inefficient literature data, or data ambiguity. In this review, we describe rhinosinusitis, skin abnormalities, eye diseases, different endocrinological disorders, and gastroesophageal reflux disease. Possible links to COPD pathogenesis have been discussed, if the data were available.

Epidemiology and clinical impact of major comorbidities in patients with COPD

Comorbidities are frequent in chronic obstructive pulmonary disease (COPD) and significantly impact on patients’ quality of life, exacerbation frequency, and survival. There is increasing evidence that certain diseases occur in greater frequency amongst patients with COPD than in the general population, and that these comorbidities significantly impact on patient outcomes. Although the mechanisms are yet to be defined, many comorbidities likely result from the chronic inflammatory state that is present in COPD. Common problems in the clinical management of COPD include recognizing new comorbidities, determining the impact of comorbidities on patient symptoms, the concurrent treatment of COPD and comorbidities, and accurate prognostication. The majority of comorbidities in COPD should be treated according to usual practice, and specific COPD management is infrequently altered by the presence of comorbidities. Unfortunately, comorbidities are often under-recognized and under-treated. This review focuses on the epidemiology of ten major comorbidities in patients with COPD. Further, we emphasize the clinical impact upon prognosis and management considerations. This review will highlight the importance of comorbidity identification and management in the practice of caring for patients with COPD.

Clinical and individual factors associated with smoking quit attempts among adults with COPD: do factors vary with regard to race?

Only half of adults with chronic obstructive pulmonary disease (COPD) report a smoking quit attempt in the past year. Adults with COPD have frequent encounters with the healthcare system that are opportunities for health behavior interventions that support quit attempts. The purpose of this research was to examine individual- and clinical-level factors associated with smoking quit attempts in adults with COPD. Cross-sectional data were from the 2011 Behavioral Risk Factor Surveillance System. Race-stratified, weighted logistic regression examined factors associated with quit attempt among current smokers with COPD. Overall, quit attempt was reported by 65% (95% confidence interval (CI): 61.9, 67.5) of adults and was more likely among blacks than whites (p < 0.0001). Among whites with COPD quit attempt was associated with: Female gender (adjusted odds ratio (AOR) = 1.3; CI: 1.0, 1.7), exercise (AOR = 2.0; CI: 1.5, 2.5), and medications for COPD (AOR = 1.6; CI: 1.3, 2.2). Among black adults with COPD quit attempt was associated with: Having a partner (AOR = 4.5; CI: 1.3, 15.0), exercise (AOR = 3.7; CI: 1.6, 8.7), spirometry (AOR = 9.5; CI: 3.2, 28.7), and having a personal doctor (AOR = 6.4; CI: 1.8, 22.5). Individual and clinical-factors associated with quit attempt varied by race. These findings suggest an impact of the healthcare system that supports quit attempts in blacks but not whites with COPD.

Patterns and determinants of COPD-related healthcare utilization by severity of airway obstruction in Korea

Background

We investigated patients with chronic obstructive pulmonary disease (COPD) to analyze patterns and identify determinants of healthcare use, according to the severity of airflow obstruction. We used retrospective cohort data from a combination of the 4^th Korea National Health and Nutritional Examination Survey (KNHANES) and Korean National Health Insurance (NHI) claims.

Methods

Demographic and medical claims data were retrospectively analyzed from the 4^th KNHANES along with NHI claims. Eligible patients were aged ≥40 years, who underwent complete pulmonary function tests (PFTs), and had at least one inpatient or outpatient claim coded as COPD between January 1, 2007 and December 31, 2010.

