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Feasibility and effectiveness of an Asthma/COPD service for primary care: a cross-sectional baseline description and longitudinal results

Feasibility and effectiveness of an Asthma/COPD service for primary care: a cross-sectional... www.nature.com/npjpcrm All rights reserved 2055-1010/15 ARTICLE OPEN Feasibility and effectiveness of an Asthma/COPD service for primary care: a cross-sectional baseline description and longitudinal results 1,2 1,2 1,2 3 4,5 Esther I Metting , Roland A Riemersma , Janwillem H Kocks , Margriet G Piersma-Wichers , Robbert Sanderman 1,2 and Thys van der Molen BACKGROUND: In 2007, an Asthma/chronic obstructive pulmonary disease (COPD) (AC) service was implemented in the North of the Netherlands to support General Practitioners (GPs) by providing advice from pulmonologists on a systematic basis. AIMS: To evaluate the feasibility and effectiveness of this service on patient-related outcomes. METHODS: We report baseline data on 11,401 patients and follow-up data from 2,556 patients. GPs can refer all patients with possible obstructive airway disease (OAD) to the service, which is conducted by the local laboratory. Patients are assessed in the laboratory using questionnaires and spirometry. Pulmonologists inspect the data through the internet and send the GP diagnosis and management advice. RESULTS: A total of 11,401 patients were assessed by the service, covering almost 60% of all adult patients with projected asthma or COPD in the area. In all, 46% (n = 5,268) of the patients were diagnosed with asthma, 18% (n = 2,019) with COPD and 7% (n = 788) with the overlap syndrome. A total of 740 (7%) patients were followed up after 3 months because the GP advised them to change medication. In this group, the proportion of unstable COPD patients (Clinical COPD Questionnaire (CCQ)⩾ 1) decreased from 63% (n = 92) at baseline to 49% (n = 72). The proportion of patients with uncontrolled asthma (Asthma Control Questionnaire (ACQ)⩾ 1.5) decreased from 41% (n = 204) to 23% (n = 115). In all, 938 (8%) patients were followed up after 12 months. From these patients, the proportion of unstable COPD patients (CCQ ⩾ 1) decreased from 47% (n = 115) to 44% (n = 107). The proportion of patients with uncontrolled asthma (ACQ⩾ 1.5) decreased from 16% (n = 95) to 14% (n = 85). CONCLUSION: The AC service assessed a considerable proportion of patients with OAD in the area, improved patients’ outcomes, and is considered to be feasible and effective. npj Primary Care Respiratory Medicine (2015) 25, 14101; doi:10.1038/npjpcrm.2014.101; published online 8 January 2015 INTRODUCTION guidelines for common diseases, of which only three are 8–10 concerned with asthma, asthma in children, and COPD. GPs Asthma and chronic obstructive pulmonary disease(COPD) are therefore could benefit from the knowledge and experience of prevalent chronic diseases in the community. In the Netherlands, pulmonologists by obtaining advice for each patient with 60 to 80% of all asthma and COPD patients are treated by their pulmonary symptoms. Cooperation between GPs and other general practitioner (GP), and patients are only referred to the caregivers in integrated care projects for COPD patients has been pulmonologist in case of severe uncontrolled asthma or severe 2 3–5 proven to be effective in improving the quality of life and health COPD. Misdiagnosis and underdiagnosis are common, as status of patients, thus reducing costs and the number of asthma and COPD overlap in symptoms, whereas their treatments 11,12 hospitalisations. Asthma/COPD services in which GPs are are different. Some patients have both asthma and COPD, the so- supported by pulmonologists in interpreting spirometry results called overlap syndrome, which can be described as (partly) are feasible and might improve diagnostic accuracy. GPs and reversible but progressive deterioration in lung function, often pulmonologists in the North of the Netherlands collaborated and combined with a history of smoking and previous diagnosis of implemented the Asthma/COPD (AC) service in 2007 as a support asthma and/or allergies. These diagnostic problems may lead to service for GPs. The aim of this service is to improve the suboptimal treatment, whereas early correct treatment can reduce management of asthma and COPD patients in primary care. costs, morbidity and mortality, can improve symptoms and 3–5,7 Although the service was not developed for scientific reasons, enhance patient outcomes. In daily clinical practice, many GPs often lack the knowledge, data from included patients are available for research. This paper time and enthusiasm to perform all tasks that are recommended describes the development and feasibility of this service, the by guidelines. For example, Dutch GPs are obliged to follow 96 patient population and its effect on patient-related outcomes. 1 2 Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; GRIAC Research Institute Groningen, University of 3 4 Groningen, University Medical Center Groningen, Groningen, The Netherlands; Certe Laboratories, Groningen, The Netherlands; Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands and Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands. Correspondence: EI Metting (E.I.Metting@umcg.nl) Received 3 June 2014; revised 26 August 2014; accepted 5 October 2014 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al MATERIALS AND METHODS Feasibility analyses. Feasibility was assessed by analysing the following: (1) the proportion of GPs in the target area who used the AC service Design and feasibility between 2007 and 2012; (2) the proportion of patients with asthma or Meetings with local physicians were organised, resulting in four starting COPD who were assessed by the service in the target area since 2007; principles: (1) the service should optimise diagnosis, treatment and (3) the quality of the spirometry; (4) the number of patients that could be management; (2) the GP is in lead; (3) the service should be easily diagnosed, and the variation in diagnostic pattern between the different accessible for patients and physicians; (4) allocation of tasks between pulmonologists by using chi-square. primary and secondary care have to be defined clearly. Yearly meetings are organised to inform physicians about current developments, discuss Follow-up visits. Patients for whom medication change was advised by casuistry and enhance commitment. the pulmonologist were automatically scheduled for an additional follow- up assessment after 3 months (range 2–4 months, n = 740). If the GP The role of the GP. GPs can refer individual patients (⩾ 8 years of age) who requested follow-up visits and no medication change was advised, patients are suspected to have asthma, COPD, overlap syndrome or present with were assessed after 12 months (range 10–14, n = 938). Baseline data of pulmonary symptoms of unknown origin further referred to as obstructive adult patients on exacerbations/year, smoking status, inhalation technique, airway disease (OAD). The GP can also choose to refer all OAD patients in ACQ and CCQ scores were compared with follow-up data. Nonparametric his/her practice on the basis of inhaled medication use and/or courses of paired tests were used to compare baseline data with follow-up data. prednisolone. When preferred by the GP, referral may also include follow- Paired t-tests were used for the longitudinal evaluation of FEV (in litres). up assessments by the AC service. Finally, the GP decides what to do with Follow-up data of baseline GOLD stages are presented to show the the advice of the pulmonologist and is responsible for the disease distribution of these patients to other GOLD stages. To prevent overlap in management. our results, we excluded patients with 41 follow-up assessment in 1 year (n = 79). Self-reported information by patients. Patients complete the ‘Asthma Control Questionnaire (ACQ),’ the ‘Clinical COPD Questionnaire (CCQ)’ and a medical history questionnaire assessing gender, age, age of onset, family RESULTS history, symptoms, exacerbations (having used oral corticosteroids or Baseline patient characteristics are presented in Tables 1 and 2. antibiotics for lung problems), allergy and other stimuli-provoking symptoms, medication, occupation and smoking history as part of the Feasibility regular assessment procedure. The ACQ is used to measure asthma control and contains six questions The service included around 2,000 (range: 1,813–2,109) new (range 0–6), and the total score can be divided into ‘controlled’ (o0.75), patients yearly from 79.3% of the GPs in the target area. ‘partially controlled’ (0.75–1.50) and ‘uncontrolled’ (⩾ 1.50). The CCQ is Approximately 50% of patients were included by practice screen- used to measure COPD health status, and it contains 10 questions. The ing. In all, 60% of all adult asthma and COPD patients in the target total score (range 0–6) can be distributed between ‘stable’ (o1), ‘not 18,19 area were assessed at least once by the AC service. 