[COPD : a still neglected condition]. / BPCO : une maladie encore négligée.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung disorder with a complex clinical picture. The diagnosis may be difficult at times, as COPD may develop insidiously and remain unnoticed for a long time. Therefore, general practitioners play a central role in early detection of disease. Suspected COPD may be confirmed by further investigations in collaboration with a pulmonologist. The most recent GOLD guideline defines three COPD risk groups (A-B-E) which should guide the personalized treatment concept. General practitioners are crucial for implementing non-pharmacological measures such as smoking cessation, regular exercise, vaccinations, and patient self-management education. However, this also underlines the challenges to implement the GOLD recommendations in daily practice.

La BPCO est une maladie hétérogène avec un tableau clinique complexe. Le diagnostic n'est pas toujours facile à évoquer, car elle peut se développer insidieusement et passer longtemps inaperçue. Les médecins de premier recours (MPR) jouent donc un rôle central dans le diagnostic précoce. La suspicion de BPCO peut être confirmée en collaboration avec un pneumologue par des examens fonctionnels respiratoires avant l'instauration d'un traitement médicamenteux. Les nouvelles recommandations GOLD, publiées en 2022 définissent trois groupes de risques pour la BPCO (A-B-E). Les MPR sont importants pour la mise en œuvre de mesures accompagnant le traitement (arrêt du tabac, activité physique régulière, vaccinations, éducation thérapeutique). Mais cela souligne également les exigences élevées de la mise en œuvre des recommandations GOLD dans la pratique quotidienne.*.

Characteristics of Severe Asthma Patients and Predictors of Asthma Control in the Swiss Severe Asthma Registry.

BACKGROUND: Asthma is a chronic airway disease, affecting over 300 million people worldwide. 5-10% of patients suffer from severe asthma and account for 50% of asthma-related financial burden. Availability of real-life data about the clinical course of severe asthma is insufficient. OBJECTIVES: The aims of this study were to characterize patients with severe asthma in Switzerland, enrolled in the Swiss Severe Asthma Registry (SSAR), and evaluate predictors for asthma control. METHOD: A descriptive characterisation of 278 patients was performed, who were prospectively enrolled in the registry until January 2022. Socio-demographic variables, comorbidities, diagnostic values, asthma treatment, and healthcare utilisation were evaluated. Groups of controlled and uncontrolled asthma according to the asthma control test were compared. RESULTS: Forty-eight percent of patients were female and the mean age was 55.8 years (range 13-87). The mean body mass index (BMI) was 27.4 kg/m2 (±6). 10.8% of patients were current smokers. Allergic comorbidities occurred in 54.3% of patients, followed by chronic rhinosinusitis (46.4%) and nasal polyps (34.1%). According to the ACT score, 54.7% had well controlled, 16.2% partly controlled and 25.9% uncontrolled asthma. The most common inhalation therapy was combined inhaled corticosteroids/long-acting ß2-agonists (78.8%). Biologics were administered to 81.7% of patients and 19.1% received oral steroids. The multivariable analysis indicated that treatment with biologics was positively associated with asthma control whereas higher BMI, oral steroids, exacerbations, and COPD were negative predictors for asthma control. CONCLUSION: Biologics are associated with improved control in severe asthma. Further studies are required to complete the picture of severe asthma in order to provide improved care for those patients.

[COPD - An Underestimated Disease]. / COPD ­ eine unterschätzte Erkrankung.

COPD - An Underestimated Disease Abstract: Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition with a complex clinical picture. The diagnosis is not easy to make because COPD can develop insidiously and remain unnoticed for a long time. Therefore, general practitioners play a central role in the early detection of the disease. Suspected COPD can be confirmed by special examinations in collaboration with pulmonologists. The new GOLD guideline defines three COPD risk groups (A-B-E) which should guide the personalized treatment concept. A short- or long-acting bronchodilator (SAMA/SABA or LAMA/LABA) is recommended for group A, and a dual long-acting bronchodilator therapy (LABA+LAMA) is recommended for group B and E. In case of blood eosinophilia (≥300 cells/µl) and/or recent hospitalization for COPD exacerbation, triple therapy (LABA+LAMA+ICS) is recommended. General practitioners are important in implementing non-pharmacological measures (smoking cessation, regular exercise, vaccinations, patient selfmanagement education). However, this also underlines the high demands of the implementation of the GOLD guideline in daily practice.