Results

Among 6,663 eligible participants, 897 (13.5%) had airway obstruction. Self-reported physician-diagnosed COPD comprised only 3%, and there were 870 undiagnosed COPD patients (97%). Self-reported physician-diagnosed asthma made up 3.7%. Of the 897 respondents, 244 (27.2%) used COPD-related healthcare services. The frequency of healthcare visits increased with increasing severity of airway obstruction. After a 3-year follow-up period, 646 (74.2% of those initially undiagnosed) remained undiagnosed and only 224 (25.8%) were diagnosed and treated for COPD. Only 27.5% of the 244 participants with airway obstruction who used COPD-related healthcare underwent PFTs during the study period. The percentage of prescribed medications associated with COPD increased in accordance with the severity of the COPD. Inhaled long-acting anticholinergics were prescribed for 10.9% of patients with moderate airway obstruction and for 52.4% of patients with severe obstruction. Inhaled long-acting β-agonists combined with corticosteroids were prescribed for 50% of patients with severe airway obstruction. Conversely, 44.6% of healthcare users were prescribed oral theophylline for COPD treatment, and 21.7% were also prescribed an oral corticosteroid. The determinants of COPD-associated healthcare use in respondents with obstructive lung disease were advanced age, severe airflow limitation, presence of comorbidities, and self-reported physician diagnosis of COPD.

Conclusions

This study ascertained marked underdiagnosed COPD. Although the percentage of prescribed medication used to treat COPD increased with the severity of the COPD, medications primarily prescribed such as oral theophylline or oral corticosteroids are inappropriate for first-line COPD treatment.

Prevalence of renal and hepatobiliary disease, laboratory abnormalities, and potentially toxic medication exposures among persons with COPD

Background

The purpose of this study was to describe the prevalence of renal and hepatic disease, related laboratory abnormalities, and potentially hepatotoxic and nephrotoxic medication use in a population-based cohort of persons with chronic obstructive pulmonary disease (COPD).

Methods

This was a retrospective case-control cohort analysis of COPD patients enrolled in one regional health system for at least 12 months during a 36-month study period (n = 2284). Each COPD patient was matched by age and gender to up to three persons not diagnosed with COPD (n = 5959).

Results

The mean age for cases and controls was 70.3 years, and 52.5% were women. The COPD cohort had significantly higher prevalences (cases/100) of acute, chronic, and unspecified renal failure as compared with controls (1.40 versus 0.59, 2.89 versus 0.79, and 1.09 versus 0.44, respectively). Among the cases, 31.3% had at least one renal or urinary tract diagnosis during the study period, as compared with 21.1% of controls. COPD cases also had more gallbladder disease (2.76 versus 1.63) and pancreatic disease (1.40 versus 0.60), but not hepatic disease. COPD patients were more likely to have at least one serum creatinine level (5.1 versus 2.1) or liver aspartate aminotransferase level (4.5 versus 2.7) that was more than twice the upper limit of normal. COPD patients had prescription fills for an average of 17.6 potentially nephrotoxic and 27.4 hepatotoxic drugs during the study period, as compared with 13.6 and 19.9 for the controls (P value for all comparisons < 0.01).

Conclusion

COPD patients have a substantially increased prevalence of renal, gallbladder, and pancreatic diseases, as well as abnormal renal and hepatic laboratory values, but not diagnosed liver disease. COPD patients are also more likely to be prescribed medications with potentially toxic renal or hepatic side effects.

New clinical insights into chronic obstructive pulmonary disease and their implications for pharmacoeconomic analyses

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death and disability worldwide, but before the development of several new pharmacological treatments little could be done for COPD patients. Recognition that these new treatments could significantly improve the prognosis for COPD patients has radically changed clinical management guidelines from a palliative philosophy to an aggressive approach intended to reduce chronic symptoms, improve quality of life and prolong survival. These new treatments have also sparked interest in COPD cost-effectiveness research. Most COPD cost-effectiveness studies have been based on clinical trial populations, limited to direct medical costs, and used standard analysis methods such as Markov modelling, and they have usually found that newer therapies have favourable cost effectiveness. However, new insights into the clinical progression of COPD bring into question some of the assumptions underlying older analyses. In this review, we examine clinical factors unique to COPD and recent changes in clinical perspectives that have important implications for pharmacoeconomic analyses. The main parameters explored include (i) the high indirect medical costs for COPD and their relevance in assessing the societal benefits of new therapy; (ii) the importance of acute deteriorations in COPD, known as exacerbations, and approaches to modelling the cost benefit of exacerbation reduction; (iii) quality/utility instruments for COPD; (iv) the prevalence of co-morbid conditions and confounding between COPD and co-morbid disease utilization; (v) the limitations of Markov modelling; and (vi) the problem of outliers.

