Diagnostic spirometry in COPD is increasing, a comparison of two Swedish cohorts.

Spirometry should be used to confirm a diagnosis of chronic obstructive pulmonary disease (COPD). This test is not always performed, leading to possible misdiagnosis. We investigated whether the proportion of patients with diagnostic spirometry has increased over time as well as factors associated with omitted or incorrectly interpreted spirometry. Data from medical reviews and a questionnaire from primary and secondary care patients with a doctors' diagnosis of COPD between 2004 and 2010 were collected. Data were compared with a COPD cohort diagnosed between 2000 and 2003. Among 703 patients with a first diagnosis of COPD between 2004 and 2010, 88% had a diagnostic spirometry, compared with 59% (p < 0.001) in the previous cohort. Factors associated with not having diagnostic spirometry were current smoking (OR 2.21; 95% CI 1.36-3.60), low educational level (OR 1.81; 1.09-3.02) and management in primary care (OR 2.28; 1.02-5.14). The correct interpretation of spirometry results increased (75% vs 82%; p = 0.010). Among patients with a repeated spirometry, 94% had a persistent FEV1/FVC or FEV1/VC ratio <0.70.

One additional educational session in inhaler use to patients with COPD in primary health care - A controlled clinical trial.

OBJECTIVE: To investigate whether one additional educational session about inhaler use, delivered to patients with COPD in primary healthcare, could affect the patients' skills in inhaler use. Specifically, to study the effects on errors related to handling the device, to inhalation technique, and to both. METHODS: This nonrandomized controlled clinical trial included 64 patients who used devices and made errors. COPD nurses assessed inhaler use using a checklist and educated patients. Intervention group received one additional educational session after two weeks. RESULTS: At baseline, patients in the IG had more devices (n = 2,1) compared to patients in the CG (n = 1,6) (p = 0.003). No other statistically significant differences were seen at baseline. At follow-up, intervention group showed a lower proportion of patients who made errors related to handling the device (p = 0.006). No differences were seen in the other categories. CONCLUSION: One additional educational session in inhaler use for patients with COPD was effective in reducing the proportion of patients making errors related to handling of their devices. PRACTICE IMPLICATIONS: Categorization of errors might help healthcare professionals to assess the suitability of patients' devices, tailor patient education, and thus improve patient health.

Improved quality of care by using the PRISMS form to support self-management in patients with COPD: A Randomised Controlled Trial.

AIMS AND OBJECTIVE: To investigate the effects on the quality of care of the Patient Report Informing Self-Management Support (PRISMS) form compared with usual care among patients with chronic obstructive pulmonary disease (COPD) consulting a COPD nurse in primary health care. BACKGROUND: Patients with COPD experience symptoms affecting their everyday lives, and there is a need for interventions in self-management support. The delivery of chronic care in an organised, structured and planned manner can lead to more productive relationships between professionals and patients. DESIGN: A multicentre randomised controlled trial with a post-test design, according to the CONSORT checklist, in one intervention group (n = 94) and one control group (n = 108). METHODS: In addition to usual care, the intervention group (n = 94) completed the PRISMS form to indicate areas where they wanted self-management support before the consultation with the COPD nurse. This form comprises 17 items that patients with COPD commonly experience as problems. The control group received usual care (n = 108). The primary outcome was patients' satisfaction with quality of care, assessed using the Quality from the Patient's Perspective (QPP) questionnaire. Means and (SD) are presented where applicable. Differences between the intervention and control group were analysed with Student's t test for independent groups for interval data, and the Mann-Whitney U test for ordinal data. RESULTS: Participants in the intervention group were more satisfied with the QPP domains "personal attention," regarding both "perceived reality" (p = .021) and "subjective importance" (p = .012). The PRISMS form revealed "shortness of breath" as the most commonly experienced problem and the issue most desired to discuss. CONCLUSION: The PRISMS form improved patient satisfaction with quality of care regarding personal attention, which is an important factor in patient participation and improving relationships and communication. RELEVANCE TO CLINICAL PRACTICE: The PRISMS form can be a useful tool in improving person-centred care when delivering self-management support. REGISTER ID: 192691 at http://www.researchweb.org/is/en/sverige/project/192691.

