Henk Otten

Inappropriate prescription of proton pump inhibitors on two pulmonary medicine wards.

Objective We recently noticed that proton pump inhibitor (PPI) use was high on a pulmonary medicine ward of a university clinic and reasons for this high usage were not clear. Our aim was to determine the indications for PPI use on two pulmonary medicine wards and to assess whether this use was appropriate. Methods We assessed prospectively the number of patients on PPIs and the indications for PPI use on two pulmonary medicine wards, one from a university and one from a regional clinic in The Netherlands. Results On admission, 88 of 300 (29%) patients already used PPIs. The use of PPIs was discontinued in three (1%) patients, whereas PPIs were initiated in 45 (15%) patients, resulting in 130 (43%) patients on PPIs during hospitalization. The most common indication for PPI use was the prevention of medication-associated complications. In 78 of 130 (60%) patients on PPIs, this medication was used for a registered indication, whereas in 52 (40%) patients a registered indication was not present (overuse). In contrast, 19 of 300 (6%) patients were not prescribed PPIs despite the presence of a registered indication for its use (underuse). No differences were found in prescription rate and indications for PPI use between the university and the regional clinic. Conclusion PPI use was very common on two pulmonary medicine wards in the Netherlands. Forty percent of the patients used their PPIs for a nonregistered indication. As use of PPIs is costly and may be associated with side effects, hospital physicians should to be better educated on guidelines for its use.

Outcome of pulmonary rehabilitation in COPD patients with severely impaired health status

Introduction Effects of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) patients with severely impaired health status are poorly documented since these patients are usually excluded from clinical trials. This retrospective, observational study aims to study the impact of disease on health status and the effects of PR on COPD patients referred to a tertiary center for PR in The Netherlands. Methods Between June 2006 and June 2010, 437 patients with COPD were allocated to our intensive, comprehensive PR program. Patients participated in this interdisciplinary program for 12 weeks for a weekly average of 20–25 hours. Before and directly after, several measures of physical performance and health-related quality of life were determined. Results At baseline, most patients (75%) had a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage of III–IV. Peak exercise performance on a cycle ergometer was on average reduced to 43 ± 29 Watt, and health-related quality of life was significantly impaired, with a total score on the St George’s Respiratory Questionnaire (SGRQ) of 66. Health-care utilization in the year preceding PR was very high. After rehabilitation, all outcome measures improved statistically significantly (P < 0.001). Exercise performance measured with the 6 minute walking distance test improved clinically significantly in 68% of the patients, whereas 75% of the patients showed a clinically meaningful improvement in quality of life as measured with the SGRQ. Multiple regression analysis revealed that 19% of the variation in responses on the 6 minute walking distance test and the SGRQ could be explained on the basis of baseline characteristics. Conclusion The present study provides data to indicate that COPD patients may substantially benefit from rehabilitation in a tertiary pulmonary rehabilitation center, despite a severely impaired health status and high level of health-care utilization, in which prior treatment in primary and secondary care have failed to improve health status. Individual rehabilitation responses can only partially be predicted on the basis of baseline characteristics. Consequently, no firm conclusions can be drawn from this study with respect to the selection of candidates that could be deemed eligible for this rehabilitation program when entering the program.

Reduction of exacerbation frequency in patients with COPD after participation in a comprehensive pulmonary rehabilitation program.

Background Pulmonary rehabilitation (PR) is an important treatment option for chronic obstructive pulmonary disease (COPD) patients and might contribute to a reduction in exacerbation and exacerbation-related hospitalization rate. Methods In this prospective study, all COPD patients that completed a comprehensive pulmonary rehabilitation program (PRP) between June 2006 and December 2012 were included. Self-reported exacerbation and hospitalization frequency 1 year before PR was retrospectively recorded. During the year following PR, exacerbation and hospitalization frequency was recorded with questionnaires. Results For 343 patients, complete information on exacerbation and hospitalization rate was obtained. The mean number of exacerbations decreased significantly after participating in a PRP by 1.37 exacerbations/year (95% confidence interval 1.029 to 1.717) from 4.56±3.26 exacerbations in the year preceding PR to 3.18±2.53 in the year following PR (P<0.0005). The number of hospitalizations due to exacerbations decreased significantly by 0.68 hospitalizations/year (95% confidence interval 0.467 to 0.903) from 1.48±1.84 in the year preceding PR to 0.80±1.31 hospitalizations/year in the year following PR (P<0.0005). The proportion of patients with a frequent exacerbation type (more than two exacerbations/year) was reduced by 24%. Multivariate regression analysis to explore determinants that might predict reduction in exacerbation frequency or change in exacerbation pattern did not reveal clinically useful predictors, although patients with more exacerbations before PR had the highest potential for reduction. Conclusion In a large population of severely impaired COPD patients with high exacerbation rates, a significant reduction in exacerbation and hospitalization frequency was observed after participation in a comprehensive PRP.

The effects of guideline implementation for proton pump inhibitor prescription on two pulmonary medicine wards.

Background  It has been demonstrated that 40% of patients admitted to pulmonary medicine wards use proton pump inhibitors (PPIs) without a registered indication.

