Annelies Lucas

Current clinical guideline definitions of airflow obstruction and COPD overdiagnosis in primary care

The aim of the present study was to establish the agreement between two recommended definitions of airflow obstruction in symptomatic adults referred for spirometry by their general practitioner, and investigate how rates of airflow obstruction change when pre-bronchodilator instead of post-bronchodilator spirometry is performed. The diagnostic spirometric results of 14,056 adults with respiratory obstruction were analysed. Differences in interpretation between a fixed 0.70 forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) cut-off point and a sex- and age-specific lower limit of normal cut-off point for this ratio were investigated. Of the subjects, 53% were female and 69% were current or ex-smokers. The mean post-bronchodilator FEV1/FVC was 0.73 in males and 0.78 in females. The sensitivity of the fixed relative to the lower limit of normal cut-off point definition was 97.9%, with a specificity of 91.2%, positive predictive value of 72.0% and negative predictive value of 99.5%. For the subgroup of current or ex-smokers aged ≥50 yrs, these values were 100, 82.0, 69.2 and 100%, respectively. The proportion of false positive diagnoses using the fixed cut-off point increased with age. The positive predictive value of pre-bronchodilator airflow obstruction was 74.7% among current or ex-smokers aged ≥50 yrs. The current clinical guideline-recommended fixed 0.70 forced expiratory volume in one second/forced vital capacity cut-off point leads to substantial overdiagnosis of obstruction in middle-aged and elderly patients in primary care. Using pre-bronchodilator spirometry leads to a high rate of false positive interpretations of obstruction in primary care.

Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study

BACKGROUND Underdiagnosis and undertreatment of patients with asthma or chronic obstructive pulmonary disease are widely discussed in the literature. Not much is known about the possible overdiagnosis and consequently the overtreatment with inhaled corticosteroids (ICS). Aim. This study investigates how often ICS are prescribed without a proper indication and how big the diagnostic problem is caused by inappropriate prescription and use of ICS. METHODS All patients referred to a primary care diagnostic centre during 6 months who used ICS without a clear indication were included. Their GPs were questioned about the reasons for prescribing ICS. If still no diagnosis could be assessed, GPs were advised to stop ICS and renew spirometry after a steroid-free period of at least 3 months. After 1 year, the use of ICS was evaluated and the diagnoses were reassessed. RESULTS Of all referred patients (2271), 1171 used ICS, 505 (30%) without a clear indication. After 1 year, final results showed that 11% of all patients originally using ICS had no indication to use ICS and had successfully ceased using this mediation. For 15%, the reasons for using ICS remained unclear. CONCLUSIONS Overtreatment with ICS in primary care seems to be considerable, which falsely labels patients as asthmatic and which generates unnecessary costs and possible side effects. The awareness of GPs of the need for proper diagnostic testing before prescribing ICS needs to be improved. Overtreatment with ICS in primary care patients can be diminished by systematically supporting the GP in the diagnostic procedures and decision making.

Effect of lifestyle intervention for people with diabetes or prediabetes in real-world primary care: propensity score analysis.

BackgroundMany lifestyle interventions for patients with prediabetes or type 2 diabetes mellitus (T2DM) have been investigated in randomised clinical trial settings. However, the translation of these programmes into primary care seems challenging and the prevalence of T2DM is increasing. Therefore, there is an urgent need for lifestyle programmes, developed and shown to be effective in real-world primary care. We evaluated a lifestyle programme, commissioned by the Dutch government, for patients with prediabetes or type 2 diabetes in primary care.MethodsWe performed a retrospective comparative medical records analysis using propensity score matching. Patients with prediabetes or T2DM were selected from ten primary healthcare centres. Patients who received the lifestyle intervention (n = 186) were compared with a matched group of patients who received usual care (n = 2632). Data were extracted from the electronic primary care records. Propensity score matching was used to control for confounding by indication. Outcome measures were exercise level, BMI, HbA1c, fasting glucose, systolic and diastolic blood pressure, total cholesterol, HDL and LDL cholesterol and triglycerides and the follow-up period was one year.ResultsThere was no significant difference at follow-up in any outcome measure between either group. The reduction at one year follow-up of HbA1c and fasting glucose was positive in the intervention group compared with controls, although not statistically significant (-0.12%, P = 0.07 and -0.17 mmol/l, P = 0.08 respectively).ConclusionsThe effects of the lifestyle programme in real-world primary care for patients with prediabetes or T2DM were small and not statistically significant. The attention of governments for lifestyle interventions is important, but from the available literature and the results of this study, it must be concluded that improving lifestyle in real-world primary care is still challenging.

Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases.

Objective. To investigate the effect of a primary care model for COPD on process of care and patient outcome. Design. Controlled study with delayed intervention in control group. Setting. The GP delegates tasks to a COPD support service (CSS) and a practice nurse. The CSS offers logistic support to the practice through a patient register and recall system for annual history-taking and lung function measurement. It also forms the link with the chest physician for diagnostic and therapeutic advice. The practice nurses most important tasks are education and counselling. Subjects. A total of 44 practices (n =22 for intervention and n =22 for control group) and 260 of their patients ≥40 years with obstructive lung diseases. Results. Within the intervention group planned visits increased from 16% to 44% and from 19% to 25% in the control condition (difference between groups p =0.014). Annual lung function measurement rose from 17% to 67% in the intervention and from 11% to 18% in the control group (difference between groups p =0.001). Compared with control, more but not statistically significant smokers received periodic advice to quit smoking (p =0.16). At baseline 41% of the intervention group were using their inhalers correctly and this increased to 54% after two years; it decreased in the control group from 47 to 29% (difference between groups p =0.002). The percentage of patients without exacerbation did not change significantly compared with the control condition. The percentage of the intervention group not needing emergency medication rose from 79% to 84% but decreased in the controls from 81 to 76% (difference between groups p =0.08). Conclusion. Combining different disciplines in one model has a positive effect on compliance with recommendations for monitoring patients, and improves the care process and some patient outcomes.

Patient-oriented intervention in addition to centrally organised checkups improves diabetic patient outcome in primary care.

Background: Logistic support to general practitioners improves the care processes for patients with diabetes but is not sufficient to meet all criteria. Aim: To introduce patient-oriented interventions by a practice nurse in general practices which already use logistic support to improve the care processes for patients with diabetes. Design of study: A controlled before–after study with delayed intervention in the control group. Setting: 51 practices (n = 23 for the intervention and n = 28 for the control group) in the south of The Netherlands and 900 of their patients with type 2 diabetes. Methods: Data were collected on the results of the checkups (fasting blood glucose, glycosylated haemoglobin (HbA1C), cholesterol, cholesterol/high-density lipoprotein ratio, triglycerides, creatinine, blood pressure, fundus photo, foot exam and body mass index), smoking status, physical activity and medication use. The effect of the patient-oriented intervention was analysed in a mixed model with repeated measurement covariance structure. Results: The HbA1C improved in the intervention group (from 7.3 to 7.1), while that of the control group deteriorated (from 7.2 to 7.3). The percentage of patients with an HbA1C ⩾8.5 was halved after the intervention (from 13 to 6). Patients in the intervention group started to exercise more besides their daily activities compared with the control group. The need for medication increased more in the control group than in the intervention group (more changes to insulin and more defined daily dose (DDD) oral medication). Conclusion: Patient-oriented interventions in addition to logistic support have a positive effect on diabetic patient outcomes.

Should the diagnosis of COPD be based on a single spirometry test

Clinical guidelines indicate that a chronic obstructive pulmonary disease (COPD) diagnosis is made from a single spirometry test. However, long-term stability of diagnosis based on forced expiratory volume in 1 s over forced vital capacity (FEV1/FVC) ratio has not been reported. In primary care subjects at risk for COPD, we investigated shifts in diagnostic category (obstructed/non-obstructed). The data were from symptomatic 40+ years (ex-)smokers referred for diagnostic spirometry, with three spirometry tests, each 12±2 months apart. The obstruction was based on post-bronchodilator FEV1/FVC < lower limit of normal (LLN) and <0.70 (fixed ratio). A total of 2,352 subjects (54% male, post-bronchodilator FEV1 76.5% predicted) were studied. By LLN definition, 32.2% were obstructed at baseline, but 32.2% of them were no longer obstructed at years 1 and/or 2. By fixed ratio, these figures were 46.6 and 23.8%, respectively. Overall, 14.3% of subjects changed diagnostic category by 1 year and 15.4% by 2 years when applying the LLN cut-off, and 15.1 and 14.6% by fixed ratio. Change from obstructed to non-obstructed was more likely for patients with higher body mass index (BMI) and baseline short-acting bronchodilator (SABA) users, and less likely for older subjects, those with lower FEV1% predicted, baseline inhaled steroid users, and current smokers or SABA users at year 1. Change from non-obstructed to obstructed was more likely for males, older subjects, current smokers and patients with lower baseline FEV1% predicted, and less likely for those with higher baseline BMI. Up to one-third of symptomatic (ex-)smokers with baseline obstruction on diagnostic spirometry had shifted to non-obstructed when routinely re-tested after 1 or 2 years. Given the implications for patients and health systems of a diagnosis of COPD, it should not be based on a single spirometry test.

