Sharon Isonaka

Symptom-based questionnaire for identifying COPD in smokers

Background: Symptom-based questionnaires may enhance chronic obstructive pulmonary disease (COPD) screening in primary care. Objectives: We prospectively tested questions to help identify COPD among smokers without prior history of lung disease. Methods: Subjects were recruited via random mailing to primary care practices in Aberdeen, UK, and Denver, Colo., USA. Current and former smokers aged 40 or older with no prior respiratory diagnosis and no respiratory medications in the past year were enrolled. Participants answered questions covering demographics and symptoms and then underwent spirometry with reversibility testing. A study diagnosis of COPD was defined as fixed airway obstruction as measured by postbronchodilator FEV1/FVC <0.70. We examined the ability of individual questions in a multivariate framework to correctly discriminate between persons with and without COPD. Results: 818 subjects completed all investigations and proceeded to analysis. The list of 54 questions yielded 52 items for analysis, which was reduced to 17 items for entry into multivariate regression. Eight items had significant relationships with the study diagnosis of COPD, including age, pack-years, body mass index, weather-affected cough, phlegm without a cold, morning phlegm, wheeze frequency, and history of any allergies. Individual items yielded odds ratios ranging from 0.23 to 12. This questionnaire demonstrated a sensitivity of 80.4 and specificity of 72.0. Conclusions: A simple patient self-administered questionnaire can be used to identify patients with a high likelihood of having COPD, for whom spirometric testing is particularly important. Implementation of this questionnaire could enhance the efficiency and diagnostic accuracy of current screening efforts.

Symptom-Based Questionnaire for Differentiating COPD and Asthma

Background: Many patients with obstructive lung disease (OLD) carry an inaccurate diagnostic label. Symptom-based questionnaires could identify persons likely to need spirometry. Objectives: We prospectively tested questions derived from a comprehensive literature review and an international Delphi panel to help identify chronic OLD (COPD) in persons with prior evidence of OLD. Methods: Subjects were recruited via random mailing to primary-care practices in Aberdeen, Scotland, and Denver, Colorado. Persons aged 40 and older reporting any prior diagnosis of OLD or any respiratory medications in the past year were enrolled. Participants answered 54 questions covering demographics and symptoms and underwent spirometry with reversibility testing. A study diagnosis of COPD was defined by fixed airway obstruction as measured by post-bronchodilator FEV1/FVC <0.70. We examined ability of individual questions in a multivariate framework to discriminate between persons with and without the study diagnosis of COPD. Results: 597 persons completed all investigations and proceeded to analysis. The list of 54 questions yielded 52 items for analyses, which was reduced to 19 items for entry into a multivariate regression model. Nine items had significant relationships with the study diagnosis of COPD, including increased age, pack-years, worsening cough, breathing-related disability or hospitalization, worsening dyspnea, phlegm quantity, cold going to the chest, and receipt of treatment for breathing. Individual items yielded odds ratios ranging from 0.33 to 20.7. This questionnaire demonstrated a sensitivity of 72.0 and a specificity of 82.7. Conclusions: A short, symptom-based questionnaire identifies persons more likely to have COPD among persons with prior evidence of OLD.

Development of a Population-Based Screening Questionnaire for COPD

COPD is commonly under-diagnosed, in part because people at risk are unaware of the relevant risk factors and do not recognize related symptoms. Providing this information might permit earlier disease identification but the questions chosen should identify those with spirometrically defined airflow obstruction. Using a population-based data set, we have determined which questions identify persons most likely to have airflow obstruction. Potential questions were selected by review of COPD risk factors and clinical features. Validation was by retrospective analysis of the NHANES III data set, a population-based U.S. household survey that included spirometry. We examined the predictive ability of individual questions in a multi-variate framework to correctly discriminate between persons with and without spirometric airway obstruction (defined as FEV1/FVC < 0.70). We then tested the discriminatory ability of the questions in combination. The following items showed significant predictive ability: increased age, smoking status, pack-years, cough, wheeze, and prior diagnosis of asthma or COPD. The best performing combination was age, smoking status, pack-years smoked, wheeze, phlegm, body mass index, and prior diagnosis of obstructive lung disease. Using this combination in a population of current and former smokers aged 40 and over, we achieved a sensitivity of 85% and specificity of 45%, with a positive predictive value of 38% and a negative predictive value of 88%. Performance of this tool is comparable to other screening methods designed for use in a general population. Symptom-based questionnaires can be a viable method to identify persons likely to have COPD in the general population. Dissemination of such tools should raise awareness among at-risk persons and help identify COPD patients in the primary care setting.

Comparison of existing symptom‐based questionnaires for identifying COPD in the general practice setting

Objective:  Underdiagnosis of COPD is widespread, at least in part due to underuse of spirometry. Symptom‐based questionnaires may be helpful as an adjunct to spirometry. The aim of this study was to determine which types of questions might aid in identifying COPD.

The Enhanced Care Program: Impact of a Care Transition Program on 30-Day Hospital Readmissions for Patients Discharged From an Acute Care Facility to Skilled Nursing Facilities

BACKGROUND Increased acuity of skilled nursing facility (SNF) patients challenges the current system of care for these patients. OBJECTIVE Evaluate the impact on 30-day readmissions of a program designed to enhance the care of patients discharged from an acute care facility to SNFs. DESIGN An observational, retrospective cohort analysis of 30-day hospital readmissions for patients discharged to 8 SNFs between January 1, 2014, and June 30, 2015. SETTING A collaboration between a large, acute care hospital in an urban setting, an interdisciplinary clinical team, 124 community physicians, and 8 SNFs. PATIENTS All patients discharged from Cedars-Sinai Medical Center to 8 partner SNFs were eligible for participation. INTERVENTION The Enhanced Care Program (ECP) involved the following 3 interventions in addition to standard care: (1) a team of nurse practitioners participating in the care of SNF patients; (2) a pharmacist-driven medication reconciliation at the time of transfer; and (3) educational in-services for SNF nursing staff. MEASUREMENT Thirty-day readmission rate for ECP patients compared to patients not enrolled in ECP. RESULTS The average unadjusted, 30-day readmission rate for ECP patients over the 18-month study period was 17.2% compared to 23.0% among patients not enrolled in ECP (P < .001). After adjustment for sociodemographic and clinical characteristics, ECP patients had 29% lower odds of being readmitted within 30 days (P < .001). These effects were robust to stratified analyses, analyses adjusted for clustering, and balancing of covariates using propensity weighting. CONCLUSIONS A coordinated, interdisciplinary team caring for SNF patients can reduce 30-day hospital readmissions. Journal of Hospital Medicine 2018;13:229-235. Published online first October 4, 2017