https://works.bepress.com/david_mannino/229/download/

COPD Surveillance—United States, 1999-2011

https://academiccommons.columbia.edu/doi/10.7916/D8GM8K7S/download

Barriers to adherence to copd guidelines among primary care providers

Background Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste. Objective To identify overuse and underuse of diagnostic tests in primary care. Design Systematic review and meta-analysis. Data sources and eligibility criteria We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care. Results We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests. The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%–100%)%). 17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%–78%, n=8). Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%–92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%–54% (n=10) and 8%–52% (n=2), respectively. Conclusions There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO registration number CRD42016048832.

https://bmjopen.bmj.com/content/bmjopen/8/2/e018557.full.pdf

Overtesting and undertesting in primary care: a systematic review and meta-analysis.

Background: Little is known about patients who frequently visit the emergency department (ED) for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We aimed to quantify the proportion and characteristics of patients with frequent ED visits for AECOPD and associated healthcare utilization. Methods: We conducted a retrospective cohort study of adults aged ≥40 years with at least one ED visit for AECOPD between 2010 and 2011, derived from population-based all-payer data of State ED and Inpatient Databases for two large and diverse states: California and Florida. Outcome measures were frequency of ED visits for AECOPD, 30-day ED revisits, subsequent hospitalizations, near-fatal events (AECOPD involving mechanical ventilation), and charges for both ED and inpatient services (available only for Florida) during the year after the first ED visit. Results: The analytic cohort comprised 98,280 unique patients with 154,736 ED visits for AECOPD. During the 1-year period, 29.4% (95% CI, 29.1%-29.7%) of the patients had two or more (frequent) visits, accounting for 55.2% (95% CI, 54.9%-55.4%) of all ED visits for AECOPD. In the multivariable model, significant predictors of frequent ED visits were age 55–74 years (vs. 40–54 years), male sex, non-Hispanic white or black race, Medicaid insurance (vs. private), and lower median household income (all P < 0.001). At the visit-level, 12.3% of ED visits for AECOPD were 30-day revisit events (95% CI, 12.1%-12.4%). Additionally, 62.8% of ED visits for AECOPD (95% CI, 62.6%-63.0%) resulted in a hospitalization; patients with frequent ED visits comprised 55.5% (95% CI, 55.2%-55.8%) of all hospitalizations. Furthermore, 7.3% (95% CI, 7.3%-7.5%) of ED visits for AECOPD led to a near-fatal event; patients with frequent ED visits accounted for 64.4% (95% CI, 63.5%-65.3%) of all near-fatal events. Total charges for AECOPD were $1.94 billion (95% CI, $1.90-1.97 billion) in Florida; patients with frequent ED visits accounted for $1.07 billion (95% CI, $1.04-1.09 billion). Conclusions: In this large cohort study, we found that 29% had frequent ED visits for AECOPD and that lower socioeconomic status was significantly associated with a higher frequency of ED visits. Individuals with frequent ED visits for AECOPD accounted for a substantial amount of healthcare utilization and financial burden.

/pdf/frequent-utilization-of-the-emergency-department-for-acute-4wgj07zp0l.pdf

Frequent utilization of the emergency department for acute exacerbation of chronic obstructive pulmonary disease

Guideline-based COPD management in a resource-limited setting - physicians' understanding, adherence and barriers: a cross-sectional survey of internal and family medicine hospital-based physicians in Nigeria.

Chronic Obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in the United States and internationally. The purpose of this study was to describe spirometry use in the diagnosis of COPD and to evaluate the management of COPD occurring in a primary care clinic. Methods: Two hundred patients with a diagnosis of COPD attending a university-based family medicine clinic were randomly chosen for a retrospective medical record review. Pulmonary function testing, provision of smoking cessation advice and pharmacological management were compared to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Results: Mean age was 65.4 years, 48% were male and 72% were Caucasian. Overall, 58.5% (n = 117) of patients had pulmonary function testing, with 60.7% acknowledged in the outpatient record; 55% (n = 110) were receiving medications in combinations that are recommended; and 40% of patients were receiving stage appropriate medications. 67.8% of current smokers were offered smoking cessation advice or treatment. Conclusions: Overall there was low use of recommended medication combinations and stage appropriate treatment, with better observance of diagnostic and risk factor reduction guidelines. In order to improve COPD care for patients, physicians need education about the recommended stepwise treatment options and office systems that promote integration of pulmonary function testing findings into care.

Diagnosis and management of chronic obstructive pulmonary disease (COPD) in a primary care clinic.

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Diagnosis and management of chronic obstructive pulmonary disease (COPD) in a primary care clinic.