[The adequacy of the diagnostic in chronic obstructive pulmonary disease]

OBJECTIVES

To assess the adequacy to the clinical guides (GOLD/SEPAR) for the diagnosis of the patients classified as COPD.

MATERIAL AND METHODS

We selected all COPD cases in the registry of chronic patients of 28 general practitioners from 9 Health Centres in the province of Ourense (Spain). A total of 382 cases were included. Diagnostic accuracy was determined according to the results of spirometry. We identify factors associated with correct diagnosis by logistic regression which included age, gender, residence (rural/urban), smoking, severity, level of follow up and time since diagnosis.

RESULTS

Of the total number included, 297 were male (77.7%) and 172 patients (45.0%) came from rural areas. The average age was 77.0 (SD=±11.0) years, with a mean age at diagnosis of 64.9 (±12.0) years and the time from diagnosis was 11.5 (±8.0) years. Less than half (49.1%) patients had been smokers, and 13.1% still smoked. Twenty-six cases (6.8%) were diagnosed in Primary Care. The FEV(1)/FVC ratio was recorded in 174 (45.5%) patients, with less than 0.7 in 138 cases (36.1%), which were considered as correctly diagnosed. In these patients the FEV(1) had been recorded in 125 cases (90.6%). A correct diagnosis was associated with severe or very severe disease (OR 5.2; 95% CI; 1.5-17.4), urban areas (OR 6.1; 95% CI, 1.7-21.2), and younger than 60 years (OR 3.7; 95% CI, 1.3-11.2).

CONCLUSION

The number of spirometry results recorded in the Primary Care medical records of patients diagnosed with COPD was found to be low, and with little adaptation to the accepted diagnostic criteria in the guidelines that are used routinely.

COPD is frequent in conditions of comorbidity in patients treated with various diseases in a university hospital

Background

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death and loss of disability-adjusted life-years. However, many COPD patients are not diagnosed because of underrecognition or underdiagnosis of this disease among many patients and physicians. One possible reason is underrecognition of spirometry. In this study, we examined the prevalence of airflow limitation and underlying disease in patients with airflow limitation.

Methodology

From April 2006 to March 2008, patients who had spirometry performed were examined. The original disease of patients, pulmonary function tests, smoking status, and respiratory symptoms were surveyed from their medical records.

Results

Of all patients who had spirometry performed, 15.8% showed airflow limitation (FEV₁/FVC < 0.7). A variety of diseases were observed in patients with airflow limitation. Among all diseases, cardiovascular disease was the highest and gastrointestinal malignant disease had the second highest prevalence in patients with airflow limitation.

Conclusion

COPD might be frequent in conditions of comorbidity in patients treated for various diseases. Attention should be paid to the possibility of co-existence of COPD and the influence of COPD on these patients.

A new method for examining the cost savings of reducing COPD exacerbations

BACKGROUND

Some treatments for chronic obstructive pulmonary disease (COPD) can reduce exacerbations, and thus could have a favourable impact on overall healthcare costs.

OBJECTIVE

To evaluate a new method for assessing the potential cost savings of COPD controller medications based on the incidence of exacerbations and their related resource utilization in the general population.

METHODS

Patients with COPD (n = 1074) enrolled in a regional managed care system in the US were identified using administrative data and divided by their medication use into three groups (salbutamol, ipratropium and salmeterol). Exacerbations were captured using International Classification of Diseases, Ninth Edition (ICD-9) and current procedural terminology (CPT) codes, then logistic regression models were created that described the risk of exacerbations for each comparator group and exacerbation type over a 6-month period. A Monte Carlo simulation was then applied 1000 times to provide the range of potential exacerbation reductions and cost consequences in response to a range of hypothetical examples of COPD controller medications.

