"The degree of airway obstruction that characterizes COPD is still under discussion since the Global Initiative for Chronic Obstructive Lung Disease (GOLD) has proposed a fixed post-bronchodilator ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of <0.70  as its criterion. This is widely applied, also for its practicability, but has been criticized for the risk of overdiagnosis . Other authors, on behalf of the American Thoracic Society (ATS) and the European Respiratory Society (ERS), have defined airway obstruction as a reduction in FEV1/FVC below the age-, gender-, and race-adjusted fifth percentile of a healthy, never-smoking population, which is regarded as the lower limit of normal (LLN) (FEV1/FVC/LLN) . "
[Show abstract][Hide abstract] ABSTRACT: The diagnosis of chronic obstructive pulmonary disease (COPD) is based on airflow obstruction. In epidemiological studies, spirometric data have often been lacking and researchers have had to rely almost solely on questionnaire answers. The aim of this study is to assess the diagnostic accuracy of questionnaire answers to detect COPD.
A sample of the Swedish general population without physician-diagnosed asthma was randomly selected and interviewed using a respiratory questionnaire. All eligible subjects aged 25-75 years (n = 3892) performed spirometry for detection of airflow obstruction using Global Initiative for Chronic Obstructive Lung Disease (GOLD) or American Thoracic Society (ATS)/European Respiratory Society (ERS) criteria. Sensitivity, specificity, positive likelihood ratio (LR+), positive predictive values (PPVs), and negative predictive values (NPVs) were calculated to define diagnostic accuracy of questionnaire answers.
The sensitivity of the question "Have you been diagnosed by a physician as having COPD or emphysema?" in detecting airflow obstruction was 5.7% using GOLD, and 9.8% using ATS/ERS, criteria; specificity was 99.7% for GOLD and 99.5% for ATS/ERS. Sensitivity, specificity, and PPV were higher for the question compared to self-reported symptoms of chronic bronchitis in identifying subjects with airflow obstruction.
The high specificity and good PPV suggest that the question "Have you been diagnosed by a physician as having COPD or emphysema?" is more likely to identify those who do not have airflow obstruction, whereas the low sensitivity of this question could underestimate the real burden of COPD in the general population.
BMC Pulmonary Medicine 03/2014; 14(1):49. DOI:10.1186/1471-2466-14-49 · 2.40 Impact Factor
"Current data suggest that there is underutilization of spirometry for detection and diagnosis of COPD . Various reasons given by primary care physicians for not utilizing spirometry include: limited access to spirometry, uncertainty about the impact of the test, inadequate or lack of reproducibility of patient effort, lack of provider training, difficulty in interpreting results, reimbursement issues, and time constraints in busy practice settings [13,14]. Despite dissemination of the newer recommendations in an effort to increase primary care physician’s utilization of COPD guidelines, many primary care physicians remain unaware of COPD guidelines and the diagnosis of COPD continues to be based on clinical findings alone . "
[Show abstract][Hide abstract] ABSTRACT: Background
Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US. Although a large number of individuals are diagnosed with COPD, many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms. Not only is there under-diagnosis but there is also evidence of sub-optimal evidence-based treatment of those who have COPD. Despite the development of international COPD guidelines, many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice.
This paper describes the design and rationale for a randomized, cluster design trial (RCT) aimed at translating the COPD evidence-based guidelines into clinical care in primary care practices. During Phase 1, a needs assessment evaluated barriers and facilitators to implementation of COPD guidelines into clinical practice through focus groups of primary care patients and providers. Using formative evaluation and feedback from focus groups, three tools were developed. These include a computerized patient activation tool (an interactive iPad with wireless data transfer to the spirometer); a web-based COPD guideline tool to be used by primary care providers as a decision support tool; and a COPD patient education toolkit to be used by the practice team. During phase II, an RCT will be performed with one year of intervention within 30 primary care practices. The effectiveness of the materials developed in Phase I are being tested in Phase II regarding physician performance of COPD guideline implementation and the improvement in the clinically relevant outcomes (appropriate diagnosis and management of COPD) compared to usual care. We will also examine the use of a patient activation tool - ‘MyLungAge’ - to prompt patients at risk for or who have COPD to request spirometry confirmation and to request support for smoking cessation if a smoker.
Using a multi-modal intervention of patient activation and a technology-supported health care provider team, we are testing the effectiveness of this intervention in activating patients and improving physician performance around COPD guideline implementation.
BMC Family Practice 05/2013; 14(1):56. DOI:10.1186/1471-2296-14-56 · 1.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Using a fixed ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) < 0.70 instead of the lower limit of normal (LLN) to define chronic obstructive pulmonary disease (COPD) may lead to overdiagnosis of COPD in elderly patients with heart failure (HF) and consequently unnecessary treatment with possible adverse health effects.
The aim of this study was to determine COPD prevalence in patients with chronic HF according to two definitions of airflow obstruction.
Spirometry was performed in 187 outpatients with stable chronic HF without pulmonary congestion who had a left ventricular ejection fraction <40% (mean age 69 ± 10 years, 78% men). COPD diagnosis was confirmed 3 months after standard treatment with tiotropium in newly diagnosed COPD patients.
COPD prevalence varied substantially between 19.8% (LLN-COPD) and 32.1% (GOLD-COPD). Twenty-three of 60 patients (38.3%) with GOLD-COPD were potentially misclassified as having COPD (FEV1/FVC < 0.7 but > LLN). In contrast to patients with LLN-COPD, potentially misclassified patients did not differ significantly from those without COPD regarding respiratory symptoms and risk factors for COPD.
One fifth, rather than one third, of the patients with chronic HF had concomitant COPD using the LLN instead of the fixed ratio. LLN may identify clinically more important COPD than a fixed ratio of 0.7.
Heart & lung: the journal of critical care 10/2013; 42(5):365-71. DOI:10.1016/j.hrtlng.2013.07.002 · 1.29 Impact Factor
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