205 results found
Gulea C, Zakeri R, Quint JK, 2019, Reply to letter to the editor by Dr. Jolobe, INTERNATIONAL JOURNAL OF CARDIOLOGY, Vol: 292, Pages: 161-161, ISSN: 0167-5273
Bloom C, douglas I, Olney J, et al., Cost saving of switching to equivalent inhalers and its effect on health outcomes, Thorax, ISSN: 1468-3296
BackgroundSwitching inhalers to cheaper equivalent products is often advocated as a necessary cost saving measure, yet the impact on patient’s health and healthcare utilisation has not been measured.MethodsWe identified asthma and chronic obstructive pulmonary disease (COPD) patients from UK primary care electronic healthcare records between 2000 and 2016. A self-controlled case series was used to estimate incidence rate ratios (IRR); comparing outcome rates during the risk period, 3-months after the exposure (financially-motivated switch), and control periods (pre-switch, and post-risk period). Four outcomes were assessed: disease exacerbation, GP consultation, non-specific respiratory events and adverse-medication events. Medication possession ratio (MPR) was calculated to assess adherence. 2017 NHS indicative prices were used to estimate cost differences per equivalent dose.ResultsWe identified a cohort of 569,901 asthma and 171,231 COPD regular inhaler users, 2% and 6% had been switched, respectively. Inhaler switches between a brand-to-generic inhaler, and all other switches (brand-to-brand, generic-to-generic, generic-to-brand), were associated with reduced exacerbations (brand-to-generic: IRR=0.75, 95% CI 0.64-0.88; all other: IRR=0.79, 95% CI 0.71-0.88). Gender, age, therapeutic class, inhaler device, and inhaler-technique checks did not significantly modify this association (p<0.05). The rate of consultations, respiratory-events and adverse-medication events did not change significantly (consultations: IRR=1.00, 95% CI 0.99-1.01; respiratory-events: IRR=0.96, 95% CI 0.95-0.97; adverse-medication-events: IRR=1.05, 95% CI 0.96-1.15). Adherence significantly increased post-switch (median MPR: pre-switch=54%, post-switch=62%; p<0.001). Switching patients, in the cohort of regular inhaler users, to the cheapest equivalent inhaler, could have saved around £6 million annually. ConclusionSwitching to an equivalent inhaler in patients with asthma
Chatzidiakou L, krause A, popoola O, et al., Characterising low-cost sensors in highly portable platforms to quantify personal exposure in diverse environments, Atmospheric Measurement Techniques, ISSN: 1867-1381
Whittaker H, Connell O, Campbell J, et al., Eligibility for lung volume reduction surgery in chronic obstructive pulmonary disease patients identified in a UK primary care setting, Chest, ISSN: 0012-3692
BackgroundAlthough lung volume reduction surgery (LVRS) improves survival in appropriately selected patients with Chronic Obstructive Pulmonary Disease (COPD), few procedures are performed. The National Institute for Clinical and Healthcare Excellence recently recommended a more systematic approach to identifying potential candidates. We investigated LVRS referrals from a UK primary care population and aimed to establish an accurate estimate of eligible patients and determine a strategy for identifying potential candidates systematically.MethodsClinical Practice Research Datalink (CPRD) GOLD (a primary care database), linked Hospital Episode Statistics (HES) inpatient and Diagnostic Imaging Dataset (DID) were used. COPD patients who had undergone LVRS, patients who met basic eligibility criteria for further screening for LVRS, and patients meeting a more stringent eligibility criteria were identified from April 2012 to September 2015. Thoracic CT, pulmonary rehabilitation status, referral to respiratory outpatient clinics, and AECOPD requiring hospitalisation were compared between actual LVRS recipients and potentially eligible patients. ResultsAmong 73,697 COPD patients included, 36 (0.05%) received LVRS, 5,984 (8.1%) met basic eligibility criteria, and 159 (0.2%) met more stringent eligibility criteria. LVRS recipients were younger (mean(SD) age: 64(9.2) years) compared to the stringently eligible patients (69(8.9) years) (p=0.01). Few patients meeting stringent eligibility criteria (6.9%) had a CT thorax in the preceding 3 years or been referred for assessment in secondary care. ConclusionsA substantial unmet need exists among COPD patients who could potentially benefit from a lung volume reduction procedure but who are not being investigated or referred to consider this possibility.