1,2 2,3 entirely stable’, ‘unstable’ and ‘very unstable’ (⩾ 3). This questionnaire Pulmonologists considered the quality of 93.6% of the spirometry contains three subdomains with four questions about functional status, graphs to be usable for diagnosis and could diagnose 79.4% of the four questions about symptoms and two questions about mental 14,15 patients (asthma: 45.8%, COPD: 17.8%, overlap syndrome: 6.9%). status. See Supplementary 1 for an overview of COPD GOLD A, B, C and D patients at baseline. Baseline diagnosis was compared with follow- Assessment by the trained lung function technician. The assessments take place in local laboratories according to a strict protocol. The following up diagnosis, and it did not change during the follow-up in 91.2% measurements are taken: (confidence interval: 89.4–92.7%) of baseline asthma patients, in 87.7% (confidence interval: 84.4–90.4%) of baseline COPD patients Body mass index. and in 74.2% (confidence interval: 68.0–79.5%) of baseline overlap Evaluation and, if needed, instruction of the inhalation technique syndrome patients. There was variation in diagnostic pattern in according to the Dutch ‘Inhalation Medication Instruction School’ adult patients between the different pulmonologists (n = 10, guidelines. Po0.000); see Figure 1. Spirometry according to international guidelines. Follow-up visits All data, including the scores on the questionnaires, are inserted in an Electronic Diagnostic Support (EDS) system. Patients frequently changed from GOLD (2013) category, and many GOLD D patients (n = 74) moved to other GOLD categories The role of the pulmonologist. Pulmonologists are trained in using the at follow-up (Follow-up category: GOLD A: 21.6%, B: 36.5%, service by following at least two training sessions. In this paper, we C: 6.8%, D: 35.1%); see Figure 2. included pulmonologists who had assessed ⩾ 300 patients to avoid the influence of learning effects. Pulmonologists assess the quality of the Patients advised to change medication (Patients followed-up after 3 spirometry, inspect all outcomes in the Electronic Diagnostic Support months, total = 740). Inhalation technique improved significantly 2,17 system and make a report (based on current international guidelines ) (correct at baseline 35.1% to 52.5% after 3 months, n total = 459, with diagnosis, follow-up and treatment advice. Treatment advice can Po0.000). The proportion of well-controlled asthma patients include lifestyle advice (e.g., dietician, smoking cessation or physical increased from 23.9% (baseline) to 49.5% (3 months, n total = 487, activity) or medication change. Pulmonologists were not provided with Po0.000), and the proportion of stable COPD patients increased strict diagnostic rules. The GPs receive the report from the pulmonologist from 27.4% (baseline) to 48.9% (3 months, n total = 145, P = 0.004). within 5 working days through the internet directly in their patient information system. The proportion of GOLD D patients decreased from 12.8% at baseline to 6.7% after 3 months; see Table 3 (n total = 145, Po0.000). Statistical data analyses IBM-SPSS version 22 was used for statistical analysis. The baseline Patients advised to continue current medication (Patients followed- population was described by age, gender, body mass index, exacerbation up after 12 months, n = 938). Inhalation technique did improve history, smoking history, lung function performances, diagnosis and GOLD significantly (correct baseline 37.4 to 49.9% after 12 months, 2013 category (A, B, C and D). A positive bronchodilator response was n = 741, Po0.000). The proportion of current smokers decreased defined as an increase in forced expiratory volume in 1 s (FEV )of ⩾ 12% from 25.2% at baseline to 23.2% after 12 months (n = 984, and ⩾ 200 ml. The median scores of GOLD A, B, C and D patients on the CCQ subscales are presented. P = 0.013). The proportion of asthma and COPD patients with ⩾ 1 npj Primary Care Respiratory Medicine (2015) 14101 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al Table 1. Baseline characteristics of the total patient population in the Table 2. Baseline characteristics of the patient population per AC tele-medicine service diagnosis Variable Total group, n = 11,401 Variable COPD, Overlap Asthma, n = 2,031 syndrome, n = 5,223 Diagnosis of n (%) n = 787 COPD 2,031 (17.8) Very unstable (CCQ⩾ 3) 161 (8.0) Gender and age n (%) n (%) n (%) Asthma 5,223 (45.8) Male 1,190 (58.6) 388 (49.3) 2,007 (38.4) Uncontrolled (ACQ⩾ 1.50) 2,049 (39.3) Self-reported ⩾ 1 243 (12.0) 312 (39.6) 2,658 (50.9) Asthma/COPD overlap syndrome 787 (6.9) allergy Very unstable (CCQ⩾ 3) 77 (9.9) Uncontrolled (ACQ⩾ 1.50) 308 (39.4) Mean (s.d.) Mean (s.d.) Mean (s.d.) Indication for restriction 159 (1.4) Age, years 66.6 (10.8) 60.6 (12.3) 43.6 (18.7) No lung disease 796 (7.0) Age of onset, years 52.2 (19.6) 33.6 (23.1) 22.3 (19.6) Unclear diagnosis 2,354 (20.6) Body mass index (kg/ 26.6 (4.8) 27.1 (4.9) 26.7 (6.0) Missing at random 15 (0.1) m ) Exacerbations in the 0.7 (1.1) 0.9 (1.2) 0.8 (1.2) Diagnosis is unclear because of n (%) last 12 months Incorrect lung function test 297 (12.6) Unknown 2,057 (87.4) Lung function post bronchodilator, mean (s.d.) FEV (L) 2.0 (0.7) 2.3 (0.7) 3.1 (0.9) Referral to pulmonologist because of n (%) FEV % predicted 69.0 (18.1) 76.0 (15.5) 94.6 (15.1) Unclear diagnosis 1,966 (54.7) FVC (L) 3.6 (1.0) 3.7 (1.1) 4.0 (1.1) Indication of restriction 18 (0.005) FVC % predicted 98.6 (18.4) 102.1 (17.2) 101.1 (16.3) Unable to perform lung function test 18 (0.005) FEV /FVC 56.0 (11.2) 61.0 (9.5) 79.3 (8.8) COPD 558 (15.5) Reversibility 6.4 (7.9) 11.2 (10.0) 6.7 (7.6) FEV o50% predicted 302 (54.3) Asthma/COPD overlap syndrome 214 (6.0) Positive BDT adults, n (%) FEV o50% predicted 27 (12.7) Post FEV /FVCo70% 198 (99.0) 236 (91.5) 204 (25.0) 1 1 Asthma 690 (19.2) Post FEV / 2 (1.0) 22 (8.5) 358 (43.8) Unstable (ACQ⩾ 1.50) 469 (68.2) FVC= 70–80% Total 3,593 (31.5) Post FEV / 214(26.2) FVC= 80–90% Quality lung function test n (%) Post FEV /FVC⩾ 90% 40 (4.9) Sufficient 10,670 (93.6) Total 200 (10.7) 258 (34.8) 817 (16.6) Insufficient 730 (6.4) Inhalation technique ,n (%) In 31.5% of the assessments, the pulmonologist advised the GP to refer Correct 325 (36.1) 205 (36.5) 1,434 (38.0) their patient to secondary care mostly because of unclear diagnosis Incorrect 576 (63.9) 357 (63.5) 2,339 (62.0) (54.7%). Most patients with unclear diagnosis (age, 51± 19; age of onset, 39± 23; 42% male) had no obstruction (FEV /FVC⩾ 70%: 90%), no positive Smoking history (age⩾ 18 years), n (%) bronchodilator response (93%) and no allergy (76%). However, these Smoking history 8 (0.4) 0 (0.0) 17 (0.4) patients were high in symptoms (CCQ ⩾ 1: 68%). missing Abbreviations: AC, asthma/COPD; ACQ, Asthma Control Questionnaire; Never smoked 70 (3.4) 54 (6.9) 2,041 (43.4) CCQ, Clinical COPD Questionnaire; COPD, chronic obstructive pulmonary Quit ⩾ 12 months ago 948 (46.7) 378 (48.0) 1,628 (34.6) disease; FEV , forced expiratory volume in one second; FVC, forced vital Current smoker 1,005 (49.5) 355 (45.1) 1,014 (21.6) capacity; GP, general practitioner. Males 517 (51.4) 151 (42.5) 383 (37.8) Males motivated to 304 (58.8) 89 (58.9) 231 (60.3) quit exacerbation last year decreased (asthma: 35.0% at baseline, Females 475 (47.3) 197 (55.5) 614 (60.6) 25.2% at 12 months, P40.000; COPD: 34.8% at baseline, 25.4% at Females motivated 295 (62.1) 112 (56.8) 407 (66.3) to quit 12 months, P = 0.010); see Table 4. Abbreviations: BDT, bronchodilator test; COPD, chronic obstructive pulmonary disease; FEV , forced expiratory volume in one second; FVC, DISCUSSION forced vital capacity. Main findings Increase in FEV pre bronchodilator compared with FEV post broncho- 1 1 dilator. In this study, we have evaluated over 11,000 patients referred by Positive bronchodilator response test defined as a reversible lung 360 different GPs to the Asthma/COPD (AC) service in the North of function of ⩾ 200 ml and ⩾ 12% increase in FEV pre bronchodilator the Netherlands. With 60% of all asthma and COPD patients in the compared with FEV post bronchodilator. area participating, the service is well implemented in the target c Adult asthma patients (male: 59%, mean age: 52 years, 19% current area. We chose to report the follow-up results from patients who smokers) with obstruction before and after bronchodilator. were advised to change medication