Supporting Behavior Change After AECOPD - Development of a Hospital-Initiated Intervention Using the Behavior Change Wheel.

After hospitalization due to acute COPD exacerbations, patient-manageable behaviors influence rehospitalization frequency. This study's aim was to develop a hospital-ward-initiated Behaviour-Change-Wheel (BCW)-based intervention targeting patients' key health behaviors, with the aim to increase quality of life and reduce rehospitalization frequency. Intervention development was performed by University Hospital Zurich working groups and followed the three BCW stages for each of the three key literature-identified problems: insufficient exacerbation management, lack of physical activity and ongoing smoking. In stage one, by analyzing published evidence - including but not limited to patients' perspective - and health professionals' perspectives regarding these problems, we identified six target behaviors. In stage two, we identified six corresponding intervention functions. As our policy category, we chose developing guidelines and service provision. For stage three, we defined eighteen basic intervention packages using 46 Behaviour Change Techniques in our basic intervention. The delivery modes will be face-to-face and telephone contact. In the inpatient setting, this behavioral intervention will be delivered by a multi-professional team. For at least 3 months following discharge, an advanced nursing practice team will continue and coordinate the necessary care package via telephone. The intervention is embedded in a broader self-management intervention complemented by integrated care components. The BCW is a promising foundation upon which to develop our COPD intervention. In future, the interaction between the therapeutic care team-patient relationships and the delivery of the behavioral intervention will also be evaluated.

[«Patient education in the context of rehabilitation¼ Self-management interventions and patient coaching integral components of pulmonary rehabilitation (PR)]. / «Patient Education im Rahmen der Rehabilitation¼.

«Patient education in the context of rehabilitation¼ Self-management interventions and patient coaching integral components of pulmonary rehabilitation (PR) Abstract. Integration of effective self management interventions to pulmonary rehabilitation may not be considered as an option but as an integral part to make sustainable changes to patient behavior which will positively affect the maintenance of PR treatment effects. While it is well established that pulmonary rehabilitation (PR) improves functional / exercise capacity and health-related quality of life, one recognized important goal of PR is to influence health behaviors (smoking cessation, physical activity, breathing management, medication adherence, recognizing and supported self-managing exacerbations) in chronic pulmonary disease that promote successful disease management and better prognosis . With the integration of effective self- management interventions to PR programs there is an increased likelihood to not only improve typical PR outcomes but to make sustainable changes to patient behavior which will positively affect the maintenance of PR treatment effects. However, an evolution of traditional patient education from giving information only to effective self- management coaching is necessary as an evidence based integral part of best practice and quality in PR. Crucially this demands a healthcare system that 1) support self-management; 2. provide flexible access to professional advice; 3. ideally ensure continuity of care and 4. Pay for effective self-management interventions.

The Impact of Case Finding on the Recruitment Yield for COPD Research in Primary Care: An Observational Study.

BACKGROUND: Recruiting patients for research in primary care is difficult with diseases that tend to remain underdiagnosed, such as chronic obstructive pulmonary disease (COPD). Researchers may consider introducing case finding into patient recruitment, but the impact on recruitment yield is largely unknown. OBJECTIVES: To assess the impact of case finding on recruitment yield and population characteristics in primary care-based COPD research. METHODS: For a cluster randomized controlled trial of COPD in primary care, an opportunistic case finding strategy was introduced into patient recruitment, in addition to recruiting patients with previously diagnosed COPD. The recruitment process and performance of the primary care physicians (PCPs) were analysed. The numbers and characteristics of patients identified by case finding were compared with those of patients with previously diagnosed COPD. RESULTS: Thirty-five PCPs approached 398 patients and successfully recruited 216 patients during 1 year. The mean number of patients recruited was 6.3 (range 0-16) per PCP. Case finding contributed 71 patients (32.9%) with significantly milder disease, with FEV1 % predicted +16.7 (95% CI: +11.3 to +22.0), a COPD Assessment Test difference of -4 points (95% CI: -2 to -6; p < 0.001), and fewer exacerbations resulting in a higher rate of GOLD class A (85.9 vs. 45.5%; p < 0.001). The smoking rate was significantly higher among patients with newly diagnosed COPD (70.4 vs. 48.6%; p = 0.002). CONCLUSION: Case finding increased the number of patients recruited by 50%. The COPD patients identified by case finding differed importantly from those with previously diagnosed COPD. Researchers should be aware of COPD underdiagnosis and the potential impact of case finding during patient recruitment.