Het klopt heel aardig

SamenvattingLucas AEM, Smeenk FJWM, Smeele IJM, Brouwer T, Van Schayck CP. ‘Het klopt heel aardig!’ Validiteit van het diagnostisch advies dat astma/COPD-diensten aan huisartsen geven. Huisarts Wet 2008;51(10):479-84.Inleiding Astma/COPD-diensten ondersteunen huisartsen bij het diagnosticeren en monitoren van astma- en COPD-patiënten. De diensten stellen gegevens van de longfunctie en de anamnese schriftelijk beschikbaar aan longartsen, die daarmee een gestructureerde beoordeling maken. We hebben onderzocht of deze papieren beoordeling en de daaruit voortkomende advisering valide zijn. Methode We vergeleken de papieren beoordelingen van longartsen met de conclusies van dezelfde artsen tijdens spreekuurcontacten met dezelfde patiënten. Hiervoor selecteerden we in de loop van 2004 at random tachtig patiënten die door hun huisarts waren verwezen naar de astma/COPD-dienst in Eindhoven.Resultaten De validiteit van de gestelde diagnose bleek hoog (Cohens kappa = 0,82). In de helft van de gevallen leidde aanvullend diagnostisch onderzoek op advies van de longarts tot een definitieve diagnose astma of COPD, of van een andere aandoening die de klachten van de patiënt verklaarde. Bij de andere helft kon de diagnose astma of COPD worden uitgesloten.Longartsen bleken de klinische stabiliteit van de patiënt wisselend te beoordelen en de hierop gebaseerde adviezen over medische behandeling hadden daarom een lage validiteit (Cohens kappa = 0,39).Conclusie Diagnostiek en diagnostisch advies op basis van papieren longfunctiegegevens en anamnese, zoals gebruikelijk bij astma/COPD-diensten, zijn een waardevolle ondersteuning voor de huisartsenpraktijken die de zorg managen voor steeds meer astma/COPD-patiënten. De klinische en generalistische blik van de huisarts blijft onveranderd onmisbaar, vooral voor het therapeutische beleid.

