Edmunds M. Udris

Obesity and COPD: associated symptoms, health-related quality of life, and medication use.

Background: There is little data about the combined effects of COPD and obesity. We compared dyspnea, health-related quality of life (HRQoL), exacerbations, and inhaled medication use among patients who are overweight and obese to those of normal weight with COPD. Methods: We performed secondary data analysis on 364 Veterans with COPD. We categorized subjects by body mass index (BMI). We assessed dyspnea using the Medical Research Council (MRC) dyspnea scale and HRQoL using the St. Georges Respiratory Questionnaire. We identified treatment for an exacerbation and inhaled medication use in the past year. We used multiple logistic and linear regression models as appropriate, with adjustment for age, COPD severity, smoking status, and co-morbidities. Results: The majority of our population was male (n = 355, 98%) and either overweight (n = 115, 32%) or obese (n = 138, 38%). Obese and overweight subjects had better lung function (obese: mean FEV1 55.4% ±19.9% predicted, overweight: mean FEV1 50.0% ±20.4% predicted) than normal weight subjects (mean FEV1 44.2% ±19.4% predicted), yet obese subjects reported increased dyspnea [adjusted OR of MRC score ≥2 = 4.91 (95% CI 1.80, 13.39], poorer HRQoL, and were prescribed more inhaled medications than normal weight subjects. There was no difference in any outcome between overweight and normal weight patients. Conclusions: Despite having less severe lung disease, obese patients reported increased dyspnea and poorer HRQoL than normal weight patients. The greater number of inhaled medications prescribed for obese patients may represent overuse. Obese patients with COPD likely need alternative strategies for symptom control in addition to those currently recommended.

The validity of using ICD-9 codes and pharmacy records to identify patients with chronic obstructive pulmonary disease

BackgroundAdministrative data is often used to identify patients with chronic obstructive pulmonary disease (COPD), yet the validity of this approach is unclear. We sought to develop a predictive model utilizing administrative data to accurately identify patients with COPD.MethodsSequential logistic regression models were constructed using 9573 patients with postbronchodilator spirometry at two Veterans Affairs medical centers (2003-2007). COPD was defined as: 1) FEV1/FVC <0.70, and 2) FEV1/FVC < lower limits of normal. Model inputs included age, outpatient or inpatient COPD-related ICD-9 codes, and the number of metered does inhalers (MDI) prescribed over the one year prior to and one year post spirometry. Model performance was assessed using standard criteria.Results4564 of 9573 patients (47.7%) had an FEV1/FVC < 0.70. The presence of ≥1 outpatient COPD visit had a sensitivity of 76% and specificity of 67%; the AUC was 0.75 (95% CI 0.74-0.76). Adding the use of albuterol MDI increased the AUC of this model to 0.76 (95% CI 0.75-0.77) while the addition of ipratropium bromide MDI increased the AUC to 0.77 (95% CI 0.76-0.78). The best performing model included: ≥6 albuterol MDI, ≥3 ipratropium MDI, ≥1 outpatient ICD-9 code, ≥1 inpatient ICD-9 code, and age, achieving an AUC of 0.79 (95% CI 0.78-0.80).ConclusionCommonly used definitions of COPD in observational studies misclassify the majority of patients as having COPD. Using multiple diagnostic codes in combination with pharmacy data improves the ability to accurately identify patients with COPD.

Adherence to Long-Acting Inhaled Therapies among Patients with Chronic Obstructive Pulmonary Disease (COPD)

Abstract Background: Long-acting inhaled medications are an important component of the treatment of patients with chronic obstructive pulmonary disease (COPD), yet few studies have examined the determinants of medication adherence among this patient population. Objective: We sought to identify factors associated with adherence to long-acting beta-agonists (LABA) and inhaled corticosteroids (ICS) among patients with COPD. Methods: We performed secondary analysis of baseline data collected in a randomized trial of 376 Veterans with spirometrically confirmed COPD. We used electronic pharmacy records to assess adherence, defined as a medication possession ratio of ≥0.80. We investigated the following exposures: patient characteristics, disease severity, medication regimen complexity, health behaviors, confidence in self-management, and perceptions of provider skill. We performed multivariable logistic regression, clustered by provider, to estimate associations. Results: Of the 167 patients prescribed LABA, 54% (n = 90) were adherent to therapy while only 40% (n = 74) of 184 the patients prescribed ICS were adherent. Higher adherence to LABA and ICS was associated with patient perception of their provider as being an “expert” in diagnosing and managing lung disease [For LABA: OR = 21.70 (95% CI 6.79, 69.37); For ICS OR = 7.93 (95% CI 1.71, 36.67)]. Factors associated with adherence to LABA, but not ICS, included: age, education, race, COPD severity, smoking status, and confidence in self-management. Conclusions: Adherence to long-acting inhaled medications among patients with COPD is poor, and determinants of adherence likely differ by medication class. Patient perception of clinician expertise in lung disease was the factor most highly associated with adherence to long-acting therapies.