Gayle A, dickinson S, poole C, et al., 2019, Incidence of type II diabetes in chronic obstructive pulmonary disease: A nested case-control study, npj Primary Care Respiratory Medicine, Vol: 29, ISSN: 2055-1010
We investigated the incidence of type II diabetes mellitus (T2DM) among people with COPD and whether exposure to inhaled corticosteroid (ICS) and exacerbation status was associated with T2DM. This descriptive cohort study used primary care data from the Clinical Practice Research Datalink (CPRD). The patient cohort included people with a diagnosis of COPD and previous smoking history registered at a CPRD practice between January 2010 and December 2016. We determined incidence rates by age, gender and deprivation. Using a nested case–control design—where cases and controls are drawn from the cohort population—we matched 1:5 with patients by age, gender and GP practice and estimated odds of T2DM using logistic regression (adjusting for smoking status, deprivation, BMI, hypertension, coronary heart disease and heart failure). We identified 220,971 COPD patients; mean age at COPD diagnosis was 66 years (SD 12) and 54% were male. The incidence rate of T2DM in COPD patients was 1.26 per 100 patient years (95% CI: 1.24–1.28) and was higher among men (1.32 vs 1.18 among women). The adjusted odds ratio for T2DM was 1.47 (95% CI: 1.36–1.60) among frequent exacerbators (≥2 treated exacerbations per year) compared to infrequent exacerbators and the odds ratio for patients receiving high-dose ICS (>800 mcg budesonide equivalent dose) was 1.73 (95% CI 1.65–1.82) compared to patients receiving no ICS therapy. Incidence of T2DM among COPD patients is high and exposure to ICS and frequent exacerbations are associated with a higher risk of T2DM among patients with COPD.
Jones A, Evans R, Man W, et al., Outcome measures in a combined exercise rehabilitation programme for COPD and Chronic Heart Failure patients: A stakeholder consensus event, Chronic Respiratory Disease, ISSN: 1479-9723
Sapey E, Bafadhel M, Bolton C, et al., Building toolkits for COPD exacerbations: lessons from the past and present, Thorax, ISSN: 1468-3296
In the nineteenth century it was recognised that acute attacks of chronic bronchitis were harmful. One hundred and forty years later, it is clearer than ever that exacerbations of Chronic Obstructive Pulmonary Disease (ECOPD) are important events. They are associated with significant mortality, morbidity, a reduced quality of life and an increasing reliance on social care. ECOPD are common and are increasing in prevalence. Exacerbations beget exacerbations, with up to a quarter of in-patient episodes ending with readmission to hospital within 30 days. The healthcare costs are immense. Yet despite this, the tools available to diagnose and treat ECOPD are essentially unchanged, with the last new intervention (non-invasive ventilation) introduced over twenty-five years ago. An ECOPD is “an acute worsening of respiratory symptoms that results in additional therapy”. This symptom and healthcare utility-based definition does not describe pathology and is unable to differentiate from other causes of an acute deterioration in breathlessness with or without a cough and sputum. There is limited understanding of the host immune response during an acute event and no reliable and readily available means to identify aetiology or direct treatment at the point of care. Corticosteroids, short acting bronchodilators with or without antibiotics have been the mainstay of treatment for over thirty years. This is in stark contrast to many other acute presentations of chronic illness, where specific biomarkers and mechanistic understanding has revolutionised care pathways. So why has progress been so slow in ECOPD? This review examines the history of diagnosing and treating ECOPD. It suggests that to move forward, there needs to be an acceptance that not all exacerbations are alike (just as not all COPD is alike) and that clinical presentation alone cannot identify aetiology or stratify treatment.LAY SUMMARY: Patients with Chronic Obstructive Pulmonary Diseas
Sinha I, calvert J, Hickman C, et al., The NHS long term plan and the National Asthma and COPD Audit Programme: opportunities for improving outcomes for people with chronic respiratory illness, Lancet Respiratory Medicine, ISSN: 2213-2600
Respiratory illness features heavily in the NHS Long Term Plan.1 The well described drivers to improve outcomes in the most prevalent respiratory conditions, COPD and asthma, include variation in care standards and outcome2, and higher rates of mortality and hospitalisation than most other European countries3,4. In this paper we discuss how the National Asthma and COPD Audit Programme (NACAP) can support the aspirations within the long term plan to improve outcomes for people with COPD and asthma.