after 3 months separately from the patients who were advised to continue with their patients moved to other categories after baseline visit; some of medication and were scheduled to have a 12-month follow-up. If a these patients (22%) even improved to GOLD category A. Given change in medication was advised, after 3 months, health status these results, we consider the AC service to be a feasible and improved in COPD patients and asthma control improved in effective collaboration service for primary and secondary care. asthma patients. Asthma and COPD patients who did not need medication change and were referred to the yearly follow-up Interpretation of findings in relation to previously published work assessment stabilised in asthma control and in COPD health status. Overlap syndrome patients in this group improved in According to the Global Initiative for Asthma guidelines, asthma control and health status. Most (65%) of the GOLD D uncontrolled asthma patients would be eligible for referral to © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited npj Primary Care Respiratory Medicine (2015) 14101 Feasibility and effectiveness of an AC service EI Metting et al secondary care. The prevalence of uncontrolled asthma patients Lucas et al. Diagnoses during follow-up visits in our AC service (see in our population (age ⩾ 16 years) is lower (40%) than the Figure 1) showed that most of the diagnoses were consistent. prevalence found in the INSPIRE study where 51% of the patients Although diagnoses are to some extent subjective, the advantage had uncontrolled asthma. Only 13% of our asthma patients were of the system is that the GP can compare his own choices with the advised to be referred to secondary care (see Table 1), meaning diagnoses and advices from the pulmonologist. We believe that that the pulmonologists did not follow the Global Initiative for this internet-based consultation in the long run might improve Asthma guidelines. However, we do not know whether the GP skills in the management of OADs. followed the referral recommendation of the pulmonologist. Van den Bemt et al. presented a service for COPD patients and The accuracy of the diagnosis in Asthma/COPD support systems concluded that it was not clinically effective. However, their is of pivotal importance. Lucas et al. showed previously that a population consisted of already-diagnosed COPD patients, and all diagnosis based on paper patient data without life contact in an patients had performed spirometry previously to inclusion, AC service is comparable with diagnoses acquired by a face-to- whereas we followed up both previously diagnosed and newly face consultation. The level of agreement on diagnoses between diagnosed patients. We speculate that the room for improvement paper data and face-to-face diagnoses was κ = 0.82, which in our population of a wide range of patients was higher, which exceeded the level of inter-doctor agreement from the different might have contributed to the positive effect. Furthermore, assessing pulmonologists (κ = 0.64 ). We used comparable history internet is used for data exchange, and GPs receive the report questions and spirometry as Lucas et al. used, and we assume that from the pulmonologist mostly within 5 working days electro- the diagnostic accuracy will be comparable as in the study of nically in their patient information system, which makes the service user friendly. Next to that, the use of Internet and the trained lung function technicians make the service cost-effective. Direct costs were covered by reimbursement for the spirometry in primary care, including the involvement of the pulmonologist. Generalisability. Our asthma patients differed from COPD patients, whereas the characteristics of overlap syndrome patients fell between asthma and COPD patients. This was also described by Postma et al. who showed that asthma patients are younger, more frequently female and have less frequently a history of smoking. Miravitlles et al. showed the same pattern of patient characteristics in their primary care population, although the proportion of male patients in their overlap syndrome population was much lower than in the AC population (Miravitlles: 26%, AC service: 49%). Characteristics of our asthma patients (⩾16 years) were comparable with asthmatics from the INSPIRE study (AC service: male, 38%; mean age, 46 ± 17 years; current smokers, 21%. INSPIRE: male 35%; mean age, 45 ± 17 years; current Figure 1. This picture shows the variation in diagnoses in adult smokers, 21%). patients between the assessing pulmonologists. Most variation is When considering overlap syndrome as a subtype of COPD, the seen in the diagnoses of asthma and other (unclear diagnoses, prevalence of overlap syndrome in our COPD population was 28%, indication for restriction or no disease). The variation in diagnoses which is comparable to the prevalence found by Ställberg et al. between the pulmonologists was significant (Chi-square = 580, n= 10,656, Po0.000). (25%) but higher than the prevalence reported by Postma et al. Figure 2. Distribution of COPD patients at baseline (n (total) = 2,004) according to the new GOLD classification of airflow limitation. Apparent is the large proportion of patients at risk: 22% of the COPD patients were classified as GOLD D. GOLD D patients have a high risk of exacerbations combined with a high burden of disease. npj Primary Care Respiratory Medicine (2015) 14101 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al Table 3. Longitudinal differences in lung function, exacerbations, health status and asthma control of patients assessed at baseline and after 3 months (range: 2–4 months, n total= 740) Diagnosis n Baseline After 3 months P value Asthma (n = 503) n (%) n (%) ⩾ 1 exacerbation last year 483 188 (38.9) Current smoker 497 92 (18.5) 87 (17.5) NS Sufficient inhalation technique 320 120 (37.5) 173 (54.1) o0.000 Well controlled (ACQo0.75) 497 119 (23.9) 246 (49.5) o0.000 Partially controlled (ACQ⩾ 0.75 and o1.50) 174 (35.0) 136 (27.4) Uncontrolled (ACQ ⩾ 1.50) 204 (41.0) 115 (23.1) Mean (s.d.) Mean (s.d.) FEV (L) 455 3.0 (0.9) 2.9 (0.9) o0.000 1pre COPD (n = 148) n (%) n (%) ⩾ 1 exacerbation 148 60 (40.5) Current smoker or quit o12 months ago 147 63 (42.9) 62 (42.2) NS Sufficient inhalation technique 79 19 (24.1) 38 (48.1) NS Stable (CCQo1) 147 55 (37.4) 75 (51.0) 0.004 Not entirely stable (CCQ⩾1&o2) 64 (43.5) 48 (32.7) Unstable (CCQ⩾ 2 and o3) 19 (12.9) 18 (12.2) Very unstable (CCQ⩾ 3) 9 (6.1) 6 (4.1) Mean (s.d.) Mean (s.d.) FEV (L) 148 2.1 (0.6) 2.1 (0.6) NS 1pre Overlap syndrome (n = 82) n (%) n (%) ⩾ 1 exacerbation 82 41 (50.0) Current smoker or quit o12 months ago 82 33 (40.2) 34 (41.5) NS Sufficient inhalation technique 58 21 (36.2) 29 (50.0) NS Well controlled (ACQo0.75) 82 35 (42.7) 48 (58.5) NS Partially controlled (ACQ⩾ 0.75 and o1.50) 30 (36.6) 19 (23.2) Uncontrolled (ACQ ⩾ 1.50) 17 (20.7) 15 (18.3) Stable (CCQo1) 31 8 (25.8) 16 (51.6) 0.073 Not entirely stable (CCQ⩾1&o2) 16 (51.6) 11 (35.5) Unstable (CCQ⩾ 2 and o3) 7 (22.6) 2 (6.5) Very unstable (CCQ⩾ 3) 0 (0.0) 2 (6.5) Mean (s.d.) Mean (s.d.) FEV (L) 81 2.3 (0.6) 2.3 (0.7) NS 1pre Patients were referred to the 3-month follow-up assessment if change in medication was advised by the pulmonologist. Abbreviations: ACQ, Asthma Control Questionnaire; CCQ, Clinical COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FEV , forced expiratory volume in one second; NS, not significant. P values are two-sided and P values ⩾ 0.10 are reported as ‘NS’. Exacerbations are defined as having used oral corticosteroids or antibiotics for lung problems last year. Inhalation technique in patients who use medication at baseline. (13–20%). Our overlap patients have more frequent exacerba- ⩾ 90%), the proportion of patients with a positive BDT was 5%, tions compared with the asthma and COPD patients, which whereas in asthma patients with very poor lung function indicate that these patients are more at risk for future exacerba- (FEV /FVC post bronchodilator o70%), this proportion was 40%. 