Eerstelijnszorgmodel voor diabetes type 2: toepasbaar en haalbaar

SamenvattingMeulepas MA, Braspenning JCC, , Vlek JFM, Lucas AEM, De Grauw WJC, Grol RPTM. Eerstelijnszorgmodel voor diabetes type 2: toepasbaar en haalbaar. Huisarts Wet 2006;49(7):356-6.Inleiding Om richtlijnen voor eerstelijnsdiabeteszorg te implementeren zijn een patiëntenregister, een oproepsysteem, een controlesysteem, feedback en kwaliteitsbewaking noodzakelijk. De taken die daarmee gemoeid zijn, vragen om verschillende deskundigheden. Wij hebben met deze vijf elementen een model gebouwd waarbij de huisarts taken kan delegeren aan praktijkondersteuner en diabetesdienst.Achtergrond Van alle 1628 geregistreerde diabetespatiënten bij 23 huisartsenpraktijken in het adherentiegebied van de diabetesdienst in Zuidoost-Brabant hebben wij nagegaan of ze zorg volgens het model ontvingen. Wij hebben onderzocht of de 23 praktijken de 5 elementen systematisch toepasten en welke bijbehorende taken ze delegeerden aan diabetesdienst en praktijkondersteuner.Belangrijkste kwaliteitsmaten Percentage praktijken met taakdelegatie volgens zorgmodel en percentage patiënten dat zorg volgens het model ontving.Interventie De praktijken werden begeleid om een eigen praktijkprotocol te ontwerpen waarin de vijf elementen van het zorgmodel werden opgenomen. Tijdens hun opleiding werden de praktijkondersteuners voorbereid op het werken volgens het model.Effecten Alle vijf elementen bleken systematisch toegepast in de praktijken, op kwaliteitsbewaking na. Van alle diabetespatiënten behandeld in de huisartsenpraktijk, was 97% in het zorgmodel ingesloten (door de huisarts geïncludeerd en door de patiënt geaccepteerd). In 70% van de praktijken voerde de praktijkondersteuner naast de kwartaalcontroles ook de jaarcontrole uit. Van alle patiënten bij wie de praktijkondersteuner de kwartaalcontrole deed, bezocht 93% alle afspraken in het meetjaar.Leerpunten en vervolg Het eerstelijnszorgmodel voor diabetes is goed toepasbaar. Dat kwaliteitsbewaking nog niet overal werd uitgevoerd, lijkt een kwestie van tijd. Het deelnamepercentage aan het controlesysteem was hoger dan elders beschreven.AbstractMeulepas MA, Braspenning JCC, Vlek JFM, Lucas AEM, De Grauw WJC, Grol RPTM. First-line care model for type 2 diabetes: applicable and feasible. Huisarts Wet 2006;49(7):356-60.Introduction The implementation of guidelines for diabetes care in general practice can be improved by several relevant elements: a patient register, an active recall system, a control system, feedback and quality improvement. We were unable to find a model integrating these five elements, and therefore constructed one around the triangle: general practitioner, practice nurse and diabetes support service.Background From all 1628 patients registered at 23 practices in the service district of the diabetes support service we checked whether they had been included in the model and, if not, why. We examined whether and how the 23 practices had integrated the five elements in their own protocols.Main quality measures The percentage of practices that delegated tasks according to the care model and the percentage of patients included in the model.Intervention The model was implemented in general practices by supporting tailor-made protocols in a standard manner. The practice nurses were prepared for the task during their training.Effects All five elements were seen to have been implemented systematically, except the monitoring of quality improvement. Of all known diabetic patients, 80% were treated in general practice. Of these patients, 97% were included in the model (selected by the general practitioner and accepted by the patient). In 70% of the practices the practice nurse carried out not only the quarterly controls but also the annual control. Of all patients seen by the practice nurse, 93% kept all appointments.Lessons learned and follow up The diabetes care model is well applicable. The general practitioner delegates tasks to the practice nurse and to the diabetes support service. The fact that monitoring quality improvement has not yet been implemented in every general practice is in all likelihood related to a stepwise implementation of the five elements. It seems to be merely a matter of time before all the elements have been integrated. The inclusion percentage in the control system was far higher than we found in other studies.

Kan de diagnose COPD op één spirometrietest berusten

SamenvattingSchermer TR, Robberts B, Grootens J, Lucas A, Thoonen BP, Smeele IJ. Kan de diagnose COPD op één spirometrietest berusten? Huisarts Wet 2017;60(10):497-9. Huisartsen stellen de diagnose COPD vaak op basis van één spirometrietest. Een te lage post-bronchodilatoire FEV1/FVC wijst dan op een luchtwegobstructie die kan passen bij COPD. In een onderzoek onder 2352 personen met verdenking op COPD, die door hun huisarts waren verwezen naar huisartsenlaboratoria, bleken aanvankelijk 758 personen (32%) luchtwegobstructie te vertonen. Na een jaar was dit bij 22% (168/758) en na twee jaar bij 32% (244/758) echter niet meer het geval. Van de 1594 personen zonder obstructie bij de eerste spirometrietest was na een jaar bij 90% wederom geen sprake van obstructie; na twee jaar bij 85%. Verschillende persoonskenmerken voorspelden de kans op verschuiving van obstructief naar niet-obstructief. De FEV1/FVC en het daarop gebaseerde oordeel wel/niet obstructief varieert dusdanig in de tijd dat eenmalige spirometrie leidt tot over- en onderdiagnostiek van COPD.

Een heel gezin gepromoveerd

Nog niet eerder had H&W de kans om tegelijkertijd een moeder en zoon aan het woord te laten die beiden recentelijk promoveerden. Bij Annelies Lucas ging het om het proefschrift Support of an Asthma/COPD service for general practitioners in daily care. Charles Helsper promoveerde op Case finding strategies for hepatitis C infection (zie ook zijn Beschouwing op de paginas 22-25). Hieronder vertellen zij over deze bijzondere situatie en over hun onderzoeksresultaten.