Honeyford K, Bell D, Chowdhury F, et al., 2019, Unscheduled hospital contacts after inpatient discharge: A national observational study of COPD and heart failure patients in England, PLoS ONE, Vol: 14, ISSN: 1932-6203
IntroductionReadmissions are a recognised challenge for providers of healthcare and incur financial penalties in a growing number of countries. However, the scale of unscheduled hospital contacts including attendances at emergency departments that do not result in admission is not well known. In addition, little is known about the route to readmission for patients recently discharged from an emergency hospital stay.MethodsThis is an observational study of national hospital administration data for England. In this retrospective cohort study, we tracked patients for 30 days after discharge from an emergency admission for heart failure (HF) or chronic obstructive pulmonary disorder (COPD).ResultsThe majority of patients (COPD:79%; HF:75%) had no unscheduled contact with secondary health care within 30 days of discharge. Of those who did have unscheduled contact, the most common first unscheduled contact was emergency department (ED) attendance (COPD:16%; HF:18%). A further 5% of COPD patients and 4% of HF patients were admitted for an emergency inpatient stay, but not through the ED. A small percentage of patients (COPD:<1%, HF:2%) died without any known contact with secondary care. ED conversion rates at first attendance for both COPD and HF were high: 75% and 79% respectively. A quarter of patients who were not admitted during this first ED attendance attended the ED again within the 30-day follow-up period, and around half (COPD:56%; HF:63%) of these were admitted at this point.Patients who live alone, had an index admission which included an overnight stay and were comorbid had higher odds of being admitted through the ED than via other routes.ConclusionWhile the majority of patients did not have unscheduled contact with secondary care in the 30 days after index discharge, many patients attended the ED, often multiple times, and many were admitted to hospital, not always via the ED. More frail patients were more likely to be admitted through the ED, suggesting a
Whittaker HR, Muellerova H, Jarvis D, et al., 2019, Inhaled corticosteroids, blood eosinophils, and FEV1 decline in patients with COPD in a large UK primary health care setting, International Journal of Chronic Obstructive Pulmonary Disease, Vol: 2019, Pages: 1063-1073, ISSN: 1176-9106
Background: Inhaled corticosteroid (ICS)-containing medications slow rate of decline of FEV1. Blood eosinophil (EOS) levels are associated with the degree of exacerbation reduction with ICS.Purpose: We investigated whether FEV1 decline differs between patients with and without ICS, stratified by blood EOS level.Patients and methods: The UK Clinical Practice Research Datalink (primary care records) and Hospital Episode Statistics (hospital records) were used to identify COPD patients aged 35 years or older, who were current or ex-smokers with ≥2 FEV1 measurements ≥6 months apart. Prevalent ICS use and the nearest EOS count to start of follow-up were identified. Patients were classified at baseline as higher stratum EOS (≥150 cell/μL) on ICS; higher stratum EOS not on ICS; lower stratum EOS (<150 cells/μL) on ICS; and lower stratum EOS not on ICS. In addition, an incident ICS cohort was used to investigate the rate of FEV1 change by EOS and incident ICS use. Mixed-effects linear regression was used to compare rates of FEV1 change in mL/year.Results: A total of 26,675 COPD patients met our inclusion criteria (median age 69, 46% female). The median duration of follow up was 4.2 years. The rate of FEV1 change in prevalent ICS users was slower than non-ICS users (−12.6 mL/year vs −21.1 mL/year; P =0.001). The rate of FEV1 change was not significantly different when stratified by EOS level. The rate of FEV1 change in incident ICS users increased (+4.2 mL/year) vs −21.2 mL/year loss in non-ICS users; P<0.001. In patients with high EOS, incident ICS patients showed an increase in FEV1 (+12 mL/year) compared to non-ICS users whose FEV1 decreased (−20.8 mL/year); P<0.001. No statistical difference was seen in low EOS patients. Incident ICS use is associated with an improvement in FEV1 change, however, over time this association is lost.Conclusion: Regardless of blood EOS level, prevalent ICS use is associated with slower rates of
Gulea C, Zakeri R, Quint JK, 2019, WHY DO PATIENTS WITH CONCOMITANT HF AND COPD RETURN TO HOSPITAL? RISK FACTORS AND REASONS FOR SHORT-TERM READMISSION, Annual Conference of the British-Cardiovascular-Society (BCS) - Digital Health Revolution, Publisher: BMJ PUBLISHING GROUP, Pages: A68-A69, ISSN: 1355-6037
Gayle AV, Axson EL, Bloom CI, et al., 2019, Changing causes of death for patients with chronic respiratory disease in England, 2005-2015, Publisher: BMJ PUBLISHING GROUP, Pages: 483-491, ISSN: 0040-6376
Gulea C, Zakeri R, Quint JK, 2019, Impact of chronic obstructive pulmonary disease on readmission after hospitalization for acute heart failure: A nationally representative US cohort study, International Journal of Cardiology, ISSN: 0167-5273