24,27,28 tions. This high risk was confirmed in other studies. Others have also shown that reversibility in asthmatic patients Although these patients are more at risk, at baseline only the depends on the severity of asthma as measured by the CCQ scores reflect this poor health status (CCQ ⩾ 3: COPD, 8%; impairment in lung function. Although COPD is considered to overlap syndrome, 10%). Overlap patients were assessed by using be a nonreversible obstructive lung disease, 11% of our COPD the ACQ and the CCQ, because these questionnaires were part of patients had a BDT response, and the average reversibility was 6%. the regular assessment in the AC collaboration service. However, In the UPLIFT study, 50% of the COPD patients showed significant no validated measurements are available to assess the health reversibility. Obviously, real-life COPD populations differ from status and disease control in overlap patients. COPD patients in selected populations, as confirmed by Kruis et al. Bronchodilator the AC service were distributed according to the GOLD guidelines response was more prevalent in COPD patients with severe using CCQ cutoff value of 41 (A: 28%, B: 40%, C: 8% and D: 24%). disease. The highest proportion of patients with positive BDT Lange et al. distributed 6,628 Danish COPD patients using the response was seen in the overlap syndrome patients (35%), which modified Medical Research Council and found another distribution is consistent with the GOLD and Global Initiative for Asthma (A: 77%, B: 14%, C: 4% and D: 4%). Apart from the difference in recommendations. symptom assessment by using the CCQ instead of the modified Medical Research Council, our COPD sample of primary care– Risk factors. The proportion of smoking COPD and overlap treated patients is obviously more at risk and has more symptoms syndrome patients (COPD: 50%, overlap syndrome: 45%) was than the Danish general population. much higher than in the Dutch population, which is 27%, and also higher than the COPD population presented by Warnier et al. Reversibility. Only 17% of our asthma patients had a positive (37%). Our definition of smokers might have contributed to the bronchodilator test (BDT) response. In asthma patients with good higher proportion, because we considered quitters o12 months lung function (FEV /forced vital capacity (FVC) after bronchodilator ago as current smokers. The AC service does not provide any © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited npj Primary Care Respiratory Medicine (2015) 14101 Feasibility and effectiveness of an AC service EI Metting et al Table 4. Longitudinal differences in lung function, exacerbations, health status and asthma control of patients referred by their GP to single or yearly follow-up assessment after 12 months (range 10–14 months, n total= 991). Patients in this table were not assessed after 3 months Diagnosis n Baseline After 12 months P value Asthma (n = 598) n (%) n (%) ⩾ 1 exacerbation 572 200 (35.0) 144 (25.2) o0.000 Current smokers or quit o12 months ago 595 88 (14.8) 81 (13.6) NS Sufficient inhalation technique 471 185 (39.3) 251 (53.3) o0.000 Well controlled (ACQo0.75) 591 377 (63.8) 383 (64.8) NS Partially controlled (ACQ⩾ 0.75 and o1.50) 119 (20.1) 123 (20.8) Uncontrolled (ACQ ⩾ 1.50) 95 (16.1) 85 (14.4) Mean (s.d.) Mean (s.d.) FEV (L) 596 3.1 (0.9) 3.0 (0.9) o0.000 1pre COPD (n = 245) n (%) n (%) ⩾ 1 exacerbation 244 85 (34.8) 62 (25.4) 0.010 Current smokers or quit o12 months ago 243 109 (44.9) 99 (40.7) 0.017 Sufficient inhalation technique 177 59 (33.3) 78 (44.1) 0.034 Stable (CCQo1) 243 128 (52.7) 136 (56.0) NS Not entirely stable (CCQ⩾ 1 and o2) 79 (32.5) 74 (30.5) Unstable (CCQ⩾2&o3) 23 (9.5) 24 (9.9) Very unstable (CCQ⩾ 3) 13 (5.3) 9 (3.7) Mean (s.d.) Mean (s.d.) FEV (L) 244 2.2 (0.7) 2.1 (0.6) o0.000 1pre Overlap syndrome (n = 88) n (%) n (%) ⩾ 1 exacerbation 88 34 (38.6) 25 (28.4) NS Current smokers or quit o12 months ago 88 38 (43.2) 34 (38.6) 0.094 Sufficient inhalation technique 66 24 (36.4) 28 (42.4) NS Well controlled (ACQo0.75) 87 37 (42.5) 48 (55.2) 0.032 Partially controlled (ACQ⩾ 0.75 and o1.50) 25 (28.7) 21 (24.1) Uncontrolled (ACQ ⩾ 1.50) 25 (28.7) 18 (20.7) Stable (CCQo1) 65 24 (36.9) 30 (46.2) 0.027 Not entirely stable (CCQ ⩾1& o2) 27 (41.5) 26 (40.0) Unstable (CCQ⩾ 2 and o3) 7 (10.8) 7 (10.8) Very unstable (CCQ⩾ 3) 7 (10.8) 2 (3.1) Mean (s.d.) Mean (s.d.) FEV (L) 88 2.3 (0.7) 2.2 (0.7) o0.000 1pre Abbreviations: ACQ, Asthma Control Questionnaire; CCQ, Clinical COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FEV , forced expiratory volume in one second; GP, general practitioner; NS, not significant. P values are two-sided and P values ⩾ 0.10 are reported as ‘ns’. Exacerbations are defined as having used oral corticosteroids or antibiotics for lung problems last year. Inhalation technique in patients who use medication at baseline. cessation intervention but informs the GP if their patients are differences in mortality rates between GOLD A, B, C and D. motivated to quit. The follow-up time of 12 months could not Therefore, we assume that missed mortality rates hardly affected reveal the number of quitters (412 months) as a result of the our COPD follow-up results. possible intervention of the GP. Like in other studies, many patients (64%) showed an Implications for future research, policy and practice insufficient inhalation technique. Although the inhalation techni- Relatively simple support for GPs in diagnosing and managing que improved after 3 (50%) and 12 months (47%) of follow-up patients with a chronic disease by specialists might result in after our standard instruction as recommended in the Dutch improved outcomes for these patients in the community. guidelines, it is debatable whether this instruction is sufficiently Principles of the AC service might also be suitable in other effective. Further research on effective instruction seems to be chronic diseases. The large electronic database from the AC needed. service provides unique opportunities for further research in primary care patients with OADs. Strengths and limitations of this study The strength of this study is the large population of primary care Conclusion OAD patients in real life and the strict protocol used to assess The AC service is feasible, effective and efficient in supporting GPs these patients. A limitation is that the AC service was not to diagnose and manage asthma, COPD and overlap syndrome established for scientific reasons, resulting in limited follow-up patients. The service stimulates cooperation between primary and results, and data could not be compared with a control group. secondary care, and delivers support to patients locally which is Therefore, we cannot rule out that results might have been important in rural areas. affected by regression to the mean, although regression to the mean (measured by 1 − ρ) is small; see Supplementary 2. We also do not have data on mortality; however, on the basis of national ACKNOWLEDGEMENTS mortality data, we assume that 1.8% of the COPD patients have We thank the Northern General Practitioners Laboratory Groningen (LabNoord died in 1 year. Leivseth et al. showed that there are no large currently Certe Laboratories) for giving us the opportunity to realise the AC service. npj Primary Care Respiratory Medicine (2015) 14101 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al CONTRIBUTIONS 19 Nationaal Kompas Volksgezondheid. Hoe vaak komt COPD voor en hoeveel mensen sterven eraan? 2013; Available at http://www.nationaalkompas.nl/ All authors have contributed to writing and revising the manuscript. gezondheid-en-ziekte/ziekten-en-aandoeningen/ademhalingswegen/copd/omvang/. Accessed 13 February 2014. 20 Partridge M, van dM, Myrseth S, Busse W. Attitudes and actions of asthma COMPETING INTERESTS patients on regular maintenance therapy: the INSPIRE study. BMC Pulm Med 2006; RAR is a member of the advisory board of Certe Laboratories. MGP-W is the 6:13. director of Certe Laboratories. 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Publishing Company: Oxford, UK, 2002, pp 204–205, 206, 207. 15 van der Molen T, Willemse BW, Schokker S, ten Hacken NH, Postma DS, Juniper EF. 38 Leivseth L, Brumpton BM, Nilsen TI, Mai XM, Johnsen R, Langhammer A. GOLD Development, validity and responsiveness of the Clinical COPD Questionnaire. classifications and mortality in chronic obstructive pulmonary disease: the HUNT Health Qual Life Outcomes 2003; 1:13. Study, Norway. Thorax 2013; 68:914–921. 16 American Thoracic Society/European Respiratory Society Task Force. Standards for the Diagnosis and Management of patients with COPD 2004; Available at http:// www.thoracic.org/clinical/copd-guidelines/resources/copddoc.pdf This work is licensed under a Creative Commons Attribution- 17 Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global stategy for NonCommercial-NoDerivatives 4.0 International License. The images the diagnosis, management, and prevention of COPD. 2013; Available at http:// or other third party material in this article are included in the article’s Creative Commons www.goldcopd.org/. license, unless indicated otherwise in the credit line; if the material is not included under 18 Nationaal Kompas Volksgezondheid. Astma. 2014; Available at http://www.natio the Creative Commons license, users will need to obtain permission from the license naalkompas.nl/gezondheid-en-ziekte/ziekten-en-aandoeningen/ademhalingswe holder to reproduce the material. To view a copy of this license, visit http:// gen/astma/. 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Feasibility and effectiveness of an Asthma/COPD service for primary care: a cross-sectional baseline description and longitudinal results