RESULTS

Exacerbation events for each group could be modelled such that the events predicted by the Monte Carlo estimates were very close to the actual prevalences. The estimated cost per exacerbation avoided depended on the incidence of exacerbation in the various subpopulations, the assumed relative risk reduction, the projected daily cost for new therapy, and the costs of exacerbation treatment.

CONCLUSIONS

COPD exacerbation events can be accurately modelled from the healthcare utilization data of a defined cohort with sufficient accuracy for cost-effectiveness analysis. Treatments that reduce the risk or severity of exacerbations are likely to be cost effective among those patients who have frequent exacerbations and hospitalizations.

Use of spirometry in the diagnosis of chronic obstructive pulmonary disease and efforts to improve quality of care

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation that is not fully reversible. In a patient presenting with respiratory symptoms and risk factors, the recommendation is to perform spirometry to determine the presence of airflow obstruction. However, only about a third of patients with a diagnosis of COPD have spirometry along with their diagnosis, although studies have shown that history and physical examination alone are neither sensitive nor specific for diagnosing COPD. Thus, in current practice, many health care providers continue to diagnose and manage COPD without an accurate diagnosis and assessment of severity based on spirometry. This can contribute to inconsistent care and outcomes, as evidenced by findings of variation in spirometry use and acute exacerbation rates of COPD across geographic regions. As there is increasing evidence that pharmacotherapy for COPD has associated risks, including poor cardiovascular outcomes and pneumonia, it is pertinent to obtain an accurate diagnosis to determine appropriate risk-benefit ratios. Previous studies have shown that spirometry has an impact on COPD management; however, there seem to be barriers to the use of spirometry at the patient, provider, and health system level. Innovative quality improvement approaches, such as the application of the various components of the Chronic Care Model, could improve spirometry use in COPD. Only with accurate diagnosis can appropriate management and evidence-based treatment strategies be applied in practice. Therefore, it is important that we continue efforts to increase the use of spirometry in the diagnosis of COPD.

Health care costs among individuals with chronic obstructive pulmonary disease within several large, multi-state employers

OBJECTIVE

To estimate chronic obstructive pulmonary disease (COPD)-attributable medical resource utilization and health care costs among employed individuals and their covered dependents with COPD.

METHOD

Retrospective health care claims analysis. Employees and dependents 40 to 63 years old with a diagnosis of COPD between January 1, 2001 and December 31, 2002 were matched to two separate control cohorts. Medical resource utilization and health care costs were compared between cohorts.

RESULTS

A total of 6445 individuals with COPD were matched to each control cohort. Mean age was 55.1 years, and cohorts were approximately 50% men. COPD subjects had significantly higher utilization and adjusted pharmacy, medical, and total health care costs than both control cohorts (P < 0.001).

CONCLUSIONS

COPD subjects had significantly higher utilization and costs than individuals without COPD. Thus, the economic burden of COPD is present in younger, working individuals, as well as in the older, retired population.

The direct medical costs of undiagnosed chronic obstructive pulmonary disease

OBJECTIVE

To estimate the costs of undiagnosed chronic obstructive pulmonary disease (COPD) by describing inpatient, outpatient, and pharmacy utilization in the years before and after the diagnosis.

METHODS

A total of 6,864 patients who were enrolled in the Lovelace Health Plan for at least 12 months during the study period (January 1, 1999 through December 31, 2004) were identified. The first date that utilization was attributed to COPD was considered the first date of diagnosis. Each COPD case was matched to up to three age- and sex-matched controls. All utilization and direct medical costs during the study period were compiled monthly and compared based on the time before and after the initial diagnosis.

