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      Factors associated with inadequate diagnosis of COPD: On-Sint cohort analysis

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          Abstract

          Background

          The purpose of this study was to evaluate the frequency of inadequate diagnosis and factors predictive of this in patients with chronic obstructive pulmonary disease (COPD) participating in the On-Sint study.

          Methods

          The On-Sint cohort was recruited for a multicenter observational study in which 356 physicians (71.6% from primary care) included adult patients who had been diagnosed with COPD. Patients’ clinical and functional information since diagnosis and details for the recruiting physicians were collected from patient files and at the inclusion visit. We performed a multivariate analysis to evaluate the influence of these variables on diagnostic inadequacy (absence of postbronchodilator forced expiratory volume in one second/forced vital capacity [FEV 1/FVC] <0.70 or, if this value was missing, prebronchodilator FEV 1/FVC <0.70).

          Results

          In total, 1,214 patients were included in the study. The patients had a mean age of 66.4±9.7 years and 78.8% were male. In total, 51.3% of patients did not have an obstructive spirometry performed, and 21.4% had a normal or non-obstructive spirometry pattern. Patient-related factors associated with inadequate diagnosis were: years since diagnosis (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05), number of exacerbations in the previous year (OR 1.01, 95% CI 1.01–1.02), comorbidities (OR 1.05, 95% CI 1.01–1.015), and obesity (OR 1.06, 95% CI 1.02–1.10 per kg/m 2 of body mass index), while a longer smoking history (OR 0.98, 95% CI 0.97–0.99 for each pack/year) and short-acting or long-acting bronchodilator therapy (OR 0.61, 95% CI 0.44–0.76 and OR 0.46, 95% CI 0.27–0.76, respectively) were inversely related. With regard to physician-related variables, being followed up by primary care physicians (OR 3.0, 95% CI 2.11–4.34) and in rural centers (OR 1.63, 95% CI 1.12–2.38) were positively associated with an inadequate diagnosis, while having regular follow-ups in the most severe cases (OR 0.66, 95% CI 0.46–0.93) and use of quality of life questionnaires (OR 0.55, 95% CI 0.40–0.76) were negatively associated.

          Conclusion

          Diagnosis of COPD was inadequate in half of the patients from the On-Sint cohort. There were multiple factors, both patient-related and physician-related, associated with this misdiagnosis.

          Related collections

          Most cited references 19

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          Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities.

          This study aimed to determine the prevalence of chronic obstructive pulmonary disease (COPD) in Spain and identify the level of undiagnosed disease and its impact on health-related quality of life (HRQL) and activities of daily living (ADL). A population-based sample of 4274 adults aged 40-80 years was surveyed. They were invited to answer a questionnaire and undergo prebrochodilator and postbronchodilator spirometry. COPD was defined as a postbronchodilator FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio of <0.70. For 3802 participants with good-quality postbronchodilator spirometry, the overall prevalence of COPD was 10.2% (95% CI 9.2% to 11.1%) and was higher in men (15.1%) than in women (5.6%). The prevalence of COPD stage II or higher was 4.4% (95%CI; 3.8%-5.1%). The prevalence of COPD increased with age and with cigarette smoking and was higher in those with a low educational level. A previous diagnosis of COPD was reported by only 27% of those with COPD. Diagnosed patients had more severe disease, higher cumulative tobacco consumption and more severely impaired HRQL compared with undiagnosed subjects. However, even patients with undiagnosed COPD stage I+ already showed impairment in HRQL and in some aspects of ADL compared with participants without COPD. The prevalence of COPD in individuals between 40 and 80 years of age in Spain is 10.2% and increases with age, tobacco consumption and lower educational levels. The rate of diagnosised COPD is very high and undiagnosed individuals with COPD already have a significant impairment in HRQL and ADL.
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            Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians

