COPD detected with screening: impact on patient management and prognosis

Bertens, Loes C. M.; Reitsma, Johannes B.; Mourik, Yvonne van; Lammers, Jan‐Willem J.; Moons, Karel G.M.; Hoes, Arno W.; Rutten, Frans H.

doi:10.1183/09031936.00074614

Cited by 20 publications

(11 citation statements)

References 26 publications

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“…Interestingly, in the entire population of frail individuals, including those with both COPD and heart failure, the overall prevalence of COPD was almost 45% and the overall prevalence of heart failure was .40%. Taken together with the high prevalence of other chronic conditions (reported in table 1 of the article [23]), these data suggest a high prevalence of multimorbidity in this elderly and frail group of patients who complain of dyspnoea.…”

supporting

confidence: 58%

“…In an interesting study published in this issue of the European Respiratory Journal, BERTENS et al [23] investigated a different aspect of COPD screening: whether screening for COPD in frail, elderly subjects complaining of dyspnoea is effective in discovering new cases of COPD, and whether it has an impact on patient management and prognosis. The simple answers are ''yes'' to the former and ''no'' to the latter.…”

mentioning

confidence: 99%

“…The study by BERTENS et al [23] is a small part of a wider programme primarily aimed at determining the relationship between COPD and heart failure. These are the most common chronic diseases responsible for dyspnoea [25,26].…”

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confidence: 99%

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Symptomatic, frail, elderly patients: the urgent need for comprehensive assessment and management

2014

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@ERSpublicationsEarly screening of chronic diseases and COPD needs attention in the elderly population to properly assess management http://ow.ly/ACbi3The working hypotheses for screening and early diagnosis of chronic obstructive pulmonary disease (COPD) have been that: 1) long-term exposure to cigarette smoke or pollutants damages the airways and/or the lungs, and causes airflow obstruction [1, 2]; 2) airflow obstruction occurs primarily in the small airways, is asymptomatic in the early stages of the disease and is progressive in the majority of COPD patients [1][2][3][4]; and 3) forced expiratory volume in 1 s (FEV1) and its ratio with forced vital capacity are necessary in establishing the diagnosis of COPD, and in assessing the excessive decline in lung function [1], but are of little use, if any, in making the early, pre-symptomatic diagnosis of COPD [5].These working hypotheses have been helpful in stimulating research in the field of structure-function relationships in the lung, and particularly in defining the role of airway and lung inflammation in the development of central and peripheral airway remodelling and emphysema [2, 3,6]. Research focused on the respiratory system has also brought about the development of physiological and imaging methods to assess peripheral airways and lung parenchyma [7][8][9], and has furthered understanding of the natural history of COPD, particularly the progressive decline in lung function and its modulation by pharmacological intervention [10]. Thanks to the results of these studies, we now know much more about COPD, about the potential and limitations of screening [11] and early diagnosis based on spirometry, and about interventions in early asymptomatic and newly discovered COPD.Screening subjects at risk, such as smokers, workers and populations exposed to environmental pollution, with serial measurements of FEV1 has been shown to identify COPD at an early stage, with a diagnostic yield that is significant even in asymptomatic individuals [12]. Studies including measurement of small airway function, though inconclusive, have been used in an attempt to identify more subtle changes in airway function, without success [5,13]. Novel imaging methods [8,9] and biomarker profiles [14,15] show promise, but we are not there yet. Consequently, a suitable alternative to spirometry has yet to be discovered. Spirometry is simple, inexpensive, and remains the best practical method for use in early detection and screening of undiagnosed airflow obstruction [16].The rationale for identifying subjects with previously undiagnosed COPD and for early diagnosis of COPD in subjects at risk is that it would benefit the patient, either because symptoms and quality of life would be improved, exacerbations and complications would be limited, and survival would be enhanced, or because

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Symptomatic, frail, elderly patients: the urgent need for comprehensive assessment and management

2014

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“…Unrecognised CRDs can be detected in frail elderly patients [33]. Optimising treatment and integrated care services of frail COPD patients with multimorbidities and polypharmacy improves certain health outcomes [34].…”

Section: Implementation Of the Airways-icps Action Planmentioning

confidence: 99%

AIRWAYS-ICPs (European Innovation Partnership on Active and Healthy Ageing) from concept to implementation

et al. 2016

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Chronic respiratory diseases (CRDs) are major non-communicable diseases (NCDs) that induce a significant burden. Asthma often occurs along the life cycle from early childhood, affecting 30 million children and adults under 45 years of age in Europe. Chronic obstructive pulmonary disease (COPD) has an estimated annual death rate of over 3 million people globally. The annual direct and indirect costs in the 28 European Union (EU) countries due to COPD or asthma are estimated at 48 billion euros and 34 billion euros respectively. Rhinitis occurs in over 100 million people in Europe, and indirect costs are enormous [4]. Asthma is a common risk factor for COPD. CRDs impact ageing and should be prevented, recognised and managed across the life cycle to promote active and healthy ageing (AHA). There is an urgent need to act globally