RESULTS

Total costs were higher by an average of $1,182 per patient in the 2 years before the initial COPD diagnosis, and $2,489 in the 12 months just before the initial diagnosis, compared to matched controls. Most of the higher cost for undiagnosed COPD was attributable to hospitalizations. Inpatient costs did not increase after the diagnosis was made, but approximately one-third of admissions after the diagnosis were attributed to respiratory disease. Outpatient and pharmacy costs did not differ substantially between cases and matched controls until just a few months before the initial diagnosis, but remained 50% to 100% higher than for controls in the 2 years after diagnosis.

CONCLUSIONS

Undiagnosed COPD has a substantial impact on health-care costs and utilization in this integrated managed care system, particularly for hospitalizations.

Optimizing maintenance therapy for chronic obstructive pulmonary disease: strategies for improving patient-centered outcomes

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with substantial morbidity and mortality. Published practice guidelines and treatment algorithms for COPD are designed to increase awareness of the problem and improve patient care; however, <40% of subjects diagnosed with COPD are receiving appropriate maintenance therapy.

OBJECTIVE

This paper reviews the use of maintenance therapy in COPD and examines the optimal timing for initiating such therapy based on the available literature.

METHODS

Relevant publications were identified through a search of MEDLINE (1995-May 2007) using the terms COPD, guidelines, treatment, maintenance therapy, bronchodilator, ipratropium, tiotropium, beta-agonist, salmeterol, and inhaled corticosteroid. English-language publications discussing pharmacologic maintenance therapy for COPD, including practice statements/guidelines, randomized controlled clinical trials, systematic reviews, and meta-analyses, with a focus on agents currently approved for use in the United States, were selected for inclusion.

RESULTS

Although guidelines and algorithms agree on the importance of regularly scheduled maintenance therapy to reduce symptoms of COPD, minimize activity limitations, and improve health status, the timing of the initiation of such therapy is debatable. In most instances, maintenance medications, which include long-acting beta(2)-agonists, long-acting anticholinergics, and combination products, are prescribed late in the disease process and mainly for patients with severe disease. However, there is increasing evidence that the use of maintenance therapy early in the disease process may be associated with improvements in such outcomes as lung function, symptoms, exercise tolerance, exacerbations of COPD, and quality of life.

CONCLUSION

The high burden associated with COPD highlights the need to initiate maintenance therapy before a substantial decline in lung function has occurred.

Development and validation of the Beliefs and Behaviour Questionnaire (BBQ)

OBJECTIVE

To develop and validate a questionnaire to screen for potential nonadherence in patients with chronic ailments.

METHODS

Themes from qualitative interviews with chronic obstructive pulmonary disease patients were used in developing content of the questionnaire. The questionnaire was distributed to 525 ambulatory patients with chronic lung diseases. Principal components analysis was performed to identify the subscales in the questionnaire. Internal consistency, validity and stability of the subscales were also evaluated.

RESULTS

The 30-item Beliefs and Behaviour Questionnaire (BBQ) measures beliefs, experiences and adherent behaviour on five-point Likert-type scales. Two hundred and eighty patients (53.3%) with a mean age of 71.1 years responded to the questionnaire. The 'beliefs' section had a two-factor solution-'confidence' and 'concerns' with internal consistencies of 0.82 and 0.45, respectively. The two domains identified from the section 'experiences'-satisfaction' and 'disappointment' had internal consistencies of 0.85 and 0.52, respectively. The 'behaviour' section, separately entitled the Tool for Adherence Behaviour Screening (TABS), had a two-factor solution--'adherence' and 'nonadherence', with internal consistencies of 0.80 and 0.59, respectively. All the domains demonstrated comparable reliabilities across two different patient populations. Their temporal stabilities ranged between 0.62 and 0.94.

CONCLUSION

The validity, reliability and utility of the BBQ and the TABS, a sub-scale of the BBQ that screens both intentional and unintentional nonadherence to pharmacological and non-pharmacological disease management, have been established.