Performance Measures in the Management of Chronic Obstructive Pulmonary Disease in Primary Care--A Retrospective Analysis.

RATIONALE: Adherence to recommendations regarding quality of care for chronic obstructive pulmonary disease (COPD) improves outcome of patients. Performance measures (PM) reflect the quality of care but information about documentation of PM in primary care, is scant. AIM: To investigate the documentation of COPD PM in primary care practices of the Canton Zurich. METHOD: Twelve months retrospective medical chart review with physician of patients diagnosed COPD. PM were assessed by calculating the percentages of documented performance parameters. In addition, PM were compared with a practice running a structured COPD program. RESULTS: Data from 14 practices, total 115 patients, 57% male, mean age 68 (44­93) years, 46% active smokers, median pack-years 56 (range 22­150) were analyzed. Comorbidities were documented in 73%, GOLD grading in 70% (GOLD I 11%, GOLD II 64%, GOLD III 21%, GOLD IV 4%). On average, patients were reported to have 1,4 exacerbations/year. Documentation of PM ranged between 16% (written action plan for exacerbations) and 95% (smoking status). Documentation was identified for smoking cessation advice (74%), influenza vaccination/recommendation (49%), adequate pharmacotherapy (65%), inhalation instruction (57%), pulmonary rehabilitation advice (27%), collaborative care (60%) and proactive follow up (51%). The practice running the COPD program showed significant better documentation for all PM (p<0,01) but for influenza vaccination. CONCLUSION: In Swiss primary care gaps in documentation and tracking of COPD performance exist. Identifying and bridging these gaps is central for health care quality.

The improving care in chronic obstructive lung disease study: CAROL improving processes of care and quality of life of COPD patients in primary care: study protocol for a randomized controlled trial.

BACKGROUND: The Swiss health ministry launched a national quality program 'QualiCCare' in 2011 to improve health care for patients with COPD.The aim of this study is to determine whether participation in the COPD quality initiative ('QualiCCare') improves adherence to recommended clinical processes and shows impact on patients' COPD care and on the impact of COPD on a person's life. METHODS: CAROL is a cluster-randomized controlled trial with randomization on the general practioner (GP) level. Thirty GPs will be randomly assigned to equally sized intervention group or control group.Each GP will approach consecutively and regardless of the reason for the current consultation, patients aged 45 years or older, with a smoking history of ≥ ten pack-years (PY). Patients with confirmed (by spirometric evaluation) COPD will be included in the study. GPs in the intervention group will receive 'QualiCCare' education, which addresses knowledge, decision-making and behavioural aspects as well as delivery of care according to COPD quality indicators and evidence-based key elements. In the control group, no educational intervention will be applied and COPD patients will be treated as usual. The study period is one year.The primary outcome measure is an aggregated score of relevant clinical processes defining elements in the care of patients with COPD: smoking cessation counseling, influenza vaccination, motivation for physical activity, appropriate pharmacotherapy, patient education and collaborative care. Given a power of 90% and a significance level alpha of 5%, 15 GPs recruiting eight patients each will be necessary in both study arms. With an assumed dropout rate of 20%, 288 patients will need to be included. DISCUSSION: It is important to develop and implement interventions that add value to COPD care considering quality and efficiency. Care pathways modifying the knowledge and behavior of physicians have the potential for improving care by transferring knowledge to clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01921556.

Smoking cessation induces profound changes in the composition of the intestinal microbiota in humans.