BackgroundPatients hospitalized for heart failure (HF) are at high risk of readmission. Chronic obstructive pulmonary disease (COPD) is one of the most prevalent comorbidities in this population. However, few data and only small studies describe the impact of COPD on the risk of readmission.Methods and resultsHospitalizations for HF were identified in the 2012 National Readmissions Database. We compared clinical characteristics and the risk of all-cause, cardiovascular (CV) and respiratory-related readmission for patients with and without COPD. We included 225,160 patients hospitalized for HF among whom 54,953 had comorbid COPD. Patients with COPD were younger (median age 76 years COPD versus 77 years without COPD; p < 0.001), had a higher burden of comorbidity and were more frequently male (53% versus 49%, p < 0.001). Thirty-day all-cause readmission risk was two-fold greater in patients with COPD compared to those without COPD (adjusted HR 2.02, 95%CI 1.97–2.08). Most readmissions were attributed to a CV cause, though fewer patients with COPD had a CV admission (49% versus 51% without COPD). COPD was independently associated with significantly more frequent unplanned respiratory-related readmission (adjusted HR 2.90, 95%CI 2.68–3.15) as well as CV readmission risk (adjusted HR 1.92, 95%CI 1.85–1.99).ConclusionsIn patients hospitalized for HF, most readmissions are due to a CV cause. However, patients with comorbid COPD are at a significantly elevated risk of respiratory in addition to CV-related readmission. These data stress the importance of a multidisciplinary management approach, including optimization of non-CV conditions, in order to reduce readmissions post index HF hospitalization.
Pikoula M, Quint J, Nissen F, et al., 2019, Identifying clinically important COPD sub-types using data-driven approaches in primary care population based electronic health records, BMC Medical Informatics and Decision Making, Vol: 19, ISSN: 1472-6947
BackgroundCOPD is a highly heterogeneous disease composed of different phenotypes with different aetiological and prognostic profiles and current classification systems do not fully capture this heterogeneity. In this study we sought to discover, describe and validate COPD subtypes using cluster analysis on data derived from electronic health records.MethodsWe applied two unsupervised learning algorithms (k-means and hierarchical clustering) in 30,961 current and former smokers diagnosed with COPD, using linked national structured electronic health records in England available through the CALIBER resource. We used 15 clinical features, including risk factors and comorbidities and performed dimensionality reduction using multiple correspondence analysis. We compared the association between cluster membership and COPD exacerbations and respiratory and cardiovascular death with 10,736 deaths recorded over 146,466 person-years of follow-up. We also implemented and tested a process to assign unseen patients into clusters using a decision tree classifier.ResultsWe identified and characterized five COPD patient clusters with distinct patient characteristics with respect to demographics, comorbidities, risk of death and exacerbations. The four subgroups were associated with 1) anxiety/depression; 2) severe airflow obstruction and frailty; 3) cardiovascular disease and diabetes and 4) obesity/atopy. A fifth cluster was associated with low prevalence of most comorbid conditions.ConclusionsCOPD patients can be sub-classified into groups with differing risk factors, comorbidities, and prognosis, based on data included in their primary care records. The identified clusters confirm findings of previous clustering studies and draw attention to anxiety and depression as important drivers of the disease in young, female patients.
Lewis A, Dullaghan D, Townes H, et al., 2019, An observational cohort study of exercise and education for people with Chronic Obstructive Pulmonary Disease not meeting criteria for formal Pulmonary Rehabilitation Programmes, Chronic Respiratory Disease, ISSN: 1479-9723
Objectives:Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality. Pulmonary Rehabilitation (PR) is offered to patients with functional breathlessness. However, access to PR is limited. The objective of this study was to evaluate whether a four week education and exercise programme offered to COPD patients with Medical Research Council (MRC) dyspnoea 1-2 improves disease self-management. Methods:Patients were recruited by their GP to attend four weekly, two- hour sessions provided by a multidisciplinary team. Patients completed outcome measures before and after the programme.Results:Forty two patients entered The programme and 26 out of 42 (61.9%) completed all sessions. The Bristol COPD Knowledge Questionnaire and Patient Activation Measure improved (both p≤0.001). Disease burden was not reduced according to the COPD Assessment Test. All patients accepted a referral for ongoing exercise. Fourteen current smokers (81.3%) accepted a referral for smoking cessation, 3 patients with anxiety or depression (37.5%) accepted a psychological therapies referral.Discussion:The programme improved COPD disease knowledge, patient activation and stimulated referrals to further services supporting disease management. Randomised controlled trials are warranted for similar interventions for COPD patients with early stage disease.
