N.H. Chavannes

Validity of spirometric testing in a general practice population of patients with chronic obstructive pulmonary disease (COPD)

Objective: To investigate the validity of spirometric tests performed in general practice. Method: A repeated within subject comparison of spirometric tests with a “gold standard” (spirometric tests performed in a pulmonary function laboratory) was performed in 388 subjects with chronic obstructive pulmonary disease (COPD) from 61 general practices and four laboratories. General practitioners and practice assistants undertook a spirometry training programme. Within subject differences in forced expiratory volume in 1 second and forced vital capacity (ΔFEV1 and ΔFVC) between laboratory and general practice tests were measured (practice minus laboratory value). The proportion of tests with FEV1 reproducibility <5% or <200 ml served as a quality marker. Results: Mean ΔFEV1 was 0.069 l (95% CI 0.054 to 0.084) and ΔFVC 0.081 l (95% CI 0.053 to 0.109) in the first year evaluation, indicating consistently higher values for general practice measurements. Second year results were similar. Laboratory and general practice FEV1 values differed by up to 0.5 l, FVC values by up to 1.0 l. The proportion of non-reproducible tests was 16% for laboratory tests and 18% for general practice tests (p=0.302) in the first year, and 18% for both in the second year evaluation (p=1.000). Conclusions: Relevant spirometric indices measured by trained general practice staff were marginally but statistically significantly higher than those measured in pulmonary function laboratories. Because of the limited agreement between laboratory and general practice values, use of these measurements interchangeably should probably be avoided. With sufficient training of practice staff the current practice of performing spirometric tests in the primary care setting seems justifiable.

Detection of asthma and chronic obstructive pulmonary disease in primary care

Chronic obstructive pulmonary disease (COPD) and asthma are major health problems, the number of patients with these diseases is still rising and only 25–50% of these patients are known to their doctors. Lung function gradually decreases in COPD and asthmatic patients during their lives. Due to adaptation of the patients or due to the doctor being unaware of the symptoms, COPD is often diagnosed late in its course and when finally diagnosed, lung function is often relatively poor. Underdiagnosis and consequently undertreatment might play an important role in the increase in morbidity and mortality as a result of COPD and asthma. Early detection and treatment might improve the long-term prognosis of these patients and this secondary prevention may also prevent irreversible loss of function. The identification of patients is useless if no effective preventive measures are available. In asthma, inhaled corticosteroids have been shown to have distinct effects on the progression of the disease. However, in COPD inhaled corticosteroids have only been shown to have some effects and the long-term effects on lung function have been disappointing. At present, the most effective treatment available for COPD is the cessation of smoking. It appears that a smoker at risk of developing COPD is more motivated to stop smoking than someone who is not at risk and this may help a physician in encouraging an attempt to quit. General practitioners appear to be already using this knowledge, as they seem more likely to advise smokers to quit smoking if they perceive their problems to be smoking related.

e-Vita: design of an innovative approach to COPD disease management in primary care through eHealth application

BackgroundCOPD is a highly complex disease to manage as patients show great variation in symptoms and limitations in daily life. In the last decade self-management support of COPD has been introduced as an effective method to improve quality and efficiency of care, and to reduce healthcare costs. Despite the urge to change the organisation of health care and the potential of eHealth to support this, large-scale implementation in daily practice remains behind, especially in the Netherlands.Methods/DesignWe designed a multilevel study, called e-Vita, to investigate different organisational implementation methods of a self-management web portal to support and empower patients with COPD in three different primary care settings. Using a parallel cohort design, the clinical effects of the web portal will be assessed using an interrupted times series (ITS) study design and measured according to changes in health status with the Clinical COPD Questionnaire (CCQ). The different implementations and net benefits of self-management through eHealth on clinical outcomes will be evaluated from human, organisational, and technical perspectives.DiscussionTo our knowledge this is the first study to combine different study designs that enable simultaneous investigation of clinical effects, as well as effects of different organisational implementation methods whilst controlling for confounding effects of the organisational characteristics. We hypothesize that an implementation with higher levels of personal assistance, and integrated in an existing care program will result in increased use of and satisfaction with the platform, thereby increasing health status and diminishing exacerbation and hospitalisation.Trial registrationNTR4098 (31-07-2013)

Morning and night symptoms in primary care COPD patients: a cross-sectional and longitudinal study. An UNLOCK study from the IPCRG.