PRACTICE IMPLICATIONS

The BBQ and the TABS have potential applications in screening adherence beliefs, experiences and behaviour in both clinical practice and research.

Factors associated with medication nonadherence in patients with COPD

STUDY OBJECTIVES

To identify the predictors of medication adherence in patients with COPD and contrast the health beliefs, experiences, and behaviors of COPD patients self-reporting good adherence with those of patients reporting suboptimal adherence to their medications.

DESIGN

Cross-sectional self-administered questionnaire.

SETTING

Ambulatory care.

PARTICIPANTS

Patients with chronic respiratory ailments identified through respiratory support groups and from a pulmonary rehabilitation database.

MEASUREMENTS AND RESULTS

A 30-item questionnaire comprising items pertaining to health beliefs, experiences, and behaviors along with a valid self-reported measure of adherence-the medication adherence report scale (MARS)-was administered to 525 ambulatory patients with chronic lung conditions. A total of 276 usable responses were received (52.6%). The mean age of the respondents was 71 years, and there were slightly more male patients (54.4%). COPD was the underlying disease condition in 90.6% of the respondents; two thirds of the respondents had comorbid conditions. The respiratory condition was managed by both general practitioners and respiratory specialists in 61.2% of cases. One third of the respondents self-reported complementary and alternative medicine use. The mean score (+/- SD) on the MARS among the respondents was 23.37 +/- 2.09. One hundred two patients self-reported perfect adherence on the MARS. Differences in knowledge about the illness and treatment, faith in and satisfaction with the treatment and doctors, concerns about the treatment, and intentional and unintentional deviations from the recommended treatment were detected between the adherent and less adherent groups. In multivariate analysis, "I vary my recommended management based on how I am feeling" and "I get confused about my medications" were found to be significant independent predictors of nonadherence.

CONCLUSIONS

Patients' acceptance of the disease process and recommended treatment, knowledge about and faith in the treatment, effective patient-clinician interaction, and routinization of drug therapy are critical for optimal medication adherence in patients with COPD.

Patterns of care for COPD by Japanese physicians

OBJECTIVE

COPD treatment guidelines are available worldwide, yet it is not known how widely they are followed. This study evaluated the clinical care of COPD patients in Japan as compared to guideline recommendations.

METHODS

A sample of general and specialist physicians was selected from private outpatient clinics and public hospitals in Japan. Physicians were provided two clinical vignettes (COPD and asthma) and asked to make a diagnosis. They were next asked to define diagnostic tests and treatment recommendations specifically for a COPD patient. Responses were compared to recommendations from current COPD guidelines.

RESULTS

For the COPD unknown vignette, 6.2% of physicians diagnosed COPD while 54% diagnosed chronic bronchitis or emphysema. For COPD diagnosis, 81.9% of physicians recommended a CXR, 49.1% spirometry, and 17.7% a computed tomography scan. The most frequently recommended medication for a newly diagnosed COPD patient was theophylline (37.2%) followed by expectorants (32.1%) and inhaled anticholinergics (25.9%). Inhaled beta-agonists were recommended by fewer than 20% of all physicians.

CONCLUSION

Care for COPD patients by selected Japanese physicians diverges from published practice guidelines. COPD is an infrequently used diagnostic label; diagnostic evaluation is characterized by a high use of computed tomography scans, particularly by specialists; and bronchodilator use was low.

Use of complementary and alternative medicines by patients with chronic obstructive pulmonary disease

OBJECTIVES

To investigate complementary and alternative medicine (CAM) use by patients with chronic obstructive pulmonary disease (COPD) and to explore their beliefs about CAM.

DESIGN AND PARTICIPANTS

Cross-sectional study of 173 patients with moderate to severe COPD, and in depth interviews with a purposive sample of 28 patients.

SETTING

Ambulatory care.

MAIN OUTCOME MEASURES

Use of CAM; beliefs about the value of CAM.