Sundaram V, Quint JK, 2019, COPD and MI: when will we get our act together?, Eur Heart J Qual Care Clin Outcomes
Elbehairy A, Quint J, Rogers J, et al., 2019, Prevalence of breathlessness and associated consulting behaviour: results of an online survey, Thorax, ISSN: 1468-3296
The online British Lung Foundation Breath Test provides an opportunity to study the relationship between breathlessness, common sociobehavioural risk factors and interaction with healthcare. We analysed data from 356 799 responders: 71% were ≥50 years old and 18% were smokers. 20% reported limiting breathlessness (Medical Research Council breathlessness score ≥3), and the majority of these (85%) worried about their breathing; of these, 29% had not sought medical advice. Of those who had, 58% reported that the advice received had not helped their breathlessness. Limiting breathlessness was associated with being older, physically inactive, smoking and a higher body mass index. These data suggest a considerable unmet need associated with breathlessness as well as possibilities for intervention.
Bloom C, Ricciardi F, Smeeth L, et al., 2019, Predicting COPD one year mortality using prognostic predictors routinely measured in primary care, BMC Medicine, Vol: 17, ISSN: 1741-7015
BackgroundChronic obstructive pulmonary disease (COPD) is a major cause of mortality. Patients with advanced disease often have a poor quality of life, such that guidelines recommend providing palliative care in their last year of life. Uptake and use of palliative care in advanced COPD is low; difficulty in predicting 1-year mortality is thought to be a major contributing factor.MethodsWe identified two primary care COPD cohorts using UK electronic healthcare records (Clinical Practice Research Datalink). The first cohort was randomised equally into training and test sets. An external dataset was drawn from a second cohort. A risk model to predict mortality within 12 months was derived from the training set using backwards elimination Cox regression. The model was given the acronym BARC based on putative prognostic factors including body mass index and blood results (B), age (A), respiratory variables (airflow obstruction, exacerbations, smoking) (R) and comorbidities (C). The BARC index predictive performance was validated in the test set and external dataset by assessing calibration and discrimination. The observed and expected probabilities of death were assessed for increasing quartiles of mortality risk (very low risk, low risk, moderate risk, high risk). The BARC index was compared to the established index scores body mass index, obstructive, dyspnoea and exacerbations (BODEx), dyspnoea, obstruction, smoking and exacerbations (DOSE) and age, dyspnoea and obstruction (ADO).ResultsFifty-four thousand nine hundred ninety patients were eligible from the first cohort and 4931 from the second cohort. Eighteen variables were included in the BARC, including age, airflow obstruction, body mass index, smoking, exacerbations and comorbidities. The risk model had acceptable predictive performance (test set: C-index = 0.79, 95% CI 0.78–0.81, D-statistic = 1.87, 95% CI 1.77–1.96, calibration slope = 0.95, 95% CI
campbell J, perry R, papadopoulos N, et al., 2019, The REal Life EVidence AssessmeNt Tool (RELEVANT): development of a novel quality assurance asset to rate observational comparative effectiveness research studies, Clinical and Translational Allergy, Vol: 9, ISSN: 2045-7022
BackgroundEvidence from observational comparative effectiveness research (CER) is ranked below that from randomized controlled trials in traditional evidence hierarchies. However, asthma observational CER studies represent an important complementary evidence source answering different research questions and are particularly valuable in guiding clinical decision making in real-life patient and practice settings. Tools are required to assist in quality appraisal of observational CER to enable identification of and confidence in high-quality CER evidence to inform guideline development.MethodsThe REal Life EVidence AssessmeNt Tool (RELEVANT) was developed through a step-wise approach. We conducted an iterative refinement of the tool based on Task Force member expertise and feedback from pilot testing the tool until reaching adequate inter-rater agreement percentages. Two distinct pilots were conducted—the first involving six members of the Respiratory Effectiveness Group (REG) and European Academy of Allergy and Clinical Immunology (EAACI) joint Task Force for quality appraisal of observational asthma CER; the second involving 22 members of REG and EAACI membership. The final tool consists of 21 quality sub-items distributed across seven methodology domains: Background, Design, Measures, Analysis, Results, Discussion/Interpretation, and Conflict of Interest. Eleven of these sub-items are considered critical and named “primary sub-items”.ResultsFollowing the second pilot, RELEVANT showed inter-rater agreement ≥ 70% for 94% of all primary and 93% for all secondary sub-items tested across three rater groups. For observational CER to be classified as sufficiently high quality for future guideline consideration, all RELEVANT primary sub-items must be fulfilled. The ten secondary sub-items further qualify the relative strengths and weaknesses of the published CER evidence. RELEVANT could also be applicable to general quality appraisal of observati
Roche N, Campbell J, Krishnan J, et al., Quality standards in respiratory real-life effectiveness research: The REal Life EVidence AssessmeNt Tool (RELEVANT). Report from the Respiratory Effectiveness Group – European Academy of Allergy and Clinical Immunology Task Force, Clinical and Translational Allergy, ISSN: 2045-7022