BACKGROUND: The human intestinal microbiota is a crucial factor in the pathogenesis of various diseases, such as metabolic syndrome or inflammatory bowel disease (IBD). Yet, knowledge about the role of environmental factors such as smoking (which is known to influence theses aforementioned disease states) on the complex microbial composition is sparse. We aimed to investigate the role of smoking cessation on intestinal microbial composition in 10 healthy smoking subjects undergoing controlled smoking cessation. METHODS: During the observational period of 9 weeks repetitive stool samples were collected. Based on abundance of 16S rRNA genes bacterial composition was analysed and compared to 10 control subjects (5 continuing smokers and 5 non-smokers) by means of Terminal Restriction Fragment Length Polymorphism analysis and high-throughput sequencing. RESULTS: Profound shifts in the microbial composition after smoking cessation were observed with an increase of Firmicutes and Actinobacteria and a lower proportion of Bacteroidetes and Proteobacteria on the phylum level. In addition, after smoking cessation there was an increase in microbial diversity. CONCLUSIONS: These results indicate that smoking is an environmental factor modulating the composition of human gut microbiota. The observed changes after smoking cessation revealed to be similar to the previously reported differences in obese compared to lean humans and mice respectively, suggesting a potential pathogenetic link between weight gain and smoking cessation. In addition they give rise to a potential association of smoking status and the course of IBD.

Management of chronic obstructive pulmonary disease in Swiss primary care: room for improvement.

BACKGROUND: Information on the quality of care for patients with chronic obstructive pulmonary disease (COPD) in Swiss primary care is limited. AIM: To identify gaps and quality improvement potential in COPD primary care in Switzerland. METHODS: Pooled analysis of selected published data. Six international COPD guidelines (German, Swiss, United Kingdom, Canadian, Australian and New Zealand, and the global initiative on obstructive lung disease [GOLD] guidelines) were reviewed for care elements with a level of evidence rated II and higher in at least three of the six guidelines. We compared published data on COPD management in Swiss primary care with these recommendations and with published international benchmarks. RESULTS: Nine elements fulfilled the criteria for evidence level II or higher in at least three of six COPD guidelines. These were summarised in six key domains: diagnosis, smoking cessation counselling, influenza vaccination, pharmacological treatment, patient education and pulmonary rehabilitation (long-term oxygen and palliative care are not the focus of COPD primary care in Switzerland and outpatient exacerbation management was subordinated to pharmacological treatment and education). Swiss primary care data revealed spirometric confirmation of diagnosis in 55% of patients, smoking cessation counselling in 50% and influenza vaccination in 66%. Inadequate prescription of inhaled corticosteroids (ICS) was high at 38% in mild COPD and 43% in moderate COPD. Referral for pulmonary rehabilitation, even for patients with severe COPD, was low at 19% and data on patient education were rare. Diagnosis, patient education and referral for pulmonary rehabilitation revealed the highest, and influenza vaccination the lowest performance gap. CONCLUSION: Gaps between current care and recommended best practice exist in Swiss primary care COPD management. Promoting and implementing evidence-based frameworks for developing high quality care for patients with COPD are necessary.

Uncontrolled arterial hypertension in primary care--patient characteristics and associated factors.

PRINCIPLES: Most patients with arterial hypertension are treated in primary care. The objective is to assess characteristics of patients with uncontrolled arterial hypertension and its associated determinants in Swiss primary care. METHOD: Data on 122 adult patients with uncontrolled hypertension (mm Hg >140 systolic and/or >90 diastolic) was collected from the baseline data of the on-going randomised controlled "CoCo" trial: Colour-coded Blood Pressure Control. Patient and general practitioner characteristics were analysed to investigate the relationship between BP and patient characteristics. RESULTS: From October 2009 to March 2011 30 general practitioners recruited 122 patients; median age 64 years (IQR 54.8-72), 50% male, median BMI 28.3 kg/m2 (IQR 25.3-31.7), 21.5% smokers. 65.6% performed home blood pressure measurement, 88.5% received pharmacological treatment, 41.8% mono-therapy. Most frequent dual drug combinations: diuretics/angiotensin-receptor-blockers (33.3%), angiotensin-converting-enzyme-inhibitors/beta blockers (both 28.1%). BMI, smoking and age were independent predictors for elevated systolic blood pressure when controlled for gender, home blood pressure measurement, education, pulse rate and number of antihypertensive substances. We found a significant non-linear association between systolic blood pressure and number of antihypertensive substances. Age and any amount of antihypertensive substances were independently and inversely correlated with diastolic blood pressure. The findings did not change when additionally controlled for general practitioner clustering effect. CONCLUSION: Smoking and high BMI are strong and independent factors associated with higher blood pressure levels in patients with uncontrolled arterial hypertension. A high rate of monotherapy and a decrease in the incremental gain on blood pressure control when more antihypertensive agents are used highlight the importance of adequate pharmacological treatment as well as risk factor control.

