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      Clinical Impact and Healthcare Resource Utilization Associated with Early versus Late COPD Diagnosis in Patients from UK CPRD Database

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          Abstract

          Purpose

          Previous studies have shown that opportunities to diagnose chronic obstructive pulmonary disease (COPD) early are often missed in primary care. This retrospective study aimed to utilize secondary data from the United Kingdom (UK) healthcare system to understand the impact of early versus late diagnosis of COPD.

          Patients and Methods

          Newly diagnosed COPD patients were identified in the UK Clinical Practice Research Database from 2011 to 2014. Patients whose 5-year medical data before diagnosis revealed ≥3 counts of eight indicators of early COPD were deemed as late-diagnosed, whereas others were deemed as early-diagnosed. We assessed patients’ characteristics; time-to-first, risk, and rates of exacerbation; and healthcare resource utilization (COPD-related clinic visits, Accident and Emergency visits, and hospitalizations) in late- versus early-diagnosed patients.

          Results

          Of 10,158 patients included in the study, 6783 (67%) were identified as late-diagnosed and 3375 (33%) as early-diagnosed. The median time-to-first exacerbation was shorter in late-diagnosed (14.5 months) versus early-diagnosed (29.0 months) patients, with a significant risk of exacerbation (hazard ratio 1.46 [95% confidence interval: 1.38–1.55]). Additionally, the exacerbation rate (per 100 person-years) over 3 years was higher in late (108.9) versus early (57.2) diagnosed patients. Late-diagnosed patients had a significantly higher rate of COPD hospitalizations (per 1000 patient years) compared with early-diagnosed patients during 2 and 3 years of follow-ups ( P = 0.0165 and P < 0.0001, respectively).

          Conclusion

          Results showed that a significant percentage of COPD patients in UK primary care are diagnosed late. A late COPD diagnosis is associated with a shorter time-to-first exacerbation and a higher rate and risk of exacerbations compared with early diagnosis. Additionally, late diagnosis of COPD is associated with a higher rate of COPD-related hospitalizations compared with early diagnosis.

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          Most cited references 4

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          The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK

          Background Real-world prescription pathways leading to triple therapy (TT) (inhaled corticosteroid [ICS] plus long-acting β2-agonist bronchodilator [LABA] plus long-acting muscarinic antagonist) differ from Global initiative for chronic Obstructive Lung Disease [GOLD] and National Institute for Health and Care Excellence treatment recommendations. This study sets out to identify COPD patients without asthma receiving TT, and determine the pathways taken from diagnosis to the first prescription of TT. Methods This was a historical analysis of COPD patients without asthma from the Optimum Patient Care Research Database (387 primary-care practices across the UK) from 2002 to 2010. Patient disease severity was classified using GOLD 2013 criteria. Data were analyzed to determine prescribing of TT before, at, and after COPD diagnosis; the average time taken to receive TT; and the impact of lung function grade, modified Medical Research Council dyspnea score, and exacerbation history on the pathway to TT. Results During the study period, 32% of patients received TT. Of these, 19%, 28%, 37%, and 46% of patients classified as GOLD A, B, C, and D, respectively, progressed to TT after diagnosis (P<0.001). Of all patients prescribed TT, 25% were prescribed TT within 1 year of diagnosis, irrespective of GOLD classification (P=0.065). The most common prescription pathway to TT was LABA plus ICS. It was observed that exacerbation history did influence the pathway of LABA plus ICS to TT. Conclusion Real life UK prescription data demonstrates the inappropriate prescribing of TT and confirms that starting patients on ICS plus LABA results in the inevitable drift to overuse of TT. This study highlights the need for dissemination and implementation of COPD guidelines to physicians, ensuring that patients receive the recommended therapy.
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            Validation of the Recording of Acute Exacerbations of COPD in UK Primary Care Electronic Healthcare Records