A Task Force was commissioned jointly by the European Academy of Allergy and Clinical Immunology (EAACI) and the Respiratory Effectiveness Group (REG) to develop a quality assessment tool for real-life observational research to identify high-quality real-life asthma studies that could be considered within future guideline development. The resulting REal Life EVidence AssessmeNt Tool (RELEVANT) was achieved through an extensive analysis of existing initiatives in this area. The first version was piloted among 9 raters across 6 articles; the revised, interim, version underwent extensive testing by 22 reviewers from the EAACI membership and REG collaborator group, leading to further revisions and tool finalisation. RELEVANT was validated through an analysis of real-life effectiveness studies identified via systematic review of Medline and Embase databases and relating to topics for which real-life studies may offer valuable evidence complementary to that from randomised controlled trials. The topics were selected through a vote among Task Force members and related to the influence of adherence, smoking, inhaler device and particle size on asthma treatment effectiveness. Although highlighting a general lack of high-quality real-life effectiveness observational research on these clinically important topics, the analysis provided insights into how identified observational studies might inform asthma guidelines developers and clinicians. Overall, RELEVANT appeared reliable and easy to use by expert reviewers. Using such quality appraisal tools is mandatory to assess whether specific observational real-life effectiveness studies can be used to inform guideline development and/or decision-making in clinical practice.
Jayatunga W, Stone P, aldridge R, et al., 2019, Code sets for respiratory symptoms in electronic health records (EHR) research: a systematic review protocol, BMJ Open, Vol: 9, ISSN: 2044-6055
Introduction Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory conditions, which result in significant morbidity worldwide. These conditions are associated with a range of non-specific symptoms, which in themselves are a target for health research. Such research is increasingly being conducted using electronic health records (EHRs), but computable phenotype definitions, in the form of code sets or code lists, are required to extract structured data from these large routine databases in a systematic and reproducible way. The aim of this protocol is to specify a systematic review to identify code sets for respiratory symptoms in EHRs research.Methods and analysis MEDLINE and Embase databases will be searched using terms relating to EHRs, respiratory symptoms and use of code sets. The search will cover all English-language studies in these databases between January 1990 and December 2017. Two reviewers will independently screen identified studies for inclusion, and key data will be extracted into a uniform table, facilitating cross-comparison of codes used. Disagreements between the reviewers will be adjudicated by a third reviewer. This protocol has been produced in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines.Ethics and dissemination As a review of previously published studies, no ethical approval is required. The results of this review will be submitted to a peer-reviewed journal for publication and can be used in future research into respiratory symptoms that uses electronic healthcare databases.
Nissen F, Quint JK, Morales DR, et al., 2019, How to validate a diagnosis recorded in electronic health records, Breathe, Vol: 15, Pages: 64-68, ISSN: 2073-4735
Systematic measurement errors in electronic health record databases can lead to large inferential errors. Validation techniques can help determine the degree of these errors and therefore aid in the interpretation of findings. http://ow.ly/iHQ630np4xU.
Lewis A, Axson E, Potts J, et al., 2019, Protocol for a systematic literature review and network meta-analysis of the clinical benefit of inhaled maintenance therapies in chronic obstructive pulmonary disease (COPD), BMJ Open, Vol: 9, ISSN: 2044-6055
Introduction Chronic obstructive pulmonary disease (COPD) exacerbations progress the course of disease and impair lung function. Inhaled maintenance therapy reduces exacerbations. It is not yet established which inhaled therapy combination is best to reduce exacerbations, lung function decline and symptom burden.Methods and analysis MEDLINE, EMBASE and the Cochrane Library will be searched for articles between January 2011 and May 2018 using a pre-specified search strategy. Conference proceedings will be searched. Systematic reviews (with or without meta-analysis), randomised controlled trials (RCTs), cohort studies and case controlled studies comparing six interventions comprising different combinations of long-acting bronchodilators and inhaled corticosteroids in unison or on their own. The primary outcome is the reduction in moderate-to-severe exacerbations. Secondary outcomes include: lung function, quality of life, mortality and other adverse events. Titles and abstracts will screened by the primary researcher. A second reviewer will repeat this on a proportion of records. The Population, Intervention, Comparator, Outcomes and Study framework will be used for data extraction. A network meta-analyses of outcomes from RCTs and real-world evidence will be integrated if feasible. The 95% credible interval will be used to assess the statistical significance of each summary effect. Ranking of interventions will be based on their surface under cumulative ranking area.Ethics and dissemination COPD exacerbations are burdensome to patients. We aim to report results that provide clinicians with a more informed choice of which inhaled therapy combinations are best to reduce exacerbations, improve disease burden and reduce lung function and exercise capacity decline, compared with the potential harms, in certain populations with COPD.