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Medicine & Public Health; Medicine/Public Health, general; Primary Care Medicine; Internal Medicine; Pneumology/Respiratory System; Thoracic Surgery
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www.nature.com/npjpcrm All rights reserved 2055-1010/15 ARTICLE OPEN Feasibility and effectiveness of an Asthma/COPD service for primary care: a cross-sectional baseline description and longitudinal results 1,2 1,2 1,2 3 4,5 Esther I Metting , Roland A Riemersma , Janwillem H Kocks , Margriet G Piersma-Wichers , Robbert Sanderman 1,2 and Thys van der Molen BACKGROUND: In 2007, an Asthma/chronic obstructive pulmonary disease (COPD) (AC) service was implemented in the North of the Netherlands to support General Practitioners (GPs) by providing advice from pulmonologists on a systematic basis. AIMS: To evaluate the feasibility and effectiveness of this service on patient-related outcomes. METHODS: We report baseline data on 11,401 patients and follow-up data from 2,556 patients. GPs can refer all patients with possible obstructive airway disease (OAD) to the service, which is conducted by the local laboratory. Patients are assessed in the laboratory using questionnaires and spirometry. Pulmonologists inspect the data through the internet and send the GP diagnosis and management advice. RESULTS: A total of 11,401 patients were assessed by the service, covering almost 60% of all adult patients with projected asthma or COPD in the area. In all, 46% (n = 5,268) of the patients were diagnosed with asthma, 18% (n = 2,019) with COPD and 7% (n = 788) with the overlap syndrome. A total of 740 (7%) patients were followed up after 3 months because the GP advised them to change medication. In this group, the proportion of unstable COPD patients (Clinical COPD Questionnaire (CCQ)⩾ 1) decreased from 63% (n = 92) at baseline to 49% (n = 72). The proportion of patients with uncontrolled asthma (Asthma Control Questionnaire (ACQ)⩾ 1.5) decreased from 41% (n = 204) to 23% (n = 115). In all, 938 (8%) patients were followed up after 12 months. From these patients, the proportion of unstable COPD patients (CCQ ⩾ 1) decreased from 47% (n = 115) to 44% (n = 107). The proportion of patients with uncontrolled asthma (ACQ⩾ 1.5) decreased from 16% (n = 95) to 14% (n = 85). CONCLUSION: The AC service assessed a considerable proportion of patients with OAD in the area, improved patients’ outcomes, and is considered to be feasible and effective. npj Primary Care Respiratory Medicine (2015) 25, 14101; doi:10.1038/npjpcrm.2014.101; published online 8 January 2015 INTRODUCTION guidelines for common diseases, of which only three are 8–10 concerned with asthma, asthma in children, and COPD. GPs Asthma and chronic obstructive pulmonary disease(COPD) are therefore could benefit from the knowledge and experience of prevalent chronic diseases in the community. In the Netherlands, pulmonologists by obtaining advice for each patient with 60 to 80% of all asthma and COPD patients are treated by their pulmonary symptoms. Cooperation between GPs and other general practitioner (GP), and patients are only referred to the caregivers in integrated care projects for COPD patients has been pulmonologist in case of severe uncontrolled asthma or severe 2 3–5 proven to be effective in improving the quality of life and health COPD. Misdiagnosis and underdiagnosis are common, as status of patients, thus reducing costs and the number of asthma and COPD overlap in symptoms, whereas their treatments 11,12 hospitalisations. Asthma/COPD services in which GPs are are different. Some patients have both asthma and COPD, the so- supported by pulmonologists in interpreting spirometry results called overlap syndrome, which can be described as (partly) are feasible and might improve diagnostic accuracy. GPs and reversible but progressive deterioration in lung function, often pulmonologists in the North of the Netherlands collaborated and combined with a history of smoking and previous diagnosis of implemented the Asthma/COPD (AC) service in 2007 as a support asthma and/or allergies. These diagnostic problems may lead to service for GPs. The aim of this service is to improve the suboptimal treatment, whereas early correct treatment can reduce management of asthma and COPD patients in primary care. costs, morbidity and mortality, can improve symptoms and 3–5,7 Although the service was not developed for scientific reasons, enhance patient outcomes. In daily clinical practice, many GPs often lack the knowledge, data from included patients are available for research. This paper time and enthusiasm to perform all tasks that are recommended describes the development and feasibility of this service, the by guidelines. For example, Dutch GPs are obliged to follow 96 patient population and its effect on patient-related outcomes. 1 2 Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; GRIAC Research Institute Groningen, University of 3 4 Groningen, University Medical Center Groningen, Groningen, The Netherlands; Certe Laboratories, Groningen, The Netherlands; Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands and Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands. Correspondence: EI Metting (E.I.Metting@umcg.nl) Received 3 June 2014; revised 26 August 2014; accepted 5 October 2014 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al MATERIALS AND METHODS Feasibility analyses. Feasibility was assessed by analysing the following: (1) the proportion of GPs in the target area who used the AC service Design and feasibility between 2007 and 2012; (2) the proportion of patients with asthma or Meetings with local physicians were organised, resulting in four starting COPD who were assessed by the service in the target area since 2007; principles: (1) the service should optimise diagnosis, treatment and (3) the quality of the spirometry; (4) the number of patients that could be management; (2) the GP is in lead; (3) the service should be easily diagnosed, and the variation in diagnostic pattern between the different accessible for patients and physicians; (4) allocation of tasks between pulmonologists by using chi-square. primary and secondary care have to be defined clearly. Yearly meetings are organised to inform physicians about current developments, discuss Follow-up visits. Patients for whom medication change was advised by casuistry and enhance commitment. the pulmonologist were automatically scheduled for an additional follow- up assessment after 3 months (range 2–4 months, n = 740). If the GP The role of the GP. GPs can refer individual patients (⩾ 8 years of age) who requested follow-up visits and no medication change was advised, patients are suspected to have asthma, COPD, overlap syndrome or present with were assessed after 12 months (range 10–14, n = 938). Baseline data of pulmonary symptoms of unknown origin further referred to as obstructive adult patients on exacerbations/year, smoking status, inhalation technique, airway disease (OAD). The GP can also choose to refer all OAD patients in ACQ and CCQ scores were compared with follow-up data. Nonparametric his/her practice on the basis of inhaled medication use and/or courses of paired tests were used to compare baseline data with follow-up data. prednisolone. When preferred by the GP, referral may also include follow- Paired t-tests were used for the longitudinal evaluation of FEV (in litres). up assessments by the AC service. Finally, the GP decides what to do with Follow-up data of baseline GOLD stages are presented to show the the advice of the pulmonologist and is responsible for the disease distribution of these patients to other GOLD stages. To prevent overlap in management. our results, we excluded patients with 41 follow-up assessment in 1 year (n = 79). Self-reported information by patients. Patients complete the ‘Asthma Control Questionnaire (ACQ),’ the ‘Clinical COPD Questionnaire (CCQ)’ and a medical history questionnaire assessing gender, age, age of onset, family RESULTS history, symptoms, exacerbations (having used oral corticosteroids or Baseline patient characteristics are presented in Tables 1 and 2. antibiotics for lung problems), allergy and other stimuli-provoking symptoms, medication, occupation and smoking history as part of the Feasibility regular assessment procedure. The ACQ is used to measure asthma control and contains six questions The service included around 2,000 (range: 1,813–2,109) new (range 0–6), and the total score can be divided into ‘controlled’ (o0.75), patients yearly from 79.3% of the GPs in the target area. ‘partially controlled’ (0.75–1.50) and ‘uncontrolled’ (⩾ 1.50). The CCQ is Approximately 50% of patients were included by practice screen- used to measure COPD health status, and it contains 10 questions. The ing. In all, 60% of all adult asthma and COPD patients in the target total score (range 0–6) can be distributed between ‘stable’ (o1), ‘not 18,19 area were assessed at least once by the AC service. 