Robert Winter

Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort.

BACKGROUND Patterns of health-care use and comorbidities present in patients in the period before diagnosis of chronic obstructive pulmonary disease (COPD) are unknown. We investigated these factors to inform future case-finding strategies. METHODS We did a retrospective analysis of a clinical cohort in the UK with data from Jan 1, 1990 to Dec 31, 2009 (General Practice Research Database and Optimum Patient Care Research Database). We assessed patients aged 40 years or older who had an electronically coded diagnosis of COPD in their primary care records and had a minimum of 3 years of continuous practice data for COPD (2 years before diagnosis up to a maximum of 20 years, and 1 year after diagnosis) and at least two prescriptions for COPD since diagnosis. We identified missed opportunites to diagnose COPD from routinely collected patient data by reviewing patterns of health-care use and comorbidities present before diagnosis. We assessed patterns of health-care use in terms of lower respiratory consultations (infective and non-infective), lower respiratory consultations with a course of antibiotics or oral steroids, and chest radiography. If these events did not lead to a diagnosis of COPD, they were deemed to be missed opportunities. This study is registered with ClinicalTrials.gov, number NCT01655667. FINDINGS We assessed data for 38,859 patients. Opportunities for diagnosis were missed in 32,900 (85%) of 38,859 patients in the 5 years immediately preceding diagnosis of COPD; in 12,856 (58%) of 22,286 in the 6-10 years before diagnosis, in 3943 (42%) of 9351 in the 11-15 years before diagnosis; and in 95 (8%) of 1167 in the 16-20 years before diagnosis. Between 1990 and 2009, we noted decreases in the age at diagnosis (0·05 years of age per year, 95% CI 0·03-0·07) and yearly frequency of lower respiratory prescribing consultations (rate ratio 0·982 opportunities per year, 95% CI 0·979-0·985). Prevalence of all comorbidities present at COPD diagnosis increased except for asthma and bronchiectasis, which decreased between 1990 and 2007, from 281 (33·4%) of 842 patients to 451 of 1465 (30·8%) for asthma, and from 53 of 842 (6·3%) to 53 of 1465 (3·6%) for bronchiectasis. In the 2 years before diagnosis, of 6897 patients who had had a chest radiography, only 2296 (33%) also had spirometry. INTERPRETATION Opportunities to diagnose COPD at an earlier stage are being missed, and could be improved by case-finding in patients with lower respiratory tract symptoms and concordant long-term comorbidities. FUNDING UK Department of Health, Research in Real Life.

Asthma deaths: what now?

It is almost 50 years since the first UK studies identified potentially preventable factors in the majority of asthma deaths.1 Those first reports led to the development of national asthma guidelines, intended to radically improve management. Since the 1980s, asthma care in the UK has shifted from secondary to primary care,2 linked to enhanced asthma nurse training and involvement. With the development of new doctor–patient partnerships in the form of personalised self-management plans and newer drugs with innovative delivery systems, improving asthma care in the future seemed a certainty. And yet, from 1992, the only ongoing inquiry into asthma death in the East of England fuelled background concern that preventable death was still a major issue.3 That concern was highlighted by the National Atlas of Variation in Healthcare for Respiratory Disease,4 published in September 2012, which showed great variation in almost every facet of asthma care delivery across the UK. The National Review of Asthma Deaths (NRAD) was a confidential enquiry that investigated in detail 900 deaths of people of all ages who had died in 2012 with an ICD-10 code J459, where the underlying cause of death was classified as asthma. It was the first national study by the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians (RCP) to span both primary and secondary care, thus providing comprehensive information about asthma death. On World Asthma Day 2014, 24 years after the publication of the first UK guideline, the NRAD report, ‘Why asthma still kills’,5 stated asthma care was poor in most cases investigated and concluded that the vast majority of asthma deaths in the UK remain potentially preventable. In all age groups, NRAD identified errors in primary and secondary care: in making the diagnosis of asthma; in the identification of risk factors (leading …