Non-communicable Lung Disease in Sub Saharan Africa: a Community-based Cross-sectional Study of Adults in Urban Malawi

Rationale Non-communicable diseases (NCD) are major causes of morbidity and mortality in sub-Saharan Africa (sSA). Valid burden of disease estimates are lacking for non-communicable lung disease in sSA. Objectives We performed a community-based survey to determine the prevalence of chronic lung disease amongst adults ≥18 years in Malawi, using ATS standard spirometry, internationally validated respiratory symptom and exposure questionnaires, and including assessment of HIV-status. Methods An age and gender stratified random sample of 2000 adults was taken from the population of Chilomoni district of Blantyre, Malawi. Fieldworkers collected questionnaire data, conducted HIV-testing and performed pre/post bronchodilator spirometry on eligible participants. Survey-weighted population prevalence estimates of respiratory symptoms and spirometric abnormalities were computed, and bivariate and multivariable regression were used to identify associated variables. Results Questionnaire data, HIV status and BOLD standard spirometry were obtained from 1059, 937 and 749 participants respectively. Current respiratory symptoms, exposure to biomass and ever smoking were reported by 11.8%, 85.2% and 10.4% respectively. HIV prevalence was 24.2%. Moderate-severe airway obstruction was seen in 3.6%. The prevalence of spirometric restriction was 38.6% using NHANES reference ranges and 9.0% using local reference ranges. Age was positively associated with obstruction while low BMI was associated with restriction. Conclusions Over 40% of the Malawian adults in our urban population-representative sample had abnormal lung function (mostly restrictive) in the context of widespread exposure to biomass smoke and high HIV prevalence. These findings have potentially major pubic health implications for Malawi and the broader sSA region

Validation of chronic obstructive pulmonary disease recording in the Clinical Practice Research Datalink (CPRD-GOLD).

OBJECTIVES: The optimal method of identifying people with chronic obstructive pulmonary disease (COPD) from electronic primary care records is not known. We assessed the accuracy of different approaches using the Clinical Practice Research Datalink, a UK electronic health record database. SETTING: 951 participants registered with a CPRD practice in the UK between 1 January 2004 and 31 December 2012. Individuals were selected for ≥1 of 8 algorithms to identify people with COPD. General practitioners were sent a brief questionnaire and additional evidence to support a COPD diagnosis was requested. All information received was reviewed independently by two respiratory physicians whose opinion was taken as the gold standard. PRIMARY OUTCOME MEASURE: The primary measure of accuracy was the positive predictive value (PPV), the proportion of people identified by each algorithm for whom COPD was confirmed. RESULTS: 951 questionnaires were sent and 738 (78%) returned. After quality control, 696 (73.2%) patients were included in the final analysis. All four algorithms including a specific COPD diagnostic code performed well. Using a diagnostic code alone, the PPV was 86.5% (77.5-92.3%) while requiring a diagnosis plus spirometry plus specific medication; the PPV was slightly higher at 89.4% (80.7-94.5%) but reduced case numbers by 10%. Algorithms without specific diagnostic codes had low PPVs (range 12.2-44.4%). CONCLUSIONS: Patients with COPD can be accurately identified from UK primary care records using specific diagnostic codes. Requiring spirometry or COPD medications only marginally improved accuracy. The high accuracy applies since the introduction of an incentivised disease register for COPD as part of Quality and Outcomes Framework in 2004

Safety of fluticasone propionate prescribed for asthma during pregnancy: A UK population-based cohort study

Background: Asthma is commonly treated during pregnancy, yet data on the safety of asthma medicines used during pregnancy are sparse. Objective: The objective of this study was to evaluate the safety of the inhaled corticosteroid (ICS) fluticasone propionate (FP), alone and in fixed-dose combination with salmeterol (FSC) in terms of the risk of all major congenital malformations (MCMs), compared with all other non-FP ICS. Methods: Women with asthma who had a pregnancy between January 1, 2000, and December 31, 2010, were identified in the United Kingdom's Clinical Practice Research Datalink. Exposure to asthma medicines during the first trimester of pregnancy was based on issued prescriptions. The mothers' and infants' medical records were linked where possible, and pregnancy outcomes with an MCM diagnosed by age 1 year were identified based on medical codes in the mother's and infant's medical records, including those MCMs prenatally diagnosed that ended in an induced pregnancy termination. The absolute and relative risks of an MCM after different ICS exposures, stratified by the asthma treatment intensity level, were calculated. Results: A total of 14,654 mother-infant pairs were identified, of which 6,174 received an ICS prescription during the first trimester, in addition to 13 first trimester ICS exposed pregnancies that ended in an induced termination after a prenatal MCM diagnosis. In total, 5,362 pregnancies were eligible for the primary analysis at age 1 year. The absolute risk of an MCM after any first trimester FP exposure was 2.4% (CI95 0.8-4.1) and2.7% (CI95 1.8-3.6) for the "moderate" and "considerable/severe" asthma treatment intensity levels, respectively. The adjusted odds ratios when compared with non-FP ICS were 1.1 (CI95 0.5-2.3) and 1.2 (CI95 0.7-2.0) for the "moderate" and "considerable/severe" intensity levels; risks for any FP and for FSC did not differ substantially. Conclusion: No increase in the overall risk of MCMs was identified after first trimester FP exposure compared with non-FP ICS. © 2015 American Academy of Allergy, Asthma & Immunology

