0596 Providers Rarely Assess Obstructive Sleep Apnea Symptoms Among Patients with Chronic Obstructive Pulmonary Disease

Introduction

Professional societies recommend providers assess sleep symptoms in COPD, but it is unclear if this occurs. We aimed to evaluate OSA symptom assessment and documentation among patients with COPD, and the patient and provider characteristics associated with this assessment.

Methods

We conducted a cross-sectional study of adults aged ≥40 years with clinically diagnosed COPD and no prior diagnosis of OSA. We selected patients receiving care at two academic general internal medicine clinics between 6/1/2011 - 6/1/2013. We abstracted charts to assess how often OSA symptoms such as snoring, somnolence, witnessed apneas, or gasping/choking arousals were documented as present or absent. We performed multivariable mixed-effects logistic regression to assess associations of patient and primary care provider (PCP) factors with assessment of OSA symptoms. Patient factors included demographics, body mass index, comorbidities, healthcare utilization, and severity of COPD, and PCP factors including demographics, degree, and years of experience.

Results

Of 523 patients with COPD, only 26 (5.0%) had documentation of OSA symptom assessment within a one-year period. In mixed effects models, only referral to general pulmonary clinic was associated with the assessment of OSA symptoms (OR: 4.56, 95% CI 1.28-15.52). Among the 26 individuals who had OSA symptoms assessed, 9 (34.6%) reported snoring, 15 (57.7%) reported daytime somnolence, 2 (7.7%) reported gasping/choking arousals, and 5 (19.2%) reported witnessed apneas. Among those assessed for OSA symptoms, providers referred 11 (42.3%) for formal sleep consultation.

Conclusion

Providers rarely document OSA symptoms for patients with COPD in primary care clinic, but assessment is greater among those with pulmonary specialty consultation. Given time constraints in primary care, external facilitation of sleep symptom assessment may improve symptom recognition and receipt of appropriate services.

Support

NIH 5K23HL111116-05, VA Center of Innovation for Veteran-Centered and Value-Driven Care.

Patient-physician communication about end-of-life care for patients with severe COPD

Since patients with chronic obstructive pulmonary disease (COPD) infrequently discuss treatment preferences about end-of-life care with physicians, the goal of the present study was to identify which specific areas of communication about end-of-life care occur between patients with severe COPD and their physicians, and how patients rate the quality of this communication. A total of 115 patients with oxygen-dependent COPD, identified in pulmonary clinics in three hospitals and through an oxygen delivery company, were enrolled in this study. A 17-item quality of communication questionnaire (QOC) was administered to patients, along with other measures, including satisfaction with care. The patients reported that most physicians do not discuss how long the patients have to live, what dying might be like or patients' spirituality. Patients rated physicians highly at listening and answering questions. Areas patients rated relatively low included discussing prognosis, what dying might be like and spirituality/religion. Patients' assessments of physicians' overall communication and communication about treatment correlated well with the QOC. Patients' overall satisfaction with care also correlated significantly with the QOC. In conclusion, this study identifies areas of communication that physicians do not address and areas that patients rate poorly, including talking about prognosis, dying and spirituality. These areas may provide targets for interventions to improve communication about end-of-life care for patients with chronic obstructive pulmonary disease. Future studies should determine the responsiveness of these items to interventions, and the effect such interventions have on patient satisfaction and quality of care.

Comparing methods to identify general internal medicine clinic patients with chronic heart failure

OBJECTIVES

Identification of patients with left ventricular systolic dysfunction is the first step in identifying which patients may benefit from clinical practice guidelines. The purpose of this study was to develop and validate a computerized tool using clinical information that is commonly available to identify patients with left ventricular systolic dysfunction (LVSD).

METHODS

We performed a cross-sectional study of patients seen in a Department of Veterans Affairs General Internal Medicine Clinic who had echocardiography or radionuclide ventriculography performed as part of their clinical care.