Quint J, Smith M, 2019, Paediatric and adult bronchiectasis: diagnosis, disease burden and prognosis, Respirology, ISSN: 1323-7799
Bronchiectasis is a chronic, debilitating disease with increasing worldwide prevalence and burden. Accurate and early diagnosis is essential for both its management and prognosis. This review will discuss the diagnosis of bronchiectasis, the international burden of the disease and its current prognosis.
Bloom C, Saglani S, Feary J, et al., Changing prevalence of current asthma and inhaled corticosteroid treatment in the UK: population based cohort 2006 to 2016, European Respiratory Journal, ISSN: 0903-1936
BACKGROUND:Asthma is the most common respiratory disorder in the UK, yet we have incomplete knowledge on the prevalence of current disease, treatment and exacerbations.METHODS:We used UK electronic healthcare records, 2006 to 2016, to estimate the prevalence of current asthma by year, gender and age (<5, 5-11, 12-17, 18-24, 25-54 and ≥55 years), and the proportion prescribed inhaled corticosteroids (ICS) and additional asthma-therapy, treated for exacerbations and other asthma care markers. RESULTS:Overall current asthma prevalence was 6.5% in 2016 (7.2% in 2006). Prevalence fell in those under 45 years. The lowest prevalence and largest absolute decrease was in children under 5-years. In 2016, 80% of current asthma patients were managed on ICS, (65% in 2006); this increase occurred in all ages, primarily due to an increase in low-dose ICS. During this time there was an increase in all age-groups in the proportion prescribed additional asthma-therapy, treated for an exacerbation within primary care, given an annual asthma review or management plan. Hospitalised exacerbations showed minimal change over time.CONCLUSION:Asthma remains highly prevalent and a significant healthcare burden. In those with a diagnosis, there was an increase in ICS prescriptions and treatment of exacerbations across all age-groups. This may reflect a trend towards more aggressive asthma management within primary care. An apparent decline in prevalence was observed in those aged under 45 years, particularly in children under 5 years.
Quint J, Minelli C, EDITORIAL: Can’t see the wood for the trees: confounders, colliders and causal inference, Thorax, ISSN: 1468-3296
Janson C, Accordini S, Cazzoletti L, et al., 2019, Pharmacological treatment of asthma in a cohort of adults during a 20-year period: results from the European Community Respiratory Health Survey I, II and III, ERJ Open Research, Vol: 5, ISSN: 2312-0541
Asthma often remains uncontrolled, despite the fact that the pharmacological treatment has undergone large changes. We studied changes in the treatment of asthma over a 20-year period and identified factors associated with the regular use of inhaled corticosteroid (ICS) treatment. Changes in the use of medication were determined in 4617 randomly selected subjects, while changes in adults with persistent asthma were analysed in 369 participants. The study compares data from three surveys in 24 centres in 11 countries. The use of ICSs increased from 1.7% to 5.9% in the general population and the regular use of ICSs increased from 19% to 34% among persistent asthmatic subjects. The proportion of asthmatic subjects reporting asthma attacks in the last 12 months decreased, while the proportion that had seen a doctor in the last 12 months remained unchanged (42%). Subjects with asthma who had experienced attacks or had seen a doctor were more likely to use ICSs on a regular basis. Although ICS use has increased, only one-third of subjects with persistent asthma take ICSs on a regular basis. Less than half had seen a doctor during the last year. This indicates that underuse of ICSs and lack of regular healthcare contacts remains a problem in the management of asthma.