            Background Acute Exacerbations of COPD (AECOPD) identified from electronic healthcare records (EHR) are important for research, public health and to inform healthcare utilisation and service provision. However, there is no standardised method of identifying AECOPD in UK EHR. We aimed to validate the recording of AECOPD in UK EHR. Methods We randomly selected 1385 patients with COPD from the Clinical Practice Research Datalink. We selected dates of possible AECOPD based on 15 different algorithms between January 2004 and August 2013. Questionnaires were sent to GPs asking for confirmation of their patients’ AECOPD on the dates identified and for any additional relevant information. Responses were reviewed independently by two respiratory physicians. Positive predictive value (PPV) and sensitivity were calculated. Results The response rate was 71.3%. AECOPD diagnostic codes, lower respiratory tract infection (LRTI) codes, and prescriptions of antibiotics and oral corticosteroids (OCS) together for 5–14 days had a high PPV (>75%) for identifying AECOPD. Symptom-based algorithms and prescription of antibiotics or OCS alone had lower PPVs (60–75%). A combined strategy of antibiotic and OCS prescriptions for 5–14 days, or LRTI or AECOPD code resulted in a PPV of 85.5% (95% CI, 82.7–88.3%) and a sensitivity of 62.9% (55.4–70.4%). Conclusion Using a combination of diagnostic and therapy codes, the validity of AECOPD identified from EHR can be high. These strategies are useful for understanding health-care utilisation for AECOPD, informing service provision and for researchers. These results highlight the need for common coding strategies to be adopted in primary care to allow easy and accurate identification of events.
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              Distribution, Temporal Stability and Appropriateness of Therapy of Patients With COPD in the UK in Relation to GOLD 2019

              Background The 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report made recommendations for the assessment, initial and subsequent treatment chronic obstructive pulmonary disease (COPD) based on biomarkers, including blood eosinophil counts. Methods We evaluated the distribution of UK COPD patients initiating maintenance therapy and established patients by GOLD group, the prevalence of comorbidities and appropriateness of therapy using electronic patient records from the Optimum Patient Care Research Database (OPCRD). Changes in effective GOLD group, therapy and exacerbation rates over the next 2 years were analysed. Findings 11,409 established COPD patients and 699 starting therapy were studied. 44·3%, 25·7%, 13·8% & 16·2% of established COPD patients and 45·2%, 28·5%, 15·7% & 10·6% initiating therapy were in GOLD groups A, B, C & D respectively. The overall proportion in each GOLD group was similar after 2 years but there was substantial movement of patients between groups. Diabetes and cardiovascular disease were the most common comorbidities in all groups in both cohorts. LAMA monotherapy was the commonest initial therapy in all GOLD groups. In both cohorts there was over-treatment with escalation, de-escalation or switching in nearly 50% during follow-up. In both cohorts, exacerbation rates were highest in group D and appeared higher in over-treated patients. Interpretation Most patients are not at risk of exacerbations and co-morbidities are common. Many patients change effective GOLD group and therapy over time. Prescribing is not in accordance with guideline recommendations and many patients still appear over treated.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                COPD
                copd
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove
                1176-9106
                1178-2005
                16 July 2020
                2020
                : 15
                : 1729-1738
                Affiliations
                [1 ]Respiratory Medicine Department, University Hospital of Ioannina , Ioannina, Greece
                [2 ]Centre of Academic Primary Care, University of Aberdeen , Aberdeen, UK
                [3 ]Novartis Pharma AG , Basel, Switzerland
                [4 ]Pharmatelligence , Cardiff, UK
                [5 ]Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg , Freiburg, Germany
                [6 ]Novartis Pharmaceuticals Corporation , East Hanover, NJ, USA
                [7 ]Plymouth University Peninsula School of Medicine and Dentistry , Plymouth, UK
                Author notes
                Correspondence: Konstantinos Kostikas Respiratory Medicine Department,University Hospital of Ioannina , Ioannina,Greece Email ktkostikas@gmail.com
                Article
                255414
                10.2147/COPD.S255414
                7371991
                © 2020 Kostikas et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 2, Tables: 4, References: 12, Pages: 10
                Funding
                Funded by: Novartis AG
                The study was funded by Novartis AG, Basel, Switzerland.
                Categories
                Original Research

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