Errors in inhaler use related to devices and to inhalation technique among patients with chronic obstructive pulmonary disease in primary health care.

AIM: The aim of this study was to describe inhaler use in primary health care patients with chronic obstructive pulmonary disease (COPD) and to categorize these patients into those making errors related to devices, those making errors related to inhalation technique and those making errors related to both. DESIGN: Observational study. METHODS: COPD nurses used a checklist to assess the use of inhalers by patients with spirometry-verified COPD (N = 183) from primary healthcare centres. The STROBE checklist has been used. RESULTS: The mean age of the patients was 71 (SD 9) years. Almost half of them (45%) made at least one error; of these, 50% made errors related to devices, 31% made errors related to inhalation technique and 19% made errors related both to devices and to inhalation technique.

Spirometry to increase smoking cessation rate: A systematic review.

INTRODUCTION: Addressing tobacco use is an important issue in general health care. In order to improve smoking cessation advice, spirometry values can be displayed to the smoker to demonstrate possible lung function impairment. The estimate of so-called lung age may show a decrease in lung function associated with smoking. It has been suggested that performing spirometry on patients who smoke but are asymptomatic can be a useful way to show the adverse effects of smoking. The aim of this systematic review was to determine if providing spirometry results in combination with smoking cessation counselling can increase smoking cessation rates compared to what is achieved through counselling alone. METHODS: In this systematic review, we included randomized controlled trials (RCTs) evaluating smoking cessation interventions for adult smokers. The systematic search was performed in PubMed, Medline, Cochrane Library, Cinahl, Embase, Amed and PsycInfo. RESULTS: The literature search resulted in 946 studies, which, after reading by two independent reviewers, were reduced to seven trials that matched the inclusion criteria. Two RCTs showed significant improvement in smoking cessation when giving patients feedback on spirometry results in combination with smoking cessation counselling, compared to patients who received only smoking cessation counselling. In both studies, the spirometry results were expressed as lung age. In the other five studies no difference was found. Five further published study protocols for ongoing RCT studies in the field have been found, and therefore this systematic overview will likely need to be updated within a few years. CONCLUSIONS: Few studies have been undertaken to examine the efficacy of spirometry in increasing smoking quit rates. Studies conducted to date have shown mixed results, and there is currently limited evidence in the literature that smoking cessation counselling that includes feedback from spirometry and a demonstration of lung age promotes quit rates.

A complex intervention of self-management for patients with COPD or CHF in primary care improved performance and satisfaction with regard to own selected activities; A longitudinal follow-up.

AIM: To test a self-management intervention in primary health care (PHC) for patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF) on self-efficacy, symptoms, functioning, and health. BACKGROUND: Patients with COPD or CHF experience often the same symptoms such as shortness of breath, cough, lack of energy, dry mouth, numbness or tingling in hands and feet, pain and sleeping problems. DESIGN: A multicentre randomized control trial. METHOD: The trial was conducted with one intervention group (N = 73) and one control group (N = 77). The trial was performed from September 2013-September 2015 at nine PHC centres in three county councils in Sweden. At baseline patients with COPD and CHF experienced any symptom. Follow-ups were performed after 3 months and 1 year. The intervention was structured on Bandura's theory of self-efficacy in six meetings and individual action plans based on personal problems were performed and discussed. RESULTS: At baseline, there were no differences between the groups except for SF-36 social function. After 3 months, the intervention group improved performance and satisfaction with regard to own selected activities, otherwise no differences were found. CONCLUSION: When designing a program, the patient's own difficulties must be taken into consideration if person-centred care is to be established. It is feasible to include both patients with COPD and CHF in the same group in PHC. Healthcare professionals need supervision in pedagogics during intervention in self-management.

Adherence to guidelines in patients with chronic heart failure in primary health care.