Patient-clinician communication: associations with important health outcomes among veterans with COPD.

BACKGROUND High quality patient-clinician communication is widely advocated, but little is known about which health outcomes are associated with communication for patients with COPD. METHODS Using a cross-sectional study of 342 veterans enrolled in a randomized controlled trial, we evaluated the association of communication, measured with the quality of communication (QOC) instrument, with subject-reported quality of clinician care, breathing problem confidence, and general self-rated health. We measured these associations using general estimating equations and adjusted odds ratios (OR) of patient-reported outcomes associated with one-point changes in QOC scores. RESULTS Nearly one-half of the subjects reported receiving the best imaginable care (47%), whereas fewer reported being confident with their breathing problems all the time (29%) or in very good or excellent health (15%). General communication was associated with best-imagined quality of care (OR, 4.29; 95% CI, 2.84-6.48; P < .001) and confidence in dealing with breathing problems all the time (OR, 1.74; 95% CI, 1.34-2.25; P < .001) but not general self-rated health (OR, 1.19; 95% CI, 0.92-1.55; P = .19). Specific clinician behaviors with larger associations with higher quality care included listening, caring, and attentiveness. The associations between general communication and quality care increased over time (P for interaction .03). CONCLUSIONS Communication between patients and clinicians is associated with quality of care and confidence in dealing with breathing problems, and this association may change over time. Attention to specific communication strategies may lead to improvements in the care of patients with COPD.

The Influence of Informal Caregivers on Adherence in COPD Patients

BackgroundContributions of informal caregivers to adherence among chronic obstructive pulmonary disease (COPD) patients remain understudied.PurposeThis study aims to evaluate the association between caregiver presence and adherence to medical recommendations among COPD patients.MethodsThree hundred and seventy-four COPD patients were asked whether they had a caregiver. Medication adherence was assessed using pharmacy refill data. Smoking status was based on patient self-report. One-way ANOVAs and chi-square analyses were performed controlling for age and number of illnesses.ResultsCompared with the “no caregiver” group, antihypertensive medications adherence was higher in the “spousal caregiver” (0.68 vs. 0.81; 95 % CI = 0.04 and 0.22) and “non-spousal caregiver” (0.68 vs. 0.80; 95 % CI = 0.03 and 0.22) groups; long-acting beta agonist adherence was higher in the “spousal caregiver” group (0.60 vs.0.80; 95 % CI = 0.05 and 0.43). Patients in the “spousal caregiver” group had fewer current smokers compared with the “no caregiver” (χ2 = 16.08; p < 0.001) and “non-spousal caregiver” (χ2 = 5.07; p < 0.05) groups; those in the “non-spousal caregiver” group reported fewer smokers than the “no caregiver” group (χ2 = 4.54; p < 0.05).ConclusionsCaregivers, especially spouses, may improve adherence in COPD. Future interventions may target patients without caregivers to optimize COPD management.

Original ResearchCOPDPatient-Clinician Communication: Associations With Important Health Outcomes Among Veterans With COPD

BACKGROUND High quality patient-clinician communication is widely advocated, but little is known about which health outcomes are associated with communication for patients with COPD. METHODS Using a cross-sectional study of 342 veterans enrolled in a randomized controlled trial, we evaluated the association of communication, measured with the quality of communication (QOC) instrument, with subject-reported quality of clinician care, breathing problem confidence, and general self-rated health. We measured these associations using general estimating equations and adjusted odds ratios (OR) of patient-reported outcomes associated with one-point changes in QOC scores. RESULTS Nearly one-half of the subjects reported receiving the best imaginable care (47%), whereas fewer reported being confident with their breathing problems all the time (29%) or in very good or excellent health (15%). General communication was associated with best-imagined quality of care (OR, 4.29; 95% CI, 2.84-6.48; P < .001) and confidence in dealing with breathing problems all the time (OR, 1.74; 95% CI, 1.34-2.25; P < .001) but not general self-rated health (OR, 1.19; 95% CI, 0.92-1.55; P = .19). Specific clinician behaviors with larger associations with higher quality care included listening, caring, and attentiveness. The associations between general communication and quality care increased over time (P for interaction .03). CONCLUSIONS Communication between patients and clinicians is associated with quality of care and confidence in dealing with breathing problems, and this association may change over time. Attention to specific communication strategies may lead to improvements in the care of patients with COPD.