Recording of hospitalizations for acute exacerbations of COPD in UK electronic health care records.

BACKGROUND: Accurate identification of hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) within electronic health care records is important for research, public health, and to inform health care utilization and service provision. We aimed to develop a strategy to identify hospitalizations for AECOPD in secondary care data and to investigate the validity of strategies to identify hospitalizations for AECOPD in primary care data. METHODS: We identified patients with chronic obstructive pulmonary disease (COPD) in the Clinical Practice Research Datalink (CPRD) with linked Hospital Episodes Statistics (HES) data. We used discharge summaries for recent hospitalizations for AECOPD to develop a strategy to identify the recording of hospitalizations for AECOPD in HES. We then used the HES strategy as a reference standard to investigate the positive predictive value (PPV) and sensitivity of strategies for identifying AECOPD using general practice CPRD data. We tested two strategies: 1) codes for hospitalization for AECOPD and 2) a code for AECOPD other than hospitalization on the same day as a code for hospitalization due to unspecified reason. RESULTS: In total, 27,182 patients with COPD were included. Our strategy to identify hospitalizations for AECOPD in HES had a sensitivity of 87.5%. When compared with HES, using a code suggesting hospitalization for AECOPD in CPRD resulted in a PPV of 50.2% (95% confidence interval [CI] 48.5%-51.8%) and a sensitivity of 4.1% (95% CI 3.9%-4.3%). Using a code for AECOPD and a code for hospitalization due to unspecified reason resulted in a PPV of 43.3% (95% CI 42.3%-44.2%) and a sensitivity of 5.4% (95% CI 5.1%-5.7%). CONCLUSION: Hospitalization for AECOPD can be identified with high sensitivity in the HES database. The PPV and sensitivity of strategies to identify hospitalizations for AECOPD in primary care data alone are very poor. Primary care data alone should not be used to identify hospitalizations for AECOPD. Instead, researchers should use data that are linked to data from secondary care

Continuing to Confront COPD International Physician Survey: Physician Knowledge and Application of COPD Management Guidelines in 12 Countries

AIM: Utilizing data from the Continuing to Confront COPD (chronic obstructive pulmonary disease) International Physician Survey, this study aimed to describe physicians\u27 knowledge and application of the GOLD (Global initiative for chronic Obstructive Lung Disease) Global Strategy for the Diagnosis, Management and Prevention of COPD diagnosis and treatment recommendations and compare performance between primary care physicians (PCPs) and respiratory specialists. MATERIALS AND METHODS: Physicians from 12 countries were sampled from in-country professional databases; 1,307 physicians (PCP to respiratory specialist ratio three to one) who regularly consult with COPD, emphysema, or chronic bronchitis patients were interviewed online, by telephone or face to face. Physicians were questioned about COPD risk factors, prognosis, diagnosis, and treatment, including knowledge and application of the GOLD global strategy using patient scenarios. RESULTS:Physicians reported using spirometry routinely (PCPs 82%, respiratory specialists 100%; P\u3c0.001) to diagnose COPD and frequently included validated patient-reported outcome measures (PCPs 67%, respiratory specialists 81%; P\u3c0.001). Respiratory specialists were more likely than PCPs to report awareness of the GOLD global strategy (93% versus 58%, P\u3c0.001); however, when presented with patient scenarios, they did not always perform better than PCPs with regard to recommending GOLD-concordant treatment options. The proportion of PCPs and respiratory specialists providing first- or second-choice treatment options concordant with GOLD strategy for a GOLD B-type patient was 38% versus 67%, respectively. For GOLD C and D-type patients, the concordant proportions for PCPs and respiratory specialists were 40% versus 38%, and 57% versus 58%, respectively. CONCLUSION: This survey of physicians in 12 countries practicing in the primary care and respiratory specialty settings showed high awareness of COPD-management guidelines. Frequent use of guideline-recommended COPD diagnostic practices was reported; however, gaps in the application of COPD-treatment recommendations were observed, warranting further evaluation to understand potential barriers to adopt guideline recommendations

Health Behaviors and Their Correlates Among Participants in the Continuing to Confront COPD International Patient Survey