OBJECTIVE: To describe adherence to international guidelines for chronic heart failure (CHF) management concerning diagnostics, pharmacological treatment and self-care behaviour in primary health care. DESIGN: A cross-sectional descriptive study of patients with CHF, using data obtained from medical records and a postal questionnaire. SETTING: Three primary health care centres in Sweden. SUBJECTS: Patients with a CHF diagnosis registered in their medical record. MAIN OUTCOME MEASURES: Adherence to recommended diagnostic tests and pharmacological treatment by the European Society of Cardiology guidelines and self-care behaviour, using the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). RESULTS: The 155 participating patients had a mean age of 79 (SD9) years and 89 (57%) were male. An ECG was performed in all participants, 135 (87%) had their NT-proBNP measured, and 127 (82%) had transthoracic echocardiography performed. An inhibitor of the renin angiotensin system (RAS) was prescribed in 120 (78%) patients, however only 45 (29%) in target dose. More men than women were prescribed RAS-inhibition. Beta blockers (BBs) were prescribed in 117 (76%) patients, with 28 (18%) at target dose. Mineralocorticoidreceptor antagonists were prescribed in 54 (35%) patients and daily diuretics in 96 (62%). The recommended combination of RAS-inhibitors and BBs was prescribed to 92 (59%), but only 14 (9%) at target dose. The mean score on the EHFScBS-9 was 29 (SD 6) with the lowest adherence to daily weighing and consulting behaviour. CONCLUSION: Adherence to guidelines has improved since prior studies but is still suboptimal particularly with regards to medication dosage. There is also room for improvement in patient education and self-care behaviour.

Availability of pulmonary rehabilitation in primary care for patients with COPD: a cross-sectional study in Sweden.

BACKGROUND: Pulmonary rehabilitation (PR) is an important, evidence-based component for the management of individuals with chronic obstructive pulmonary disease (COPD). In daily practice, the majority of COPD patients are treated in primary care. However, information about the availability of PR in primary care in Sweden is lacking. The aim was to investigate the availability of rehabilitation resources in primary care settings for patients with COPD in Sweden. METHODS: A cross-sectional descriptive design was applied, using web-based questionnaires sent to all primary care centres in four regions, comprising more than half of the 9.6 million inhabitants of Sweden. The main questionnaire included questions about the content and availability of rehabilitation resources for COPD patients. PR was defined as exercise training and one or more of the following activities: education, nutritional intervention, energy conservation techniques or psychosocial support. RESULTS: A total of 381 (55.9%) of the 682 primary care centres answered the main questionnaire. In addition to physicians and nurses, availability of healthcare professionals for rehabilitation in primary care settings was physiotherapists 92.0%, occupational therapists 91.9%, dieticians 83.9% and social workers or psychologists 98.4%. At 23.7% of all centres, PR was not available to COPD patients - neither in primary care nor at hospitals. CONCLUSION: Despite high availability of professionals for rehabilitation in primary care settings, about one-quarter of managers at primary care centres stated that their COPD patients had no access to PR. This indicates a need to structure resources for rehabilitation and to present and communicate the available resources within the healthcare system.

Keep moving to retain the healthy self: the meaning of physical exercise in individuals with Parkinson's disease.

PURPOSE: The aim of this study was to explore and generate an understanding of the meaning of physical exercise in the lives of individuals with Parkinson's disease (PD) participating in an exercise program. METHOD: A qualitative design, using Grounded Theory methodology, was used. Eleven individuals diagnosed with PD were interviewed. RESULTS: The core category "Keep moving to retain the healthy self" identified the continuing process of maintaining functions and activities in the individuals' lives, in which exercise was a major contribution. Two categories, "Having explicit life goals" and "Having confidence in one's own ability", were important prerequisites for adherence to physical exercise. Four categories - "Taking rational position", "Exercising to slow progression", "Exercising to achieve well-being" and "Using exercise as coping strategy" - were generated as important for starting and maintaining exercise habits. CONCLUSIONS: Insights into the process of exercising in view of living with PD were generated, which have implications for strategies in promoting physical exercise in older individuals with PD. IMPLICATIONS FOR REHABILITATION: Physical exercise can contribute to the process of retaining the healthy self in older individuals with PD. Having explicit life goals and having confidence in one's own ability may facilitate exercise adherence. Health personnel need to be perceptive for patients' life stories in order to understand the goals of the individual and how to support the individual in his achievement of them.