RESULTS

71 patients (41%) claimed to be using some form of CAM. Most commonly used were multivitamins and minerals, and garlic was the most commonly used herbal preparation. Patients reported that advertisements and people with prior experience of using CAM were their major sources of information. Extent of knowledge about CAM, degree of faith in CAM and personal attitudes influenced decisions to try CAM. Patients used CAM to promote general wellbeing, to counteract drug side effects, to compensate for dietary deficiencies and to ameliorate their disease. Efficacy appeared less important to users than safety. CAM practitioners were regarded as more convincing, informative, considerate and available compared with mainstream health professionals.

CONCLUSIONS

Communication between patients and mainstream health professionals about CAM use could be improved by health professionals being more accepting of CAM use and having some basic knowledge about commonly used CAM preparations.

Treatment implications on morbidity and mortality in COPD

Inhaled corticosteroids (ICSs) remain controversial in COPD, although recent clinical trials have consistently found that they reduce chronic respiratory symptoms and, in some population-based studies, improve survival. Their impact on the general COPD population depends on the variability in clinical response among individuals, the magnitude of treatment benefits, and the prevalence of adverse events in the population. The clinical benefits of ICSs in COPD are less obvious than in asthma; however, even patients with COPD without airway hyperresponsiveness experience significant improvement in baseline lung function and other outcomes after treatment with ICS. Population-based surveys suggest that a majority of patients with COPD have asthma or chronic bronchitis features and, therefore, are predisposed to a stronger treatment benefit from ICS. Clinical data support the use of ICS in patients with moderate-to-severe COPD, and suggest that they have impacts on morbidity and mortality that are as great or greater than those seen among commonly accepted treatments for other chronic diseases.

Development and validation of the medication regimen complexity index

BACKGROUND

Medication regimen attributes, such as the number of drugs, dosage frequency, administration instructions, and the prescribed dosage forms, have been shown to influence patient outcomes. No single tool for quantifying the complexity of general medication regimens has been published in the medical literature.

OBJECTIVE

To develop and validate a tool to quantify the complexity of prescribed medication regimens.

METHODS

Literature findings and the expertise of the authors were used for developing the tool. Eight pharmacy researchers helped in establishing the tool's face and content validity. The new tool was tested on 134 medication regimens from patients with moderate to severe chronic obstructive pulmonary disease. Six regimens with a spread of scores on the tool were presented to a 5-member expert panel that subjectively ranked these regimens to confirm the tool's criterion-related validity. The relationships between scores on the tool and various independent variables were tested to judge the tool's construct validity. Two raters scored 25 regimens using the tool to test its inter-rater and test-retest reliabilities.

RESULTS

A 65-item Medication Regimen Complexity Index (MRCI) was developed. The expert panel had strong agreement (Kendall's W = 0.8; p = 0.001) on their individual rankings of the 6 regimens. The panel's consensus ranking had perfect correlation with the MRCI ranking. The total MRCI score had significant correlation with the number of drugs in the regimen (Spearman's Rho = 0.9; p < 0.0001), but not with the age and gender of the patients. Inter-rater and test-retest reliabilities for the total score and scores for individual sections on the MRCI were > or = 0.9.

CONCLUSIONS

The MRCI is a reliable and valid tool for quantifying drug regimen complexity with potential applications in both practice and research.

[Reliability of chronic obstructive pulmonary disease diagnosis by primary care physicians and pneumologists in Spain. Predictive factors]

OBJECTIVE

The aims of this study were to assess the methods used by primary care physicians and pneumologists to diagnose chronic obstructive pulmonary disease (COPD) in Spain, and to analyze the factors affecting correct diagnosis of the disease.

MATERIAL AND METHODS

This observational, descriptive, cross-sectional and multicenter study enrolled a stratified randomized sample from each Spanish region from the practices of primary care physicians and pneumologists.