COPD symptoms show a diurnal variability. However, morning and night variability has generally not been taken into consideration in disease management plans. The aims of this study were to cross-sectionally assess morning and night symptom prevalence and correlation with health status and disease severity in COPD, and to determine to what extent they could predict longitudinal outcomes, exacerbations and health status. A further aim is to explore whether the CCQ is able to depict this morning/night symptomatology. We included 2,269 primary care COPD patients (58% male, 49% current smokers, with a mean age of 65±11 years) from a Dutch Asthma/COPD service. Spirometry, patient history, the Clinical COPD Questionnaire(CCQ) and the Asthma Control Questionnaire(ACQ) were assessed; we used the latter to evaluate morning (question 2) and night symptoms (question 1). A total of 1159 (51.9%) patients reported morning symptoms (ACQ question 2>0) and 879 (39.4%) had night complaints (ACQ question 1>0). Patients with morning/night symptoms were mostly smokers and had on average poorer lung function, higher CCQ scores and used more rescue inhalers (P<0.0001). Patients using long-acting muscarinic antagonists (LAMAs) had less night symptoms, showing a possible favourable effect. Only a small proportion of stable or slightly unstable patients (CCQ total scores <2) had severe morning symptoms (ACQ 2⩾4: n=19, 1.1%) or severe night symptoms (ACQ 1⩾4: n=11, 0.7%). Night symptoms seemed to predict future exacerbations; however, baseline exacerbations were the strongest predictors (n=346, OR:4.13, CI: 2.45−6.95, P<0.000). Morning symptoms increased the odds of poor health status at follow-up (n=346, OR:12.22, CI:4.76−31.39, P<0.000). Morning and night symptoms in COPD patients are common, and they are associated with poor health status and predicted future exacerbations. Our study showed that patients with morning/night symptoms have higher scores in CCQ, and therefore we do not really miss patients with high morning/night symptomatology when we only measure CCQ. Severe morning symptoms predicted worsening of COPD health status.

PORTALS: design of an innovative approach to anticoagulation management through eHealth

BackgroundFor the monitoring of International Normalized Ratio (INR) values, venous thromboembolism (VTE) and atrial fibrillation (AF) patients can visit anticoagulation clinics, laboratories, or physicians for venous puncture. Point-of-care testing (POCT) made it possible for patients to monitor INR themselves (self-monitoring) and even self-adjust their medication dosage (self-dosage). Both skills are accepted as forms of self-management. eHealth applications can improve this self-management, resulting in better clinical outcomes.MethodsOur study, called PORTALS, aims at identifying the optimal implementation strategy of training to improve self-management and explore factors that enhance good self-management skills. In addition, the relationship between the implementation strategy of training, clinical outcomes, and individual characteristics will be investigated. Of the 247 recruited participants, 110 chose to continue with regular care. 137 patients have been randomly divided in subgroups and compared using a parallel cohort design: one group will be trained and educated by e-learning, and the other group will receive face-to-face group training.DiscussionMore insight in factors that enhance good self-management will help to improve clinical outcomes and patient satisfaction on anticoagulation therapy. Our study will provide practical insights and knowledge of eHealth in daily practice and of the importance of education on the adoption of self-management. We expect the self-management program including training to help patients to better manage their own INR values and medication use, thereby increasing health status and diminishing thromboembolic events and hospitalisation.Trial registrationThe Netherlands National Trial Register, number NTR3947.

Minder inhalatiecorticosteroïden voor patiënten met COPD

SamenvattingTe veel patiënten met mild tot matig COPD gebruiken inhalatiecosteroïden (ICS), maar bij deze patiënten zijn ICS niet effectief. Het gebruik leidt echter wel tot onnodige bijwerkingen en hogere kosten van de gezondheidszorg. Daarom ontwikkelden de auteurs een ICS-reductietool voor patiënten met COPD die geen ICS hoeven te gebruiken.

Medische apps: zorg voor de toekomst?

SamenvattingLoohuis AMM, Chavannes NH. Medische apps: zorg voor de toekomst? Huisarts Wet 2017;60(9):440-3.n E-health en m-health bereiken het spreekuur van de huisarts. Patiënten vragen advies, app-aanbieders doen mooie beloften. Voor sommige klachten zijn tientallen apps, maar wat ze doen is onduidelijk en nauwelijks onderzocht. Er is een wildgroei ontstaan van medische apps die slecht zijn afgestemd op de gebruiker en waarvan de effectiviteit twijfelachtig is. Dat vraagt om actie vanuit de overheid en de beroepsgroep. Er moeten duidelijke normen komen voor kwaliteit, functionaliteit, gebruiksgemak en beveiliging, zodat app-ontwikkelaars daar al vanaf het begin rekening mee kunnen houden. Vervolgens kan de beroepsgroep een duidelijke aanbeveling geven in de vorm van vergelijkende overzichten.