Factors associated with good self-rated health and quality of life in subjects with self-reported COPD.

BACKGROUND: Recent guidelines for chronic obstructive pulmonary disease (COPD) state that COPD is both preventable and treatable. To gain a more positive outlook on the disease it is interesting to investigate factors associated with good, self-rated health and quality of life in subjects with self-reported COPD in the population. METHODS: In a cross-sectional study design, postal survey questionnaires were sent to a stratified, random population in Sweden in 2004 and 2008. The prevalence of subjects (40-84 years) who reported having COPD was 2.1% in 2004 and 2.7% in 2008. Data were analyzed for 1475 subjects. Regression models were used to analyze the associations between health measures (general health status, the General Health Questionnaire, the EuroQol five-dimension questionnaire) and influencing factors. RESULTS: The most important factor associated with good, self-rated health and quality of life was level of physical activity. Odds ratios for general health varied from 2.4 to 7.7 depending on degree of physical activity, where subjects with the highest physical activity level reported the best health and also highest quality of life. Social support and absence of economic problems almost doubled the odds ratios for better health and quality of life. CONCLUSIONS: In this population-based public health survey, better self-rated health status and quality of life in subjects with self-reported COPD was associated with higher levels of physical activity, social support, and absence of economic problems. The findings indicated that of possible factors that could be influenced, promoting physical activity and strengthening social support are important in maintaining or improving the health and quality of life in subjects with COPD. Severity of the disease as a possible confounding effect should be investigated in future population studies.

Nurse-led multidisciplinary programme for patients with COPD in primary health care: a controlled trial.

AIM: To investigate the effects of a nurse-led multidisciplinary programme (NMP) of pulmonary rehabilitation in primary health care with regard to functional capacity, quality of life (QoL), and exacerbations among patients with chronic obstructive pulmonary disease (COPD). METHOD: A 1-year longitudinal study with a quasi-experimental design was undertaken in patients with COPD, 49 in the intervention group and 54 in the control group. Functional capacity was assessed using the 6-minute walking test, and quality of life (QoL) was assessed using the Clinical COPD Questionnaire. Exacerbations were calculated by examination of patient records. RESULTS: No significant differences were found between the groups in functional capacity and QoL after 1 year. The exacerbations decreased in the intervention group (n = -0.2) and increased in the control group (n = 0.3) during the year after NMP. The mean difference of change in exacerbation frequency between the groups was statistically significant after one year (p=0.009). CONCLUSIONS: The NMP in primary care produced a significant reduction in exacerbation frequency, but functional capacity and QoL were unchanged. More and larger studies are needed to evaluate potential benefits in functional capacity and QoL.

How often is diagnosis of COPD confirmed with spirometry?

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality worldwide. Diagnosis is customarily confirmed with spirometry, but there are few studies on documented spirometry use in everyday clinical practice. METHODS: In a cross-sectional survey and study of the medical records of primary and secondary care COPD patients aged 18-75 in a Swedish region, patients with COPD were randomly selected from the registers of 56 primary care centres and 14 hospital outpatient clinics. Spirometry data at diagnosis +/-6 months were analyzed. RESULTS: From 1114 patients with COPD, 533 with a new diagnosis of COPD during the four-year study period were identified. In 59% (n=316), spirometry data in connection with diagnosis were found in the medical records. Spirometry data with post-bronchodilator forced expiratory volume in 1s (FEV(1))/ vital capacity (VC) ratios were available in 45% (n=241). FEV1/VC ratio <0.70 were found in 160 patients, which corresponds to 30% of the patients with a new diagnosis. Lower age, female gender, current smoking, higher body mass index (BMI) and shorter forced exhalation time were related to COPD diagnosis despite an FEV(1)/VC ratio of >/=0.70. The most common problem in the quality assessment was an insufficient exhalation time. CONCLUSIONS: Only a third of Swedish patients with COPD had their diagnosis confirmed with spirometry. Our data indicate that female gender, current smoking, higher BMI and short exhalation time increase the risk of being diagnosed with COPD without fulfilling the spirometric criteria for the disease.

