[A cross-sectional survey of the knowledge on chronic obstructive pulmonary disease in physicians of tertiary hospitals in Northern China]

Development and Validation of a Multivariable Prediction Model to Identify Acute Exacerbation of COPD and Its Severity for COPD Management in China (DETECT Study): A Multicenter, Observational, Cross-Sectional Study

Purpose

There is an unmet clinical need for an accurate and objective diagnostic tool for early detection of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). DETECT (NCT03556475) was a multicenter, observational, cross-sectional study aiming to develop and validate multivariable prediction models for AECOPD occurrence and severity in patients with chronic obstructive pulmonary disease (COPD) in China.

Patients and Methods

Patients aged ≥40 years with moderate/severe COPD, AECOPD, or no COPD were consecutively enrolled between April 22, 2020, and January 18, 2021, across seven study sites in China. Multivariable prediction models were constructed to identify AECOPD occurrence (primary outcome) and AECOPD severity (secondary outcome). Candidate variables were selected using a stepwise procedure, and the bootstrap method was used for internal model validation.

Results

Among 299 patients enrolled, 246 were included in the final analysis, of whom 30.1%, 40.7%, and 29.3% had COPD, AECOPD, or no COPD, respectively. Mean age was 64.1 years. Variables significantly associated with AECOPD occurrence (P<0.05) and severity (P<0.05) in the final models included COPD disease-related characteristics, as well as signs and symptoms. Based on cut-off values of 0.374 and 0.405 for primary and secondary models, respectively, the performance of the primary model constructed to identify AECOPD occurrence (AUC: 0.86; sensitivity: 0.84; specificity: 0.77), and of the secondary model for AECOPD severity (AUC: 0.81; sensitivity: 0.90; specificity: 0.73) indicated high diagnostic accuracy and clinical applicability.

Conclusion

By leveraging easy-to-collect patient and disease data, we developed identification tools that can be used for timely detection of AECOPD and its severity. These tools may help physicians diagnose AECOPD in a timely manner, before further disease progression and possible hospitalizations.

Pathway-Driven Coordinated Telehealth System for Management of Patients With Single or Multiple Chronic Diseases in China: System Development and Retrospective Study

Background

Integrated care enhanced with information technology has emerged as a means to transform health services to meet the long-term care needs of patients with chronic diseases. However, the feasibility of applying integrated care to the emerging “three-manager” mode in China remains to be explored. Moreover, few studies have attempted to integrate multiple types of chronic diseases into a single system.

Objective

The aim of this study was to develop a coordinated telehealth system that addresses the existing challenges of the “three-manager” mode in China while supporting the management of single or multiple chronic diseases.

Methods

The system was designed based on a tailored integrated care model. The model was constructed at the individual scale, mainly focusing on specifying the involved roles and responsibilities through a universal care pathway. A custom ontology was developed to represent the knowledge contained in the model. The system consists of a service engine for data storage and decision support, as well as different forms of clients for care providers and patients. Currently, the system supports management of three single chronic diseases (hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease) and one type of multiple chronic conditions (hypertension with type 2 diabetes mellitus). A retrospective study was performed based on the long-term observational data extracted from the database to evaluate system usability, treatment effect, and quality of care.

Results

The retrospective analysis involved 6964 patients with chronic diseases and 249 care providers who have registered in our system since its deployment in 2015. A total of 519,598 self-monitoring records have been submitted by the patients. The engine could generate different types of records regularly based on the specific care pathway. Results of the comparison tests and causal inference showed that a part of patient outcomes improved after receiving management through the system, especially the systolic blood pressure of patients with hypertension (P<.001 in all comparison tests and an approximately 5 mmHg decrease after intervention via causal inference). A regional case study showed that the work efficiency of care providers differed among individuals.

Conclusions

Our system has potential to provide effective management support for single or multiple chronic conditions simultaneously. The tailored closed-loop care pathway was feasible and effective under the “three-manager” mode in China. One direction for future work is to introduce advanced artificial intelligence techniques to construct a more personalized care pathway.