Is integrated COPD care cost-effective?

SamenvattingBoland MRS, Kruis AL, Tsiachristas A, Assendelft WJJ, Gussekloo J, Blom CM, Chavannes NH, Rutten-van Mölken MPHM. Is geïntegreerde COPD-zorg kosteneffectief? Een analyse van het RECODE-onderzoek. Huisarts Wet 2015;59(8):343-5.AchtergrondWij vergeleken de kosteneffectiviteit van een integraal eerstelijns zorgprogramma voor COPD-patiënten met die van gebruikelijke COPD-zorg.Methode RECODE is een clustergerandomiseerde trial met 24 maanden follow-up (Nederlands trialregister NTR2268), uitgevoerd van september 2010 tot september 2013 in 40 West-Nederlandse huisartsenpraktijken. In de interventiegroep implementeerden 20 teams een integraal zorgprogramma voor 554 COPD-patiënten, in de controlegroep verleenden 20 teams de gebruikelijke zorg aan 532 patiënten. Elk team bestond uit een huisarts, een prakijkondersteuner en een fysiotherapeut.Resultaten De kosten per patiënt lagen in de interventiegroep hoger dan in de controlegroep. Over twee jaar berekend was het verschil € 584,- per patiënt vanuit gezondheidszorgperspectief en €645,- vanuit maatschappelijk perspectief. De gezondheidsuitkomsten waren vergelijkbaar, het aantal voor kwaliteit gecorrigeerde levensjaren lag iets lager (–0,04).Conclusie Het RECODE-programma, dat zich voornamelijk richt op scholing en ondersteuning van de hulpverleners en de implementatie van het geïntegreerde zorgplan aan hen overlaat, is niet kosteneffectief.

Stoppen van onderhoudsbehandeling met inhalatiesteroïden bij COPD

SamenvattingSchermer TRJ, Chavannes NH, Hendriks AJC, Dekhuijzen PNR, Wouters EFM, Van den Hoogen H, Van Schayck CP, Van Weel C. Stoppen van onderhoudsbehandeling met inhalatiesteroïden bij COPD. Huisarts Wet 2006;49(11):544-9. Doel (1) De kans op een negatieve respiratoire uitkomst te bepalen na het stoppen van een onderhoudsbehandeling met inhalatiesteroïden bij eerstelijnspatiënten met chronisch obstructief longlijden (COPD) en (2) na te gaan of die kans verband houdt met patiëntkenmerken.Methode Prospectief open stoponderzoek in 45 huisartsenpraktijken bij 201 patiënten met lichte tot ernstige COPD die een onderhoudsbehandeling met inhalatiesteroïden ontvingen. De onderzochte effectmaten waren de kans op, en tijd tot,een negatieve respiratoire uitkomst (dat wil zeggen exacerbatie of aanhoudende toename van de luchtwegklachten) na het discontinueren van de inhalatiesteroïden.Resultaten De gemiddelde leeftijd van de deelnemende patiënten was 60,6 (SD 9,5) jaar, de postbronchodilatatoire FEV1 was 65,6% (SD 15,7) van de voorspelde waarde. De totale kans op een negatieve respiratoire uitkomst na het stoppen met de inhalatiesteroïden was 0,37 (95%-BI 0,31-0,44). Multivariate survivalanalyse liet zien dat leeftijd, geslacht, rookstatus en reversibiliteit van de luchtwegobstructie onafhankelijke voorspellers zijn van een negatieve respiratoire uitkomst. Voor vrouwen was het gecorrigeerde risico (hazardratio) 2,14 (95%-BI 1,31-3,50), vergeleken met mannen. Voor leeftijd was de hazardratio 1,05 (95%-BI 1,02-1,08) per levensjaar.Conclusie Het staken van een onderhoudsbehandeling met inhalatiesteroïden vergroot de kans op een exacerbatie of toename van luchtwegklachten aanzienlijk. Leeftijd, geslacht, rookstatus en reversibiliteit van de luchtwegobstructie zijn daarop mede van invloed. Als men overweegt om een COPD-patiënt te laten stoppen met inhalatiesteroïden, is het aan te bevelen vooraf een gedegen inschatting te maken van de kans op een negatieve uitkomst, en vroege uitingen daarvan zorgvuldig te monitoren.