Spirometry in primary care case-identification, diagnosis and management of COPD.

Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality worldwide, yet it remains significantly under-diagnosed. Systematic and opportunistic case-identification efforts in primary care, using questionnaires, careful assessment to identify symptoms, and follow-up spirometry, might improve diagnosis rates and enable earlier detection and management of COPD. The aims of spirometry performed for case-identification purposes are to exclude those patients with symptoms but normal lung function and identify those who require more complete investigation for COPD, including 'diagnostic standard' spirometry. Among patients with a confirmed diagnosis of COPD, spirometry monitoring is useful in identifying those with rapid deterioration in lung function who require further assessment. Spirometry in primary care can also support patient education and may encourage smoking cessation and treatment adherence.

Physical activity and quality of life in subjects with chronic disease: chronic obstructive pulmonary disease compared with rheumatoid arthritis and diabetes mellitus.

OBJECTIVE: Chronic diseases interfere with the life situation of the affected person in different ways. The aim was to compare the burden of disease in three chronic diseases - chronic obstructive pulmonary disease (COPD), rheumatoid arthritis (RA), diabetes mellitus (DM) - and in healthy subjects, with a particular interest in physical activity, quality of life, and psychological health. DESIGN: Cross-sectional, observational study. SETTING AND SUBJECTS: Postal survey questionnaire to a stratified, random population of 68 460 subjects aged 18-84 years in Sweden. The subjects included were 40-84 years old (n = 43 589) and data were analysed for COPD (n = 526), RA (n = 1120), DM (n = 2149) and healthy subjects (n = 6960). RESULT: Some 84% of subjects with COPD, 74% (RA), 72% (DM), and 60% in healthy subjects (p < 0.001, COPD versus RA, DM, and healthy subjects) had a physical activity level considered too low to maintain good health according to guidelines. Quality of life (EuroQol five-dimension questionnaire, EQ-5D) was lower in COPD and RA than in DM. Anxiety/depression was more common in subjects with COPD (53%) than in those with RA (48%) and DM (35%) (p < 0.001, COPD versus RA and DM), whereas mobility problems were more common in RA (55%) than COPD (48%) and DM (36%) (p < 0.001, RA versus COPD and DM). All differences between groups remained significant after adjusting for age, sex, and socioeconomic background factors. CONCLUSION: Subjects with chronic diseases had a low level of physical activity, most evident in subjects with COPD. COPD and RA had a higher negative impact on quality of life than DM. Our results indicate that increased attention regarding physical inactivity in subjects with chronic diseases is needed to minimize the burden of disease.

COPD patients perspectives at the time of diagnosis: a qualitative study.

AIMS: To gain an understanding of patients perspectives and perceptions of chronic obstructive pulmonary disease (COPD) at the time of diagnosis. METHODS: A qualitative study using grounded theory. Ten patients in primary care in Sweden, newly diagnosed with COPD or with suspected COPD, were interviewed. RESULTS: The analysis created a process model with a core category "Consequences of smoking" and main categories "Shame", "Appearance of symptoms", "Adaptation", "Reflection", and "Action". "Restrictions in physical capacity" was a key indicator of evolving disease and "Getting a diagnosis" was crucial for the patient. CONCLUSIONS: The COPD patient needs a clear diagnosis at an early stage. It is important to seize the opportunity when the presumptive COPD patient is receptive towards support and further action. To detect and support the patient, health professionals must be aware of minor symptoms and underlying mechanisms of possible shame.