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“…7 However, these symptoms are not unique to heart failure and can be associated with other conditions or patients may have several coexisting diseases. [8][9][10] Patients with symptoms that may be associated with heart failure often present to primary care. Identifying the patients likely to have heart failure, and therefore requiring referral for diagnostic testing, can be difficult.…”

Section: Heart Failure Diagnosismentioning

confidence: 99%

The REFER (REFer for EchocaRdiogram) study: a prospective validation and health economic analysis of a clinical decision rule, NT-proBNP or their combination in the diagnosis of heart failure in primary care

et al. 2017

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Background Heart failure is a treatable condition but making a diagnosis can be challenging. Objective To evaluate the performance of a clinical decision rule (CDR) with or without a natriuretic peptide assay for identifying heart failure in symptomatic patients presenting to primary care. Design Prospective, observational, diagnostic validation study and economic evaluation. Setting Twenty-eight general practices in central England, UK. Participants Primary care patients aged ≥ 55 years presenting with recent new-onset shortness of breath, lethargy or peripheral ankle oedema of > 48 hours’ duration. Instrument The CDR included a clinical element (male, history of myocardial infarction, crepitations at the lung bases and oedema) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test. The reference standard was an expert consensus panel of three cardiology specialists. Main outcome measure The main outcome measure was test performance of the CDR and the natriuretic peptide test alone, and in combination, in estimating sensitivity and specificity, positive predictive value (PPV) and negative predictive value (NPV) for a diagnosis of heart failure. Economic evaluation of a decision tree with a NHS/Personal Social Services perspective determined the cost per quality-adjusted life-year (QALY) gained. Results In total, 304 participants were recruited to the validation cohort. The mean age was 73.9 years (standard deviation 8.8 years) and 124 (40.8%) participants were male. In total, 104 [34.2%, 95% confidence interval (CI) 28.9% to 39.8%] had a confirmed diagnosis of heart failure. The CDR had a sensitivity of 90% (95% CI 83% to 95%), specificity of 46% (95% CI 39% to 53%), PPV of 46% (95% CI 39% to 53%) and NPV of 90% (95% CI 83% to 95%). NT-proBNP level alone with a cut-off point of < 400 pg/ml had a sensitivity of 77% (95% CI 68% to 85%) and specificity of 92% (95% CI 87% to 95%). At the lower cut-off point of 125 pg/ml, sensitivity was 94% (95% CI 88% to 98%) and specificity was 49% (95% CI 42% to 56%). The economic model results suggest that referring a patient for a confirmatory diagnosis if they have had a previous myocardial infarction or have a NT-proBNP level that is greater than a 400 pg/ml threshold (current practice in England) is the most cost-effective option, with a cost of £4400 per QALY gained compared with a do nothing strategy. The base-case results were robust to deterministic and probabilistic sensitivity analyses. Conclusions Natriuretic peptide testing alone performed as well as the validated CDR in determining which patients presenting with symptoms went on to have a diagnosis of heart failure. The current NT-proBNP cut-off point of 400 pg/ml used in the UK is too high and means that one in five patients with heart failure may not be appropriately referred for further investigation and diagnosis, but this threshold was cost-effective in the REFer for EchocaRdiogram (REFER) trial. The study found only three patients with heart failure with reduced ejection fraction (HFREF), which might limit the benefits of early detection. The other diagnostic strategies with lower NT-proBNP referral levels become more cost-effective as the proportion of HFREF patients increases. International consensus on the optimal cut-off point for natriuretic peptide testing in patients with symptoms suggestive of heart failure should be sought. Trial registration Current Controlled Trials ISRCTN17635379. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and NIHR partnership.

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COPD detected with screening: impact on patient management and prognosis

Cited by 20 publications

References 26 publications

Symptomatic, frail, elderly patients: the urgent need for comprehensive assessment and management

Symptomatic, frail, elderly patients: the urgent need for comprehensive assessment and management

AIRWAYS-ICPs (European Innovation Partnership on Active and Healthy Ageing) from concept to implementation

The REFER (REFer for EchocaRdiogram) study: a prospective validation and health economic analysis of a clinical decision rule, NT-proBNP or their combination in the diagnosis of heart failure in primary care

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