Background and aims: We used data from the Continuing to Confront COPD International Patient Survey to test the hypothesis that patients with COPD who report less engagement with their disease management are also more likely to report greater impact of the disease. Methods: This was a population-based, cross-sectional survey of 4,343 subjects aged ≥ 40 years from 12 countries, fulfilling a case definition of COPD based on self-reported physician diagnosis or symptomatology. The impact of COPD was measured with COPD Assessment Test, modified Medical Research Council Dyspnea Scale, and hospital admissions and emergency department visits for COPD in the prior year. The 13-item Patient Activation Measure (PAM-13) instrument and the 8-item Morisky Medication Adherence Scale (MMAS-8) were used to measure patient disease engagement and medication adherence, respectively. Results: Twenty-eight percent of subjects reported being either disengaged or struggling with their disease (low engagement: PAM-13 levels 1 and 2), and 35% reported poor adherence (MMAS-8 \u3c 6). In univariate analyses, lower PAM-13 and MMAS-8 scores were significantly associated with poorer COPD-specific health status, greater breathlessness and lower BMI (PAM-13 only), less satisfaction with their doctor’s management of COPD, and more emergency department visits. In multivariate regression models, poor satisfaction with their doctor’s management of COPD was significantly associated with both low PAM-13 and MMAS-8 scores; low PAM-13 scores were additionally independently associated with higher COPD Assessment Test and modified Medical Research Council scores and low BMI (underweight). Conclusion: Poor patient engagement and medication adherence are frequent and associated with worse COPD-specific health status, higher health care utilization, and lower satisfaction with health care providers. More research will be needed to better understand what factors can be modified to improve medication adherence and patient engagement

Lung function decline and outcomes in an adult population

Rationale: Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality. Objectives: To determine risk factors for and outcomes of rapid lung function decline in a cohort of adults in the United States. Methods: We analyzed data from 15,536 adults aged 44–66 yr in the Atherosclerosis Risk in Communities study. We used Cox proportional hazard models to determine the risk of rapid lung function decline at 3 yr on mortality and COPD hospitalizations over the subsequent 8 yr. Measurements and Main Results: Of those in the baseline cohort, 13,756 (88.5%) had spirometry at the Year 3 visit. The strongest risk factors for not having a follow-up spirometry were as follows: having Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 3 or 4 disease at baseline (adjusted odds ratio [OR] 2.8; 95% confidence interval [CI], 2.1–3.8), being black (adjusted OR, 2.4; 95% CI, 2.1–2.7), and being a current smoker (adjusted OR, 1.8; 95% CI, 1.5–2.0). Participants with GOLD stage 3 or 4 disease were also more likely to be in the most rapidly declining lung function quartile (adjusted OR, 3.7; 95% CI, 2.7–5.0). Overall, participants with the most rapidly declining lung function had a modestly increased risk of death (adjusted hazard ratio, 1.4; 95% CI, 1.2–1.7) and time to a COPD-related hospitalization (adjusted hazard ratio, 1.4; 95% CI, 1.2–1.8). Conclusion: Rapid lung function decline was independently associated with a modest increased risk of COPD hospitalizations and deaths

Chronic Obstructive Pulmonary Disease and Hospitalizations for Pneumonia in a US Cohort

Objective To better understand risk factors for pneumonia hospitalizations in people with impaired lung function. Methods We analyzed longitudinal data from participants in the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular Health Study (CHS). We limited our analysis to 20,375 participants aged 45 and older at baseline. We stratified the sample based on prebronchodilator baseline lung function data, according to modified GOLD criteria, including a “restrictive” category (FEV1/FVC \u3e 70% and FVC \u3c 80%). We defined “pneumonia” as a hospitalization with a pneumonia discharge diagnosis (ICD-9 codes 480–486) within 36 months. We used Cox proportional hazard models to determine pneumonia risk associated with COPD stage, adjusting for age, sex, race, smoking status and comorbid disease (diabetes mellitus or cardiovascular disease at the baseline examination). Results Pneumonia hospitalization risk was associated with older age, male gender, comorbid conditions, smoking status, and level of lung function impairment. Overall, people with normal lung function had the lowest pneumonia hospitalization rate (1.5 per 1000 person-years) and those with GOLD stage 3 or 4 COPD had the highest rate (22.7 per 1000 person-years). After adjusting for other potential confounding factors, GOLD stages 3 or 4 and 2 COPD were associated with an increased risk of pneumonia (hazard ratio [HR] 5.65, 95% confidence interval [CI] 3.29, 9.67 and 2.25 (1.35, 3.75), respectively) relative to normal lung function. Conclusion COPD severity (GOLD stage) is an important and independent predictor of pneumonia hospitalizations in this cohort