1,2 2,3 entirely stable’, ‘unstable’ and ‘very unstable’ (⩾ 3). This questionnaire Pulmonologists considered the quality of 93.6% of the spirometry contains three subdomains with four questions about functional status, graphs to be usable for diagnosis and could diagnose 79.4% of the four questions about symptoms and two questions about mental 14,15 patients (asthma: 45.8%, COPD: 17.8%, overlap syndrome: 6.9%). status. See Supplementary 1 for an overview of COPD GOLD A, B, C and D patients at baseline. Baseline diagnosis was compared with follow- Assessment by the trained lung function technician. The assessments take place in local laboratories according to a strict protocol. The following up diagnosis, and it did not change during the follow-up in 91.2% measurements are taken: (confidence interval: 89.4–92.7%) of baseline asthma patients, in 87.7% (confidence interval: 84.4–90.4%) of baseline COPD patients Body mass index. and in 74.2% (confidence interval: 68.0–79.5%) of baseline overlap Evaluation and, if needed, instruction of the inhalation technique syndrome patients. There was variation in diagnostic pattern in according to the Dutch ‘Inhalation Medication Instruction School’ adult patients between the different pulmonologists (n = 10, guidelines. Po0.000); see Figure 1. Spirometry according to international guidelines. Follow-up visits All data, including the scores on the questionnaires, are inserted in an Electronic Diagnostic Support (EDS) system. Patients frequently changed from GOLD (2013) category, and many GOLD D patients (n = 74) moved to other GOLD categories The role of the pulmonologist. Pulmonologists are trained in using the at follow-up (Follow-up category: GOLD A: 21.6%, B: 36.5%, service by following at least two training sessions. In this paper, we C: 6.8%, D: 35.1%); see Figure 2. included pulmonologists who had assessed ⩾ 300 patients to avoid the influence of learning effects. Pulmonologists assess the quality of the Patients advised to change medication (Patients followed-up after 3 spirometry, inspect all outcomes in the Electronic Diagnostic Support months, total = 740). Inhalation technique improved significantly 2,17 system and make a report (based on current international guidelines ) (correct at baseline 35.1% to 52.5% after 3 months, n total = 459, with diagnosis, follow-up and treatment advice. Treatment advice can Po0.000). The proportion of well-controlled asthma patients include lifestyle advice (e.g., dietician, smoking cessation or physical increased from 23.9% (baseline) to 49.5% (3 months, n total = 487, activity) or medication change. Pulmonologists were not provided with Po0.000), and the proportion of stable COPD patients increased strict diagnostic rules. The GPs receive the report from the pulmonologist from 27.4% (baseline) to 48.9% (3 months, n total = 145, P = 0.004). within 5 working days through the internet directly in their patient information system. The proportion of GOLD D patients decreased from 12.8% at baseline to 6.7% after 3 months; see Table 3 (n total = 145, Po0.000). Statistical data analyses IBM-SPSS version 22 was used for statistical analysis. The baseline Patients advised to continue current medication (Patients followed- population was described by age, gender, body mass index, exacerbation up after 12 months, n = 938). Inhalation technique did improve history, smoking history, lung function performances, diagnosis and GOLD significantly (correct baseline 37.4 to 49.9% after 12 months, 2013 category (A, B, C and D). A positive bronchodilator response was n = 741, Po0.000). The proportion of current smokers decreased defined as an increase in forced expiratory volume in 1 s (FEV )of ⩾ 12% from 25.2% at baseline to 23.2% after 12 months (n = 984, and ⩾ 200 ml. The median scores of GOLD A, B, C and D patients on the CCQ subscales are presented. P = 0.013). The proportion of asthma and COPD patients with ⩾ 1 npj Primary Care Respiratory Medicine (2015) 14101 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al Table 1. Baseline characteristics of the total patient population in the Table 2. Baseline characteristics of the patient population per AC tele-medicine service diagnosis Variable Total group, n = 11,401 Variable COPD, Overlap Asthma, n = 2,031 syndrome, n = 5,223 Diagnosis of n (%) n = 787 COPD 2,031 (17.8) Very unstable (CCQ⩾ 3) 161 (8.0) Gender and age n (%) n (%) n (%) Asthma 5,223 (45.8) Male 1,190 (58.6) 388 (49.3) 2,007 (38.4) Uncontrolled (ACQ⩾ 1.50) 2,049 (39.3) Self-reported ⩾ 1 243 (12.0) 312 (39.6) 2,658 (50.9) Asthma/COPD overlap syndrome 787 (6.9) allergy Very unstable (CCQ⩾ 3) 77 (9.9) Uncontrolled (ACQ⩾ 1.50) 308 (39.4) Mean (s.d.) Mean (s.d.) Mean (s.d.) Indication for restriction 159 (1.4) Age, years 66.6 (10.8) 60.6 (12.3) 43.6 (18.7) No lung disease 796 (7.0) Age of onset, years 52.2 (19.6) 33.6 (23.1) 22.3 (19.6) Unclear diagnosis 2,354 (20.6) Body mass index (kg/ 26.6 (4.8) 27.1 (4.9) 26.7 (6.0) Missing at random 15 (0.1) m ) Exacerbations in the 0.7 (1.1) 0.9 (1.2) 0.8 (1.2) Diagnosis is unclear because of n (%) last 12 months Incorrect lung function test 297 (12.6) Unknown 2,057 (87.4) Lung function post bronchodilator, mean (s.d.) FEV (L) 2.0 (0.7) 2.3 (0.7) 3.1 (0.9) Referral to pulmonologist because of n (%) FEV % predicted 69.0 (18.1) 76.0 (15.5) 94.6 (15.1) Unclear diagnosis 1,966 (54.7) FVC (L) 3.6 (1.0) 3.7 (1.1) 4.0 (1.1) Indication of restriction 18 (0.005) FVC % predicted 98.6 (18.4) 102.1 (17.2) 101.1 (16.3) Unable to perform lung function test 18 (0.005) FEV /FVC 56.0 (11.2) 61.0 (9.5) 79.3 (8.8) COPD 558 (15.5) Reversibility 6.4 (7.9) 11.2 (10.0) 6.7 (7.6) FEV o50% predicted 302 (54.3) Asthma/COPD overlap syndrome 214 (6.0) Positive BDT adults, n (%) FEV o50% predicted 27 (12.7) Post FEV /FVCo70% 198 (99.0) 236 (91.5) 204 (25.0) 1 1 Asthma 690 (19.2) Post FEV / 2 (1.0) 22 (8.5) 358 (43.8) Unstable (ACQ⩾ 1.50) 469 (68.2) FVC= 70–80% Total 3,593 (31.5) Post FEV / 214(26.2) FVC= 80–90% Quality lung function test n (%) Post FEV /FVC⩾ 90% 40 (4.9) Sufficient 10,670 (93.6) Total 200 (10.7) 258 (34.8) 817 (16.6) Insufficient 730 (6.4) Inhalation technique ,n (%) In 31.5% of the assessments, the pulmonologist advised the GP to refer Correct 325 (36.1) 205 (36.5) 1,434 (38.0) their patient to secondary care mostly because of unclear diagnosis Incorrect 576 (63.9) 357 (63.5) 2,339 (62.0) (54.7%). Most patients with unclear diagnosis (age, 51± 19; age of onset, 39± 23; 42% male) had no obstruction (FEV /FVC⩾ 70%: 90%), no positive Smoking history (age⩾ 18 years), n (%) bronchodilator response (93%) and no allergy (76%). However, these Smoking history 8 (0.4) 0 (0.0) 17 (0.4) patients were high in symptoms (CCQ ⩾ 1: 68%). missing Abbreviations: AC, asthma/COPD; ACQ, Asthma Control Questionnaire; Never smoked 70 (3.4) 54 (6.9) 2,041 (43.4) CCQ, Clinical COPD Questionnaire; COPD, chronic obstructive pulmonary Quit ⩾ 12 months ago 948 (46.7) 378 (48.0) 1,628 (34.6) disease; FEV , forced expiratory volume in one second; FVC, forced vital Current smoker 1,005 (49.5) 355 (45.1) 1,014 (21.6) capacity; GP, general practitioner. Males 517 (51.4) 151 (42.5) 383 (37.8) Males motivated to 304 (58.8) 89 (58.9) 231 (60.3) quit exacerbation last year decreased (asthma: 35.0% at baseline, Females 475 (47.3) 197 (55.5) 614 (60.6) 25.2% at 12 months, P40.000; COPD: 34.8% at baseline, 25.4% at Females motivated 295 (62.1) 112 (56.8) 407 (66.3) to quit 12 months, P = 0.010); see Table 4. Abbreviations: BDT, bronchodilator test; COPD, chronic obstructive pulmonary disease; FEV , forced expiratory volume in one second; FVC, DISCUSSION forced vital capacity. Main findings Increase in FEV pre bronchodilator compared with FEV post broncho- 1 1 dilator. In this study, we have evaluated over 11,000 patients referred by Positive bronchodilator response test defined as a reversible lung 360 different GPs to the Asthma/COPD (AC) service in the North of function of ⩾ 200 ml and ⩾ 12% increase in FEV pre bronchodilator the Netherlands. With 60% of all asthma and COPD patients in the compared with FEV post bronchodilator. area