Community outreach identifies asthma and COPD

SAN DIEGO — If you can’t find the patient, you can’t treat them. But as researchers in a randomized controlled trial showed, case-finding methods can: Spirometry Results can identify undiagnosed individuals in the community Chronic obstructive pulmonary disease (COPD) or asthma With proper care, their lives can be vastly improved.

Once these patients are identified and randomly assigned to receive treatment by a pulmonologist and an asthma-COPD educator according to clinical guidelines, these undiagnosed patients are , medical utilization, lung function, symptoms, and quality of life are significantly improved. Treatment by a general practitioner.

“By diagnosing people early and treating them intensively, we can really improve their quality of life,” said lead researcher Dr. said Dr. Sean D. Aaron.

Patients in the study who were randomly assigned to receive care from a general practitioner also showed improvements in lung function and quality of life, although to a lesser extent than those assigned to a specialist team, Aaron said at the International Congress of the American Thoracic Society. mentioned in. .

He reported the results of the UCAP study in the latest oral abstracts session. The research results also Published online in New England Medical Journal.

undiagnosed disease

“The simple problem is that 70% of people with asthma or COPD are likely undiagnosed,” Aaron says.

He noted that the 2007-2012 U.S. National Health and Nutrition Examination Survey found obstructive pulmonary disease in 13% of randomly selected U.S. adults, but 71% of these people were diagnosed with asthma or COPD. He pointed out that he had never been.

“So our questions were in this study: one, can we find adults with undiagnosed asthma or COPD in the community? Second, if we do, “Are they sick? And the third and most important question was, can we treat them? Can we treat them early and improve their health?” he said.

Both asthma and COPD present with similar respiratory symptoms such as difficulty breathing, coughing, wheezing, and chest tightness, and a common physiological disorder that can be detected with spirometry is obstruction of expiratory airflow. I am.

Research details

To identify participants, researchers hired a private survey company to contact households and ask members aged 18 and older to report symptoms such as shortness of breath, wheezing, increased mucus or phlegm, or persistent cough in the past six months. I asked if he had any respiratory symptoms. Those who answered yes were contacted by the study coordinator, and symptomatic family members were asked to complete an asthma screening questionnaire over the phone. Participants aged 60 and older and those younger than 60 with an asthma screening score of 6 or higher also completed a COPD diagnostic questionnaire.

People with a score of 6 or higher on the asthma screen or a score of 20 or higher on the COPD screen were invited to undergo spirometry at the study site.

The researchers ultimately identified 508 adults with undiagnosed asthma or COPD and randomly assigned them equally to the intervention group (253 patients) or the control group (255 patients).

In the intervention group, treatment was provided by a study pulmonologist and an asthma/COPD educator who initiated guideline-based treatment. Patients were prescribed inhalers and taught how to use them, and many were given action plans that included smoking cessation assistance, exercise and weight counseling, and vaccinations. influenza And pneumonia.

Participants assigned to the control group will receive usual care from their primary care physician.

Lots of improvements

During the 12-month study period, 92% of patients in the intervention group and 60% of patients in the control group started taking a new medication for their condition.

Only 13.4% of the intervention group received no respiratory treatment or only short-acting beta-agonists throughout the study period, compared with 49.8% of the control group, “so the usual care group was undertreated compared to the intervention group. And because of that undertreatment, we saw a big difference in the primary outcome,” Aaron said.

The primary outcome, the annual rate of patient-directed health care utilization for respiratory disease, was significantly lower in the intervention group, with an incidence rate ratio of 0.48 (P < .001).

Secondary outcomes were also better in the intervention group. For example, the St. George's Respiratory Questionnaire (SGRQ) total score decreased by 10.2 points from baseline in the intervention group, but by 6.8 points in the usual care group. The average difference was 3.5 points (P = .009). Lower scores on the 0-100 SGRQ scale indicate better health.

Similarly, total scores on the COPD Assessment Test, on a scale of 0 to 40 with lower scores indicating better health, decreased by 3.8 and 2.6 points, respectively, over 12 months, with an average difference of 1.3 points (P = .03).

Additionally, the intervention group improved forced expiratory volume in 1 second by 119 mL over the 12-month study period, compared to only a 22 mL improvement in the usual care group.

Translatable results?

Aaron said the researchers could have kept patients assigned to the control group from knowing their diagnosis for the duration of the study, but since all of the patients enrolled were symptomatic, doing so would have been difficult. He admitted it would have been unethical. All participants were informed of the diagnosis at the time of randomization, and this information was also communicated to each patient's physician.

In fact, many patients in the control group decided to receive treatment for asthma or COPD after learning of their diagnosis, which may have led to improved outcomes in the control group, he said.

“What this means is that if we diagnose people early in the community and at least get them seen by their GP, their quality of life and health will improve,” he concluded. .

In an interview, Ravi Kalhan, MD, M.A., of Northwestern University Feinberg School of Medicine in Chicago, who co-facilitated the session but was not involved in the study, said in an interview that the case-finding model used in this trial was difficult. He said that. Replicate elsewhere.

“The idea of ​​using spirometry to find undiagnosed people, so-called 'case finding,' or using spirometry to test people with severe symptoms, is very difficult in the U.S. because symptoms are actively collected. “That's because there aren't that many,” he said.

People in the United States with acute respiratory symptoms usually seek medical care at an emergency clinic or make an unscheduled visit to their primary care physician. “And by all accounts, people like that should get spirometry tests, and we're not doing it in the best way in the United States,” he added.

He agreed that taking patients to see a specialist may lead to better outcomes, but implementing a systematic approach like the one described in the study has been fragmented. He said that would be extremely difficult in the U.S. health care system.

said Culhan's co-host, Nuala J. Meyer, MD, MSc, of the Philadelphia Hospital of the University of Pennsylvania. chest doctor “It's interesting that even those who shared these details with their doctors, even though they weren't in the intervention group, still saw improvements,” she said, adding that if their doctors were regularly informed about the outcome of their emergency treatment, Said it was beneficial. visit.

However, problems in the flow of information between emergency clinics, primary care clinics, and specialty clinics in the U.S. mean that symptomatic patients may not always receive the additional care they need, he said. added.

This research was supported by the Canadian Institutes of Health Research. Mr. Aaron, Mr. Calhan and Mr. Meyer all reported that they had no relevant disclosures.