RESULTS

We identified 2246 subjects who had at least one cardiac imaging study. A total of 778 (34.6%) subjects met study criteria for LVSD. Subjects with LVSD were slightly older than subjects without LVSD (70 years vs 68 years, P =.00002) but were similar with regard to sex and race. Subjects with LVSD were more likely to have prescriptions for angiotensin-converting enzyme (ACE) inhibitors, carvedilol, digoxin, loop diuretics, hydralazine, nitrates, and angiotensin II receptor antagonists. Of the variables included in the final predictive model, ACE inhibitors, loop diuretics, and digoxin exerted the greatest predictive power. Discriminant analysis demonstrated that models containing pharmacy information were consistently more accurate (75% accurate [65% sensitivity, 81% specificity]) than those models that contained only International Classification of Diseases, 9th revision (ICD-9), codes, including ICD-9 codes for congestive heart failure (72% accurate [80% sensitivity, 68% specificity]).

CONCLUSIONS

We demonstrated that an automated, computer-driven algorithm identifying LVSD permits simple, rapid, and timely identification of patients with congestive heart failure by use of only routinely collected data. Future research is needed to develop accurate electronic identification of heart failure and other common chronic conditions.

Regional variations in health status

CONTEXT

Knowledge about variations in the health status of patients seeking primary care in different parts of the United States is limited.

OBJECTIVE

To examine regional variations in the physical and mental health of patients receiving primary care in the largest integrated health care system in the United States which is operated by the Department of Veteran Affairs (VA).

STUDY DESIGN AND SETTING

We performed a mailed, cross sectional survey of 54,844 patients who were enrolled in seven VA General Internal Medicine clinics.

RESULTS

Among the 30,690 patients who returned an initial set of screening questionnaires, the prevalence of common chronic conditions varied by as much as 60% among the seven clinics. Moreover, patients' general health (measured by the SF-36) also varied significantly in a pattern that mirrored the observed differences in the prevalence of chronic conditions. After adjustment for important comorbid illnesses and sociodemographic factors, geographic site accounted for a small percentage of the explained variance in patient assessed health status.

CONCLUSIONS

The substantial differences in the health of patients enrolled in different VA primary clinics have important implications for the evaluation of clinical performance and health outcomes. Most of these differences can be attributed to sociodemographic and comorbid factors.

Risk of myocardial ischaemia and beta-adrenoceptor agonists

Modern therapy for both cardiovascular disease and obstructive lung disease involves diametrically opposed manipulations of the beta-adrenoceptor. Beta-agonists reduce airflow limitation and improve symptoms among patients with obstructive lung disease while beta-blockers reduce symptoms, recurrent myocardial ischaemia and all-cause mortality among patients with ischaemic heart disease. There is biological plausibility for beta-agonists leading to adverse cardiovascular outcomes, and observational trials have raised concern about the safety of beta-agonists among patients with cardiovascular disease. Although there are many potential causal and noncausal explanations for these observational findings, the implications from these studies are the same. Physicians should be careful when prescribing beta-agonists for patients at risk for ischaemic heart disease. Furthermore, careful consideration should be given to distinguish symptoms caused by cardiovascular versus respiratory aetiologies.

The risk of myocardial infarction associated with inhaled beta-adrenoceptor agonists

Beta-adrenoceptor agonists (beta-agonists), in widespread clinical use for obstructive lung disease, have been associated with an increased risk of cardiovascular mortality. The objective of this study was to assess the association between incident myocardial infarction and the use of inhaled beta-agonists. We performed a case-control study within the Group Health Cooperative of Puget Sound (GHC). Between 1989 and 1994, we identified 1,444 cases with an incident myocardial infarction and 4,094 control subjects frequency-matched on age, sex, hypertension, and index date. The computerized pharmacy database of the health maintenance organization (HMO) was used to assess the use of beta-agonists by metered dose inhaler (MDI). Cardiovascular risk factor information was obtained from medical record review. In comparison to subjects who did not fill a beta-agonist prescription, subjects who had filled one beta-agonist MDI prescription in the 3 mo prior to their index date had an elevated estimated risk of myocardial infarction (adjusted odds ratio [OR]: 1.67 [95% CI, 1.07 to 2.60]). The elevated risk was limited to those subjects who had a history of cardiovascular disease (adjusted OR: 3.22 [95% CI, 1.63 to 6.35]) and among those with cardiovascular disease, to new users of beta-agonists (adjusted OR: 7.32 [95% CI, 2.34 to 22.8]). There was no dose-response relationship between beta-agonists use and risk of myocardial infarction. In this study, new use of beta-agonists was associated with an increased risk of myocardial infarction, although we cannot determine if the association is causal. Our study suggests that clinicians should exercise caution when giving an initial beta-adrenoceptor agonist prescription to patients with cardiovascular disease.