Inaccuracy of Estimating Peak Work Rate from Six-Minute Walk Distance in Patients with COPD

Abstract Introduction. The cardiopulmonary exercise test (CPET) and the 6-minute walk test (6MWT) are used to prescribe the appropriate training load for cycling and walking exercise in patients with chronic obstructive pulmonary disease (COPD). The primary aims were: (i) to compare estimated peak work rate (Wpeakestimated) derived from six existing Wpeak regression equations with actual peak work rate (Wpeakactual); and (ii) to derive a new Wpeak regression equation using six-minute walk distance (6MWD) and conventional outcome measures in COPD patients. Methods. In 2906 patients with COPD, existing Wpeak regression equations were used to estimate Wpeak using 6MWD and a new equation was derived after a stepwise multiple regression analysis. Results. The 6 existing Wpeak regression equations were inaccurate to predict Wpeakactual in 82% of the COPD patients. The new Wpeak regression equation differed less between Wpeakestimated and Wpeakactual compared to existing models. Still, in 74% of COPD patients Wpeakestimated and Wpeakactual differed more than (±) 5 watts. Conclusion. In conclusion, estimating peak work load from 6MWD in COPD is inaccurate. We recommend assessment of Wpeak using CPET during pre-rehabilitation assessment in addition to 6MWT.

Assessment of Burden of COPD (ABC) tool: Perception versus evidence

It is not disputable that chronic obstructive pulmonary disease (COPD) is a multifaceted disease affecting patients’ health beyond the lungs with immense variability between individuals [1–3]. Given that complexity and variability, multidimensional assessment and treatment integrating concepts of complex adaptive systems are needed [4]. Agusti and MacNee [5] stated that physicians need a “control panel” including at least three dimensions (severity, activity and impact) to assess different elements of the disease. This “control panel” might be useful for routine clinical practice and to move COPD management towards personalised medicine [5]. However, can one “control panel” reflect the complexity and heterogeneity of this complex, multisystem disease? Can one tool guarantee a personalised approach? Multidimensionality should be assessed by studying multi-dimensions, not by using a multidimensional assessment tool http://ow.ly/ht1c3091F29

Diagnostic value of metronome paced tachypnea in COPD-patients with dynamic hyperinflation

Before pulmonary rehabilitation COPD-patients undergo extensive assessment. One of the goals of this assessment is to determine whether COPD-patients demonstrate dynamic hyperinflation (DH). Both constant-work-rate test (CWRT) and metronome paced tachypnea (MPT) were used to diagnose DH. This prospective cohort study was intended to assess the diagnostic value of MPT and to determine whether MPT alone is sufficient to diagnose DH. By doing so, the volume measurements, necessary to determine DH, do not to have be carried out during CWRT, which is currently the golden standard. From January to October 2015, 75 patients with COPD were included (FEV1 45±17; FRC 151±36; in% predicted) and performed CWRT and MPT. The used cut-off value to diagnose DH after CWRT was a decrease in inspiratory capacity (IC) of 20%. To determine the cut-off value to diagnose DH after MPT, a receiver operating characteristic (ROC) analysis was performed. A contingency table was used to separate patients that demonstrate DH at CWRT and/or MPT from those who did not. Thereafter, sensitivity, specificity, PPV and NPV of MPT were determined. Results: At a 20% decrease of IC as cut-off value for DH during CWRT the optimum cut-off value for MPT was 19,2%(AUC 0,691; 95%CI 62-84%). If the cut-off value of 19,2% was used for MPT, it had a sensitivity of 74% (95%CI 62-84%) and a specificity of 54% (95%CI 32-72%). The PPV and NPV were 70% and 52% respectively. Conclusion: MTP seems to be an accurate way to diagnose DH. Therefore, using only MPT to diagnose DH may be considered. Additional clinical symptoms of DH could support this diagnosis in the laboratory. Further study into specification of the exclusion criteria seems appropriate

The Use of Regression Equations to Estimate Peak Work Rate in People with COPD - Reply from the Authors

1. Program Development Centre; CIRO+, centre of expertise for chronic organ failure; Horn, the Netherlands2. Department of Medical Psychology; Radboud University Nijmegen Medical Centre; Nijmegen, the Netherlands3. Department of Pulmonary Diseases; Radboud University Nijmegen Medical Centre; Nijmegen, the Netherlands4. Rehabilitation Centre Breda; Revant Rehabilitation Centre; Breda, the Netherlands5. Department of pulmonary diseases, VU Medical Centre, Amsterdam, the Netherlands6. Asthma Centre Heideheuvel; Merem Behandelcentra; Hilversum, the Netherlands7. Director; CIRO+, centre of expertise for chronic organ failure; Horn, the Netherlands8. Department of Respiratory Medicine; Maastricht University Medical Centre (MUMC+); Maastricht, the Netherlands9. Department of Respiratory Medicine; Erasmus Medical Center; Rotterdam, the Netherlands10. Sports Training; CIRO+, centre of expertise for chronic organ failure; Horn, the Netherlands