Gayle A, Axson E, Bloom C, et al., 2019, Changing causes of death for chronic respiratory disease patients in England, 2005-2015, Thorax, ISSN: 1468-3296
Background Chronic respiratory diseases (CRD) are common, are increasing in prevalence, and cause significant morbidity and mortality worldwide. However, we have limited knowledge on causes of death of patients with CRD in the general population.Objective We evaluated mortality rates and causes of death over time in patients with CRD.Methods We used linked primary care and mortality data to determine mortality rates and the most common causes of death in people with CRD (including asthma, bronchiectasis, COPD and interstitial lung diseases (ILD)) during 2005–2015 in England.Results We identified 558 888 patients with CRD (451 830 asthma, 137 709 COPD, 19 374 bronchiectasis, 10 745 ILD). The age-standardised mortality rate of patients with CRD was 1607 per 100 000 persons (asthma=856, COPD=1503, ILD=2609, bronchiectasis=1463). CRD mortality was overall 54% higher than the general population. A third of patients with CRD died from respiratory-related causes. Respiratory-related mortality was constant, while cardiovascular-related mortality decreased significantly over time. COPD accounted for the majority of respiratory-related deaths (66% overall) in all patient groups except ILD.Conclusions Patients with CRD continue to experience substantial morbidity and mortality due to respiratory diseases. Disease-modifying intervention strategies are needed to improve outcomes for patients with CRD.
Bloom C, Elkin S, Quint JK, 2019, Changes in COPD inhaler prescriptions in the United Kingdom, 2000 to 2016, International Journal of Chronic Obstructive Pulmonary Disease, Vol: 14, Pages: 279-287, ISSN: 1176-9106
Background: Over the past two decades, there have been significant changes in the pharmacological management of COPD, due to an explosion of inhaler trials, and timely updation of national and international guidelines. We sought to describe temporal changes in prescribing practices in the United Kingdom, and some of the factors that may have influenced them.Patients and methods: COPD patients were identified from UK primary care nationally representative electronic healthcare records (Clinical Practice Research Datalink), between 2000 and 2016. Prescription data were described by the three maintenance inhaled medication classes used, inhaled corticosteroids (ICS), long-acting beta agonist (LABA), long-acting muscarinic antagonist (LAMA), and their combinations, dual LABA-ICS, dual LAMA-LABA, or triple therapy LABA-ICS-LAMA. Differing patient characteristics across the six different therapy regimens were measured in 2016.Results: COPD patients were identified: 187,588 prevalent and incident inhaler users and 169,511 incident inhaler users. Since 2002, LAMA showed increasing popularity, while ICS alone exhibited an inverse trend. Triple therapy prescriptions rapidly increased as the first-line therapy until 2014 when LAMA-LABA prescriptions started to increase. By 2014, 41% of all COPD patients were maintained on triple therapy, and 13% were maintained on LAMA only. Characterizing the patients in 2016 revealed that those on triple therapy were more likely to have more severe disease, yet, over a third of patients on triple therapy had only mild disease.Conclusion: UK prescribing practices were not in keeping with national guidelines but did appear to align with evidence from major drug trials and updated international guidelines. There has been a huge upsurge in triple therapy but incident data show this trend is beginning to reverse for initial management.
Nissen F, douglas I, mullerova H, et al., 2019, Clinical profile of predefined asthma phenotypes in a large cohort of UK primary care patients (Clinical Practice Research Datalink), Journal of Asthma and Allergy, Vol: 12, Pages: 7-19, ISSN: 1178-6965
Background: Distinct asthma phenotypes have previously been suggested, including benign asthma, atopic asthma and obese non-eosinophilic asthma. This study aims to establish if these phenotypes can be identified using data recorded in primary care clinical records and reports on patient characteristics and exacerbation frequency.Methods: A population-based cohort study identified 193,999 asthma patients in UK primary care from 2007 to 2017. We used linked primary and secondary care data from the Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics. Patients were classified into predefined phenotypes or included in an asthma “not otherwise specified” (NOS) group. We used negative binomial regression to calculate the exacerbation rates and adjusted rate ratios. Rate ratios were further stratified by asthma treatment step.Results: In our cohort, 3.9% of patients were categorized as benign asthma, 28.6% atopic asthma and 4.8% obese non-eosinophilic asthma. About 62.7% of patients were asthma NOS, including asthma NOS without treatment (10.4%), only on short-acting beta agonist (6.1%) and on maintenance treatment (46.2%). Crude severe exacerbation rates per 1,000 person-years were lowest for benign asthma (106.8 [95% CI: 101.2–112.3]) and highest for obese non-eosinophilic asthma (469.0 [451.7–486.2]). Incidence rate ratios for all phenotype groups decreased when stratified by treatment step but remained raised compared to benign asthma.Conclusion: Established phenotypes can be identified in a general asthma population, although many patients did not fit into the specific phenotypes which we studied. Phenotyping patients and knowledge of asthma treatment step could help anticipate clinical course and therefore could aid clinical management but is only possible in a minority of primary care patients based on current phenotypes and electronic health records (EHRs).
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