RESULTS

Five hundred sixty-eight (63.2%) of the 898 subjects enrolled had airway obstruction, 92 (10.3%) did not fulfill functional criteria for COPD and 238 (26.5%) did not perform spirometric tests to confirm the diagnosis and establish severity of disease. Primary care physicians classified 29.3% of the patients correctly, whereas pneumologists diagnosed 84.8% correctly. Clinical and/or radiologic criteria were the basis for correct diagnosis in 38.6% of the cases managed by primary care physicians and 10.2% of those treated by pneumologists. Spirometry was available to 49.1% of the primary care physicians and 97.8% of the pneumologists' cases (p < 0.001). Moreover, only 29.9% of the primary care settings had a technician in charge of performing the study, in comparison with 97.8% of the specialized pneumology settings (p < 0.001). The use of spirometry in diagnosing COPD was related to level of patient care (primary or specialized), availability of the test in the primary care setting, place of residence and a patient's situation of temporary absence from work due to COPD.

CONCLUSIONS

Many COPD patients are incorrectly diagnosed, particularly in primary care. There are differences in diagnostic procedures at the different levels of patient care. The availability of spirometry is an important factor for correctly diagnosing COPD.

Obtaining evidence for use by healthcare payers on the success of chronic obstructive pulmonary disease management

Healthcare payers make decisions on funding for treatments for diseases, such as chronic obstructive pulmonary disease (COPD), on a population level, so require evidence of treatment success in appropriate populations, using usual routine care as the comparison for alternative management approaches. Such health outcomes evidence can be obtained from a number of sources. The 'gold standard' method for obtaining evidence of treatment success is usually taken as the randomized controlled prospective clinical trial. Yet the value of such studies in providing evidence for decision-makers can be questioned due to the restricted entry criteria limiting the ability to generalize to real life populations, narrow focus on individual parameters, use of placebo for comparison rather than usual therapy and unrealistic intense monitoring of patients. Evidence obtained from retrospective and observational studies can supplement that from randomized clinical trials, providing that care is taken to guard against bias and confounders. However, very large numbers of patients must be investigated if small differences between drugs and treatment approaches are to be detected. Administrative databases from healthcare systems provide an opportunity to obtain observational data on large numbers of patients. Such databases have shown that high healthcare costs in patients with COPD are associated with co-morbid conditions and current smoking status. Analysis of an administrative database has also shown that elderly patients with COPD who received inhaled corticosteroids within 90 days of discharge from hospital had 24% fewer repeat hospitalizations for COPD and were 29% less likely to die during the 1-year follow-up period. In conclusion, there are a number of sources of meaningful evidence of the health outcomes arising from different therapeutic approaches that should be of value to healthcare payers making decisions on resource allocation.

Admissions with chronic obstructive pulmonary disease after publication of national guidelines

BACKGROUND

The British Thoracic Society (BTS) published guidelines on managing acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in 1997.

AIM

To audit admissions with AECOPD and to see how well these guidelines were adhered to. Methods All patients admitted were identified and 50 selected for audit.

RESULTS

The mean age was 72 years and 52% were female. Admission C reactive protein (CRP) and white cell count (WCC) were 49 (12.7) mg/l and 10.97 (0.64) x 10(9)/l respectively. Six were acidotic and 16 hypercapnoeic. Median length of stay (LOS) was six days. Twenty-one fulfilled admission criteria. Thirty-seven had > or = 2 Anthonisen criteria. Nine had spirometry performed. Correlations were seen between appropriateness of admission score and pH (r=-0.41, p=0.01) and LOS (r=-0.43, p=0.002) and between Anthonisen criteria score and age (r=0.33, p=0.018). Symptom score correlated with PaO2 (r=-0.38, p=0.02), LOS (r=0.27, p=0.06) and age (r=0.38, p=0.007). LOS correlated with PaCO2 (r=0.33, p=0.04).

CONCLUSION

Admissions are chiefly comprised of an ill, elderly population. Careful adherence to guidelines could result in fewer admissions.