participating, the service is well implemented in the target c Adult asthma patients (male: 59%, mean age: 52 years, 19% current area. We chose to report the follow-up results from patients who smokers) with obstruction before and after bronchodilator. were advised to change medication after 3 months separately from the patients who were advised to continue with their patients moved to other categories after baseline visit; some of medication and were scheduled to have a 12-month follow-up. If a these patients (22%) even improved to GOLD category A. Given change in medication was advised, after 3 months, health status these results, we consider the AC service to be a feasible and improved in COPD patients and asthma control improved in effective collaboration service for primary and secondary care. asthma patients. Asthma and COPD patients who did not need medication change and were referred to the yearly follow-up Interpretation of findings in relation to previously published work assessment stabilised in asthma control and in COPD health status. Overlap syndrome patients in this group improved in According to the Global Initiative for Asthma guidelines, asthma control and health status. Most (65%) of the GOLD D uncontrolled asthma patients would be eligible for referral to © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited npj Primary Care Respiratory Medicine (2015) 14101 Feasibility and effectiveness of an AC service EI Metting et al secondary care. The prevalence of uncontrolled asthma patients Lucas et al. Diagnoses during follow-up visits in our AC service (see in our population (age ⩾ 16 years) is lower (40%) than the Figure 1) showed that most of the diagnoses were consistent. prevalence found in the INSPIRE study where 51% of the patients Although diagnoses are to some extent subjective, the advantage had uncontrolled asthma. Only 13% of our asthma patients were of the system is that the GP can compare his own choices with the advised to be referred to secondary care (see Table 1), meaning diagnoses and advices from the pulmonologist. We believe that that the pulmonologists did not follow the Global Initiative for this internet-based consultation in the long run might improve Asthma guidelines. However, we do not know whether the GP skills in the management of OADs. followed the referral recommendation of the pulmonologist. Van den Bemt et al. presented a service for COPD patients and The accuracy of the diagnosis in Asthma/COPD support systems concluded that it was not clinically effective. However, their is of pivotal importance. Lucas et al. showed previously that a population consisted of already-diagnosed COPD patients, and all diagnosis based on paper patient data without life contact in an patients had performed spirometry previously to inclusion, AC service is comparable with diagnoses acquired by a face-to- whereas we followed up both previously diagnosed and newly face consultation. The level of agreement on diagnoses between diagnosed patients. We speculate that the room for improvement paper data and face-to-face diagnoses was κ = 0.82, which in our population of a wide range of patients was higher, which exceeded the level of inter-doctor agreement from the different might have contributed to the positive effect. Furthermore, assessing pulmonologists (κ = 0.64 ). We used comparable history internet is used for data exchange, and GPs receive the report questions and spirometry as Lucas et al. used, and we assume that from the pulmonologist mostly within 5 working days electro- the diagnostic accuracy will be comparable as in the study of nically in their patient information system, which makes the service user friendly. Next to that, the use of Internet and the trained lung function technicians make the service cost-effective. Direct costs were covered by reimbursement for the spirometry in primary care, including the involvement of the pulmonologist. Generalisability. Our asthma patients differed from COPD patients, whereas the characteristics of overlap syndrome patients fell between asthma and COPD patients. This was also described by Postma et al. who showed that asthma patients are younger, more frequently female and have less frequently a history of smoking. Miravitlles et al. showed the same pattern of patient characteristics in their primary care population, although the proportion of male patients in their overlap syndrome population was much lower than in the AC population (Miravitlles: 26%, AC service: 49%). Characteristics of our asthma patients (⩾16 years) were comparable with asthmatics from the INSPIRE study (AC service: male, 38%; mean age, 46 ± 17 years; current smokers, 21%. INSPIRE: male 35%; mean age, 45 ± 17 years; current Figure 1. This picture shows the variation in diagnoses in adult smokers, 21%). patients between the assessing pulmonologists. Most variation is When considering overlap syndrome as a subtype of COPD, the seen in the diagnoses of asthma and other (unclear diagnoses, prevalence of overlap syndrome in our COPD population was 28%, indication for restriction or no disease). The variation in diagnoses which is comparable to the prevalence found by Ställberg et al. between the pulmonologists was significant (Chi-square = 580, n= 10,656, Po0.000). (25%) but higher than the prevalence reported by Postma et al. Figure 2. Distribution of COPD patients at baseline (n (total) = 2,004) according to the new GOLD classification of airflow limitation. Apparent is the large proportion of patients at risk: 22% of the COPD patients were classified as GOLD D. GOLD D patients have a high risk of exacerbations combined with a high burden of disease. npj Primary Care Respiratory Medicine (2015) 14101 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al Table 3. Longitudinal differences in lung function, exacerbations, health status and asthma control of patients assessed at baseline and after 3 months (range: 2–4 months, n total= 740) Diagnosis n Baseline After 3 months P value Asthma (n = 503) n (%) n (%) ⩾ 1 exacerbation last year 483 188 (38.9) Current smoker 497 92 (18.5) 87 (17.5) NS Sufficient inhalation technique 320 120 (37.5) 173 (54.1) o0.000 Well controlled (ACQo0.75) 497 119 (23.9) 246 (49.5) o0.000 Partially controlled (ACQ⩾ 0.75 and o1.50) 174 (35.0) 136 (27.4) Uncontrolled (ACQ ⩾ 1.50) 204 (41.0) 115 (23.1) Mean (s.d.) Mean (s.d.) FEV (L) 455 3.0 (0.9) 2.9 (0.9) o0.000 1pre COPD (n = 148) n (%) n (%) ⩾ 1 exacerbation 148 60 (40.5) Current smoker or quit o12 months ago 147 63 (42.9) 62 (42.2) NS Sufficient inhalation technique 79 19 (24.1) 38 (48.1) NS Stable (CCQo1) 147 55 (37.4) 75 (51.0) 0.004 Not entirely stable (CCQ⩾1&o2) 64 (43.5) 48 (32.7) Unstable (CCQ⩾ 2 and o3) 19 (12.9) 18 (12.2) Very unstable (CCQ⩾ 3) 9 (6.1) 6 (4.1) Mean (s.d.) Mean (s.d.) FEV (L) 148 2.1 (0.6) 2.1 (0.6) NS 1pre Overlap syndrome (n = 82) n (%) n (%) ⩾ 1 exacerbation 82 41 (50.0) Current smoker or quit o12 months ago 82 33 (40.2) 34 (41.5) NS Sufficient inhalation technique 58 21 (36.2) 29 (50.0) NS Well controlled (ACQo0.75) 82 35 (42.7) 48 (58.5) NS Partially controlled (ACQ⩾ 0.75 and o1.50) 30 (36.6) 19 (23.2) Uncontrolled (ACQ ⩾ 1.50) 17 (20.7) 15 (18.3) Stable (CCQo1) 31 8 (25.8) 16 (51.6) 0.073 Not entirely stable (CCQ⩾1&o2) 16 (51.6) 11 (35.5) Unstable (CCQ⩾ 2 and o3) 7 (22.6) 2 (6.5) Very unstable (CCQ⩾ 3) 0 (0.0) 2 (6.5) Mean (s.d.) Mean (s.d.) FEV (L) 81 2.3 (0.6) 2.3 (0.7) NS 1pre Patients were referred to the 3-month follow-up assessment if change in medication was advised by the pulmonologist. Abbreviations: ACQ, Asthma Control Questionnaire; CCQ, Clinical COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FEV , forced expiratory volume in one second; NS, not significant. P values are two-sided and P values ⩾ 0.10 are reported as ‘NS’. Exacerbations are defined as having used oral corticosteroids or antibiotics for lung problems last year. Inhalation technique in patients who use medication at baseline. (13–20%). Our overlap patients have more frequent exacerba- ⩾ 90%), the proportion of patients with a positive BDT was 5%, tions compared with the asthma and COPD patients, which whereas in asthma patients with very poor lung function indicate that these patients are more at risk for future exacerba- (FEV /FVC post bronchodilator o70%), this proportion was 40%. 