Using Mobile Health Technology to Deliver a Community-Based Closed-Loop Management System for Chronic Obstructive Pulmonary Disease Patients in Remote Areas of China: Development and Prospective Observational Study

Background

Mobile health (mHealth) technology is an increasingly recognized and effective method for disease management and has the potential to intervene in pulmonary function, exacerbation risk, and psychological status of patients with chronic obstructive pulmonary disease (COPD).

Objective

This study aimed to investigate the feasibility of an mHealth-based COPD management system designed for Chinese remote areas with many potential COPD patients but limited medical resources.

Methods

The system was implemented based on a tailored closed-loop care pathway that breaks the heavy management tasks into detailed pieces to be quantified and executed by computers. Low-cost COPD evaluation and questionnaire-based psychological intervention are the 2 main characteristics of the pathway. A 6-month prospective observational study at the community level was performed to evaluate the effect of the system. Primary outcomes included changes in peak expiratory flow values, quality of life measured using the COPD assessment test scale, and psychological condition. Acute exacerbations, compliance, and adverse events were also measured during the study. Compliance was defined as the ratio of the actual frequency of self-monitoring records to the prescribed number.

Results

A total of 56 patients was enrolled; 39 patients completed the 6-month study. There was no significant difference in the mean peak expiratory flow value before and after the 6-month period (366.1, SD 106.7 versus 313.1, SD 116.6; P=.11). Psychological condition significantly improved after 6 months, especially for depression, as measured using the Patient Health Questionnaire-9 scale (median 6.0, IQR 3.0-9.0 versus median 4.0, IQR 0.0-6.0; P=.001). The COPD assessment test score after 6 months of intervention was also lower than that at the baseline, and the difference was significant (median 4.0, IQR 1.0-6.0 versus median 3.0, IQR 0.0-6.0; P=.003). The median overall compliance was 91.1% (IQR 67%-100%). In terms of acute exacerbation, 110 exacerbations were detected and confirmed by health care providers (per 6 months, median 2.0, IQR 1.0-5.0). Moreover, 72 adverse events occurred during the study, including 1 death, 19 hospitalizations, and 52 clinic visits due to persistent respiratory symptoms.

Conclusions

We designed and validated a feasible mHealth-based method to manage COPD in remote Chinese areas with limited medical resources. The proposed closed-loop care pathway was effective at the community level. Proper education and frequent communication with health care providers may encourage patients’ acceptance and use of smartphones to support COPD self-management. In addition, WeChat might play an important role in improving patient compliance and psychological distress. Further research might explore the effect of such systems on a larger scale and at a higher evidence level.

REALizing and improving management of stable COPD in China: a multi-center, prospective, observational study to realize the current situation of COPD patients in China (REAL) - rationale, study design, and protocol

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of death in China with a reported prevalence of 8.2% people aged ≥40 years. It is recommended that Chinese physicians follow Global Initiative for Chronic Obstructive Lung Disease (GOLD) and national guidelines, yet many patients with COPD in China remain undiagnosed. Furthermore, missed diagnoses and a lack of standardized diagnosis and treatment remain significant problems. The situation is further complicated by a lack of large-scale, long-term, prospective studies of real-world outcomes, including exacerbation rates, disease severity, efficacy of treatment, and compliance of COPD patients in China.

METHODS/DESIGN

The REALizing and improving management of stable COPD in China (REAL) study is a 52-week multi-center, prospective, observational trial. REAL aims to recruit approximately 5000 outpatients aged ≥40 years with a clinical diagnosis of COPD per GOLD 2016. Outpatients will be consecutively recruited from approximately 50 tertiary and secondary hospitals randomly selected across six geographic regions to provide a representative population. Patients will receive conventional medical care as determined by their treating physicians. The primary objective is to evaluate COPD patient outcomes including lung function, health status, exacerbations, hospitalization rate, and dyspnea following 1 year of current clinical practice. Secondary objectives are to assess disease severity, treatment patterns, adherence to medication, and associated risk factors. Data will be collected at two study visits, at patients' usual care visits, and by telephone interview every 3 months.

DISCUSSION

Knowledge of COPD among physicians in China is poor. The REAL study will provide reliable information on COPD management, outcomes, and risk factors that may help improve the standard of care in China. Patient recruitment began on 30 June 2017 and the estimated primary completion date is 30 July 2019.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03131362. Registered on 20 March 2017.