Case management in oncology rehabilitation (CAMON): the effect of case management on the quality of life in patients with cancer after one year of ambulant rehabilitation. a study protocol for a randomized controlled clinical trial in oncology rehabilitation.

BACKGROUND: Cancer diseases and their therapies have negative effects on the quality of life. The aim of this study is to assess the effectiveness of case management in a sample of oncological outpatients with the intent of rehabilitation after cancer treatment. Case management wants to support the complex information needs of the patients in addition to the segmented structure of the health care system. Emphasis is put on support for self-management in order to enhance health - conscious behaviour, learning to deal with the burden of the illness and providing the opportunity for regular contacts with care providers. We present a study protocol to investigate the efficacy of a case management in patients following oncology rehabilitation after cancer treatment. METHODS: The trial is a multicentre, two-arm randomised controlled study. Patients are randomised parallel in either 'usual care' plus case management or 'usual care' alone. Patients with all types of cancer can be included in the study, if they have completed the therapy with chemo- and/or radiotherapy/surgery with curative intention and are expected to have a survival time >1 year. To determine the health-related quality of life the general questionnaire FACT G is used. The direct correlation between self-management and perceived self-efficacy is measured with the Jerusalem & Schwarzer questionnaire. Patients satisfaction with the care received is measured using the Patient Assessment of Chronic Illness Care 5 As (PACIC-5A). Data are collected at the beginning of the trial and after 3, 6 and 12 months. The power analysis revealed a sample size of 102 patients. The recruitment of the centres began in 2009. The inclusion of patients began in May 2010. DISCUSSION: Case management has proved to be effective regarding quality of life of patients with chronic diseases. When it comes to oncology, case management is mainly used in cancer treatment, but it is not yet common in the rehabilitation of cancer patients. Case management in oncology rehabilitation is not well-established in Switzerland. A major challenge of the study will therefore probably be the recruitment of the patients due to the physicians' and patients' scarcely existing awareness of this issue. Trial registrationISRCTN41474586

Allergic rhinitis in patients with asthma: the Swiss LARA (Link Allergic Rhinitis in Asthma) survey.

OBJECTIVE: To determine the characteristics of asthma (A) and allergic rhinitis (AR) among asthma patients in primary care practice. RESEARCH DESIGN AND METHODS: Primary care physicians, pulmonologists, and allergologists were asked to recruit consecutive asthma patients with or without allergic rhinitis from their daily practice. Cross-sectional data on symptoms, severity, treatment and impact on quality of life of A and AR were recorded and examined using descriptive statistics. Patients with and without AR were then compared. RESULTS: 1244 asthma patients were included by 211 physicians. Asthma was controlled in 19%, partially controlled in 27% and not controlled in 54%. Asthma treatment was generally based on inhaled corticosteroids (ICS) with or without long acting beta 2 agonists (78%). A leukotriene receptor antagonist (LTRA) was used by 46% of the patients. Overall, 950 (76%) asthma patients had AR (A + AR) and 294 (24%) did not (A - AR). Compared to patients with A - AR, A + AR patients were generally younger (mean age +/- standard deviation: 42 +/- 16 vs. 50 +/- 19 years, p < 0.001) and fewer used ICS (75% vs. 88%, p < 0.001). LTRA usage was similar in both groups (46% vs. 48%). Asthma was uncontrolled in 53% of A + AR and 57% of A - AR patients. Allergic rhinitis was treated with a mean of 1.9 specific AR medications: antihistamines (77%), nasal steroids (66%) and/or vasoconstrictors (38%), and/or LTRA (42%). Rhinorrhoea, nasal obstruction, or nasal itching were the most frequently reported AR symptoms and the greatest reported degree of impairment was in daily activities/sports (55%). CONCLUSIONS: Allergic rhinitis was more common among younger asthma patients, increased the burden of symptoms and the need for additional medication but was associated with improved asthma control. However, most asthma patients remained suboptimally controlled regardl-ess of concomitant AR.