            Purpose: Even with the dissemination of several clinical guidelines, chronic obstructive pulmonary disease (COPD) remains underdiagnosed and mismanaged by many primary care physicians (PCPs). The objective of this study was to elucidate barriers to consistent implementation of COPD guidelines. Patients and methods: A cross-sectional study implemented in July 2008 was designed to assess attitudes and barriers to COPD guideline usage. Results: Five hundred US PCPs (309 family medicine physicians, 191 internists) were included in the analysis. Overall, 23.6% of the surveyed PCPs reported adherence to spirometry guidelines over 90% of the time; 25.8% reported adherence to guidelines related to long-acting bronchodilator (LABD) use in COPD patients. In general, physicians were only somewhat familiar with COPD guidelines, and internal medicine physicians were significantly more familiar than family physicians (P < 0.05). In a multivariate model controlling for demographics and barriers to guideline adherence, we found significant associations with two tested guideline components. Adherence to spirometry guidelines was associated with agreement with guidelines, confidence in interpreting data, ambivalence to outcome expectancy, and ability to incorporate spirometry into patient flow. Adherence to LABD therapy guidelines was associated with agreement with guidelines and confidence in gauging pharmacologic response. Conclusions: Adherence to guideline recommendations of spirometry use was predicted by agreement with the recommendations, self-efficacy, perceived outcome expectancy if recommendations were adhered to, and resource availability. Adherence to recommendations of LABD use was predicted by agreement with guideline recommendations and self-efficacy. Increasing guideline familiarity alone may have limited patient outcomes, as other barriers, such as low confidence and outcome expectancy, are more likely to impact guideline adherence.
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              Mortality trends in chronic obstructive pulmonary disease in Europe, 1994-2010: a joinpoint regression analysis.

              Findings from studies done over the past 20 years suggest that mortality from chronic obstructive pulmonary disease (COPD) is decreasing worldwide, but little information is available for trends in Europe. We aimed to describe COPD mortality trends by sex and calendar year for the period of 1994 to 2010. We extracted data for COPD deaths between 1994 and 2010 in the 27 countries in the European Union (EU) from the statistical office of the EU (Eurostat), using the International Classification of Diseases 10 (ICD-10) codes J40-J44 and J47. We estimated age-standardised mortality rates (ASR), and analysed data using joinpoint regression, for women and men in the EU overall and by individual country for each year. We used the standard European population as the reference and present our findings as deaths per 100,000 person-years. We compared findings for each country with the EU average by calculating standardised rate ratios (SRR) and 95% CIs. Between 1994 and 2010, there were 2,348,184 recorded COPD deaths in the EU. COPD mortality was higher in men than in women throughout the study period in all EU countries. In the EU overall, deaths per 100,000 population decreased in men almost linearly from 90·07 in 1994 to 61·33 in 2010, and in women from 26·99 in 1994 to 25·15 in 2010, representing a narrowing in gender gap over the study period. Several countries had a higher SRR mortality than the EU average-eg, Ireland, Hungary, and Belgium for men and Denmark, the UK, and the Netherlands for women. Our joinpoint regression analysis identified no statistically significant changes in the trend for the whole EU, but several countries had changing trends over the study period. In men, we recorded a 2·56% constant and statistically significant decrease in ASRs in the EU. Five countries had an increase in ASR. Overall, in women, we recorded a 0·76% statistically significant decrease in ASRs. 14 countries had an increase in ASR. Our findings indicate a downward trend in COPD mortality in Europe between 1994 and 2010. The data also suggest a narrowing of the gap between COPD mortality in men and in women. The wide heterogeneity in mortality rates within European countries could serve as a reference to allow informed policy making. None. Copyright © 2014 Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                1176-9106
                1178-2005
                2015
                18 May 2015
                : 10
                : 961-967
                Affiliations
                [1 ]Department of Pneumology, Complexo Hospitalario de Vigo, Instituto de Investigación Biomédica de Vigo, Vigo, Spain
                [2 ]Medical-Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain
                [3 ]Centro de Investigación Biomédica en Red de Respiratorio, Instituto de Salud Carlos III, Madrid, Spain
                [4 ]Medical Department, Novartis Farmacéutica, Barcelona, Spain
                Author notes
                Correspondence: Alberto Fernández-Villar, Servicio de Neumología. Complexo Hospitalario de Vigo. Pizarro, 22. 36201. Vigo. Spain, Tel +34 986 816 069, Fax +34 986 816 029, Email alberto.fernandez.villar@ 123456sergas.es
                Article
                copd-10-961
                10.2147/COPD.S79547
                4441359
                © 2015 Fernández-Villar et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

                Respiratory medicine

                chronic obstructive pulmonary disease, diagnosis, spirometry

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