The effect of end-of-life discussions on perceived quality of care and health status among patients with COPD.

BACKGROUND Despite strong preferences for discussions about end-of-life care, patients with COPD do not often have these discussions with their providers. Our objective was to determine whether patients who reported having end-of-life discussions also reported higher perceived markers of quality of care and health status. METHODS A cross-sectional study of data collected at baseline for a trial to improve the occurrence and quality of end-of-life communication in patients with COPD was conducted. The primary exposure was self-reported acknowledgment of having discussions about end-of-life planning with their physicians. The primary outcome measures were patient-reported quality of care and satisfaction with care, which were dichotomized as best imaginable quality of care vs other ratings of quality and highest satisfaction vs other ratings of satisfaction. We adjusted for confounding factors, including patient and provider characteristics, using logistic regression clustered by provider. RESULTS Three hundred seventy-six patients were enrolled, of whom 55 (14.6%) reported having end-of-life discussions. Individuals who reported having end-of-life discussions with their physicians were significantly more likely to rate their quality of care as the best imaginable (OR, 2.07; 95% CI, 1.05-4.09) and to be very satisfied with their medical care (OR, 1.98; 95% CI, 1.10-3.55). Discussions were more likely to have occurred among patients with worse health status as measured by St. George Respiratory Questionnaire total and impact scores. CONCLUSIONS Patients who reported having end-of-life care discussions with their physicians had higher perceived quality of care and satisfaction with their physicians. Discussing end-of-life care with patients who have COPD may improve their perceived overall quality of and satisfaction with care.

Provider response to computer-based care suggestions for chronic heart failure.

Objectives:We sought to assess the responses of providers to recommendations generated by a computer-management system for chronic heart failure (CHF). Methods:This study is an analysis of primary care providers’ responses to evidence-based computer-generated suggestions regarding patients with CHF at one center of a randomized trial. The trial randomized primary care providers from 2 VA Medical Centers to receive care suggestions regarding patients with CHF, with or without inclusion of patient symptom data obtained from previsit questionnaires. At one center, providers were asked to respond to the suggestions with hand-written comments and a numerical agreement scale. Results:Providers responded to 774 care suggestions (62% of the 1246 delivered). They agreed with 41%, had major disagreements with 12%, and had minor disagreements with 22%. For 7% of the care suggestions, providers asked to not see it again for that patient. The most common reasons for major or minor disagreements were a belief that the suggestion was wrong or unnecessary (45%) or would not be tolerated by the patient (32%). External barriers to implementation of guidelines, lack of guideline awareness, or disagreement with guidelines were uncommon reasons cited by providers in this study. Conclusions:Providers agreed with less than half of computer-generated care suggestions from evidence-based CHF guidelines, most often because the suggestions were felt to be inapplicable to their patients or unlikely to be tolerated.

Preferences for death and dying among veterans with chronic obstructive pulmonary disease.

Rationale: Studies identify common factors important for a “good death.” However, it is important for clinicians to individualize end-of-life care by eliciting patients’ preferences. We sought to determine preferences for death and dying among veterans with chronic obstructive pulmonary disease (COPD) by performing a cross-sectional study. Participants (n = 376) completed a preferences about death and dying questionnaire. Results: Common themes ranked as most important by veterans include health care costs (86.6%) and avoiding strain on loved ones (78.8%). Unique items include being unafraid of dying (67.1%) and having discussed your treatment preferences with your clinician (59.3%). Conclusion: Preferences for death and dying are consistent among individuals with life-limiting illness, thus should be incorporated as core components in all end-of-life care planning. We identified unique preferences important to patients with COPD. This study suggests that clinicians need to engage in end-of-life discussions to learn about individual preferences to improve the patients’ dying experience.

Impact of Guideline Changes on Indications for Inhaled Corticosteroids Among Veterans with COPD

This letter was reposted with corrections on September 13, 2018.