24,27,28 tions. This high risk was confirmed in other studies. Others have also shown that reversibility in asthmatic patients Although these patients are more at risk, at baseline only the depends on the severity of asthma as measured by the CCQ scores reflect this poor health status (CCQ ⩾ 3: COPD, 8%; impairment in lung function. Although COPD is considered to overlap syndrome, 10%). Overlap patients were assessed by using be a nonreversible obstructive lung disease, 11% of our COPD the ACQ and the CCQ, because these questionnaires were part of patients had a BDT response, and the average reversibility was 6%. the regular assessment in the AC collaboration service. However, In the UPLIFT study, 50% of the COPD patients showed significant no validated measurements are available to assess the health reversibility. Obviously, real-life COPD populations differ from status and disease control in overlap patients. COPD patients in selected populations, as confirmed by Kruis et al. Bronchodilator the AC service were distributed according to the GOLD guidelines response was more prevalent in COPD patients with severe using CCQ cutoff value of 41 (A: 28%, B: 40%, C: 8% and D: 24%). disease. The highest proportion of patients with positive BDT Lange et al. distributed 6,628 Danish COPD patients using the response was seen in the overlap syndrome patients (35%), which modified Medical Research Council and found another distribution is consistent with the GOLD and Global Initiative for Asthma (A: 77%, B: 14%, C: 4% and D: 4%). Apart from the difference in recommendations. symptom assessment by using the CCQ instead of the modified Medical Research Council, our COPD sample of primary care– Risk factors. The proportion of smoking COPD and overlap treated patients is obviously more at risk and has more symptoms syndrome patients (COPD: 50%, overlap syndrome: 45%) was than the Danish general population. much higher than in the Dutch population, which is 27%, and also higher than the COPD population presented by Warnier et al. Reversibility. Only 17% of our asthma patients had a positive (37%). Our definition of smokers might have contributed to the bronchodilator test (BDT) response. In asthma patients with good higher proportion, because we considered quitters o12 months lung function (FEV /forced vital capacity (FVC) after bronchodilator ago as current smokers. The AC service does not provide any © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited npj Primary Care Respiratory Medicine (2015) 14101 Feasibility and effectiveness of an AC service EI Metting et al Table 4. Longitudinal differences in lung function, exacerbations, health status and asthma control of patients referred by their GP to single or yearly follow-up assessment after 12 months (range 10–14 months, n total= 991). Patients in this table were not assessed after 3 months Diagnosis n Baseline After 12 months P value Asthma (n = 598) n (%) n (%) ⩾ 1 exacerbation 572 200 (35.0) 144 (25.2) o0.000 Current smokers or quit o12 months ago 595 88 (14.8) 81 (13.6) NS Sufficient inhalation technique 471 185 (39.3) 251 (53.3) o0.000 Well controlled (ACQo0.75) 591 377 (63.8) 383 (64.8) NS Partially controlled (ACQ⩾ 0.75 and o1.50) 119 (20.1) 123 (20.8) Uncontrolled (ACQ ⩾ 1.50) 95 (16.1) 85 (14.4) Mean (s.d.) Mean (s.d.) FEV (L) 596 3.1 (0.9) 3.0 (0.9) o0.000 1pre COPD (n = 245) n (%) n (%) ⩾ 1 exacerbation 244 85 (34.8) 62 (25.4) 0.010 Current smokers or quit o12 months ago 243 109 (44.9) 99 (40.7) 0.017 Sufficient inhalation technique 177 59 (33.3) 78 (44.1) 0.034 Stable (CCQo1) 243 128 (52.7) 136 (56.0) NS Not entirely stable (CCQ⩾ 1 and o2) 79 (32.5) 74 (30.5) Unstable (CCQ⩾2&o3) 23 (9.5) 24 (9.9) Very unstable (CCQ⩾ 3) 13 (5.3) 9 (3.7) Mean (s.d.) Mean (s.d.) FEV (L) 244 2.2 (0.7) 2.1 (0.6) o0.000 1pre Overlap syndrome (n = 88) n (%) n (%) ⩾ 1 exacerbation 88 34 (38.6) 25 (28.4) NS Current smokers or quit o12 months ago 88 38 (43.2) 34 (38.6) 0.094 Sufficient inhalation technique 66 24 (36.4) 28 (42.4) NS Well controlled (ACQo0.75) 87 37 (42.5) 48 (55.2) 0.032 Partially controlled (ACQ⩾ 0.75 and o1.50) 25 (28.7) 21 (24.1) Uncontrolled (ACQ ⩾ 1.50) 25 (28.7) 18 (20.7) Stable (CCQo1) 65 24 (36.9) 30 (46.2) 0.027 Not entirely stable (CCQ ⩾1& o2) 27 (41.5) 26 (40.0) Unstable (CCQ⩾ 2 and o3) 7 (10.8) 7 (10.8) Very unstable (CCQ⩾ 3) 7 (10.8) 2 (3.1) Mean (s.d.) Mean (s.d.) FEV (L) 88 2.3 (0.7) 2.2 (0.7) o0.000 1pre Abbreviations: ACQ, Asthma Control Questionnaire; CCQ, Clinical COPD Questionnaire; COPD, chronic obstructive pulmonary disease; FEV , forced expiratory volume in one second; GP, general practitioner; NS, not significant. P values are two-sided and P values ⩾ 0.10 are reported as ‘ns’. Exacerbations are defined as having used oral corticosteroids or antibiotics for lung problems last year. Inhalation technique in patients who use medication at baseline. cessation intervention but informs the GP if their patients are differences in mortality rates between GOLD A, B, C and D. motivated to quit. The follow-up time of 12 months could not Therefore, we assume that missed mortality rates hardly affected reveal the number of quitters (412 months) as a result of the our COPD follow-up results. possible intervention of the GP. Like in other studies, many patients (64%) showed an Implications for future research, policy and practice insufficient inhalation technique. Although the inhalation techni- Relatively simple support for GPs in diagnosing and managing que improved after 3 (50%) and 12 months (47%) of follow-up patients with a chronic disease by specialists might result in after our standard instruction as recommended in the Dutch improved outcomes for these patients in the community. guidelines, it is debatable whether this instruction is sufficiently Principles of the AC service might also be suitable in other effective. Further research on effective instruction seems to be chronic diseases. The large electronic database from the AC needed. service provides unique opportunities for further research in primary care patients with OADs. Strengths and limitations of this study The strength of this study is the large population of primary care Conclusion OAD patients in real life and the strict protocol used to assess The AC service is feasible, effective and efficient in supporting GPs these patients. A limitation is that the AC service was not to diagnose and manage asthma, COPD and overlap syndrome established for scientific reasons, resulting in limited follow-up patients. The service stimulates cooperation between primary and results, and data could not be compared with a control group. secondary care, and delivers support to patients locally which is Therefore, we cannot rule out that results might have been important in rural areas. affected by regression to the mean, although regression to the mean (measured by 1 − ρ) is small; see Supplementary 2. We also do not have data on mortality; however, on the basis of national ACKNOWLEDGEMENTS mortality data, we assume that 1.8% of the COPD patients have We thank the Northern General Practitioners Laboratory Groningen (LabNoord died in 1 year. Leivseth et al. showed that there are no large currently Certe Laboratories) for giving us the opportunity to realise the AC service. npj Primary Care Respiratory Medicine (2015) 14101 © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited Feasibility and effectiveness of an AC service EI Metting et al CONTRIBUTIONS 19 Nationaal Kompas Volksgezondheid. Hoe vaak komt COPD voor en hoeveel mensen sterven eraan? 2013; Available at http://www.nationaalkompas.nl/ All authors have contributed to writing and revising the manuscript. gezondheid-en-ziekte/ziekten-en-aandoeningen/ademhalingswegen/copd/omvang/. Accessed 13 February 2014. 20 Partridge M, van dM, Myrseth S, Busse W. Attitudes and actions of asthma COMPETING INTERESTS patients on regular maintenance therapy: the INSPIRE study. BMC Pulm Med 2006; RAR is a member of the advisory board of Certe Laboratories. MGP-W is the 6:13. director of Certe Laboratories. 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The images the diagnosis, management, and prevention of COPD. 2013; Available at http:// or other third party material in this article are included in the article’s Creative Commons www.goldcopd.org/. license, unless indicated otherwise in the credit line; if the material is not included under 18 Nationaal Kompas Volksgezondheid. Astma. 2014; Available at http://www.natio the Creative Commons license, users will need to obtain permission from the license naalkompas.nl/gezondheid-en-ziekte/ziekten-en-aandoeningen/ademhalingswe holder to reproduce the material. To view a copy of this license, visit http:// gen/astma/. Accessed 23 May 2014. creativecommons.org/licenses/by-nc-nd/4.0/ Supplemental Information accompanies the paper on the npj Primary Care Respiratory Medicine website (http://www.nature.com/npjpcrm) © 2015 Primary Care Respiratory Society UK/Macmillan Publishers Limited npj Primary Care Respiratory Medicine (2015) 14101

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