Opportunistic screening for COPD among socially marginalized patients.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common disease associated with premature death. Tobacco exposure is the main risk factor, but lower socioeconomic status, early life insults, and occupational exposures are also important risk factors. Socially marginalized people, facing homelessness, substance use disorder, and mental illness, are likely to have a higher risk of developing COPD, and, furthermore, experience barriers to healthcare access and consequently poorer outcomes. OBJECTIVE: This study aims to assess COPD prevalence and the impact of opportunistic screening among hospitalized patients who are in contact with hospital social nurses. These patients constitute a group of patients with a high prevalence of psychiatric and somatic diseases, substance use, low life expectancy, and are socially marginalized. METHODS: The present prospective longitudinal study includes a clinical examination at baseline. Participants will have spirometry done and be interviewed regarding risk factors, socioeconomic conditions, and respiratory symptoms. The 5-year follow-up assessment incorporates data from baseline and register data over the 5 years, including information on morbidity, use of COPD medication, hospital contacts, mortality, and socioeconomic factors. ANTICIPATED RESULTS: Referral for further diagnostic work-up and management after the screening, including COPD treatment and smoking cessation support, is expected to improve survival rates. The study is still enrolling patients. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov , NCT04754308 with study status: "enrolling".

Biomarker-guided withdrawal of inhaled corticosteroids in asthma patients with a non-T2 inflammatory phenotype - a randomized controlled trial study protocol.

BACKGROUND: Non-T2 asthma is characterized by the absence of elevated type 2 inflammatory biomarkers such as blood-eosinophils, total and allergen-specific Immunoglobulin E and Fractional exhaled Nitric Oxide (FeNO). According to guidelines, inhaled corticosteroids (ICS) are the cornerstone of asthma management. However, ICS treatment is associated with a risk of local side effects, including hoarseness and thrush, and long-term high-dose therapy may cause systemic adverse effects. Furthermore, whereas treatment with ICS is highly effective in T2 asthma, studies have shown a markedly reduced ICS efficacy in patients with a lower degree of T2 inflammation, thus posing a clinical challenge in this subgroup of patients. Hence, owing to the ICS dosage step-up approach in current clinical guidelines, patients with low T2 biomarkers are at risk of being exposed to high doses of ICS, and by that at risk of side effects. Thus, an ICS-treatment regime guided by biomarkers that reflects the inflammatory phenotype is warranted in order to reduce the corticosteroid burden in patients with non-T2 asthma. This study combines a panel of non-T2 inflammatory markers (low periostin, low blood-eosinophils, and low FeNO), to determine if this group of patients can maintain asthma control during ICS withdrawal. METHODS: This is an ongoing prospective multicenter open-label randomized, controlled trial aiming to assess if ICS can be safely tapered in patients with non-T2 asthma. The patients are randomized 1:1 to either standard of care or an ICS tapering regimen (n = 55 in each group) where the initial ICS dose is reduced by 50% for 8 weeks followed by total ICS removal. The primary endpoint is change in asthma control questionnaire (ACQ) from baseline to post-tapered ICS. The secondary endpoints are time from baseline to drop-out caused by loss of asthma control, changes in serum-periostin, blood-eosinophils, FeNO, Forced Expiratory Volume in 1 s (FEV1) and in sputum-eosinophils. DISCUSSION: This study aims to provide data on ICS tapering in non-T2 asthma patients and to contribute to a more individualized and corticosteroid-sparing treatment regime in this group of patients. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03141424. Registration date: May 5th, 2017.

Pulmonary telerehabilitation vs. conventional pulmonary rehabilitation - a secondary responder analysis.

Home-based pulmonary telerehabilitation (PTR) has been proposed to be equivalent to supervised outpatient pulmonary rehabilitation (PR) but available randomised trials have failed to reach the minimal important changes (MIC). The purpose of this study was to analyse the proportion of MIC responders and non-responders on short-term (10 weeks from baseline) and long-term (62 weeks from baseline) in total and between groups in 134 patients with COPD randomised (1:1) to either home-based PTR or traditional hospital-based outpatient PR. Difference between PTR and PR on 6MWD response proportion could not be shown at 10 (OR=0.72, CI=0.34 to 1.51, p=0.381) or 62 weeks (OR=1.12, CI=0.40 to 3.14, p=0.834). While the evidence and knowledge of PTR accumulate, outpatient supervised PR for now remains the standard of care, with home-based PTR as a strong secondary option for those unable to attend out-patient programmes.

Impact of offspring and their educational level on readmission and death among older adults with chronic obstructive pulmonary disease: a nationwide cohort study using multistate survival models.

BACKGROUND: It is well described that there is social inequality in the disease course of chronic obstructive pulmonary disease (COPD), but the impact of social relations is less explored. We aimed to investigate the impact of adult offspring and their educational level on readmission and death among older adults with COPD. METHODS: In total, 71 084 older adults born 1935-53 with COPD diagnosed at age ≥65 years in 2000-2018 were included. Multistate survival models were performed to estimate the impact of adult offspring (offspring (reference) vs no offspring) and their educational level (low, medium or high (reference)) on the transition intensities between three states: COPD diagnosis, readmission and all-cause death. RESULTS: During follow-up, 29 828 (42.0%) had a readmission and 18 504 (26.0%) died with or without readmission. Not having offspring was associated with higher hazards of death without readmission (HRwomen: 1.52 (95% CI: 1.39 to 1.67), HRmen: 1.29 (95% CI: 1.20 to 1.39)) and a higher hazard of death after readmission for women only (HRwomen: 1.19 (95% CI: 1.08 to 1.30). Having offspring with low educational level was associated with higher hazards of readmission (HRwomen: 1.12 (95% CI: 1.06 to 1.19)), (HRmen: 1.06 (95%CI: 1.002 to 1.12)), death without readmission (HRwomen: 1.24 (95% CI: 1.11 to 1.39)), HRmen: 1.16 (95% CI: 1.05 to 1.29) and death after readmission for men only (HRmen: 1.15 (95% CI: 1.05 to 1.25)). Having offspring with medium educational level was associated with a higher hazard of death without readmission for women (HRwomen: 1.11 (95% CI: 1.02 to 1.21)). CONCLUSION: Adult offspring and their educational level were associated with higher risk of readmission and death among older adults with COPD.

High-protein diet during pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

INTRODUCTION: The prevalence of cachexia in patients with chronic obstructive pulmonary disease (COPD) is high and associated with reduced quality of life, increased mortality and morbidity. We aimed to test the effect of a high protein diet combined with exercise on fat-free mass (FFM), functional capacity, symptom burden and dyspnoea. METHODS: Outpatients with COPD and severe or very severe (GOLD grade III-IV) disease and malnutrition commencing pulmonary rehabilitation were randomised to a high-protein diet or standard care. FFM was measured by bio-impedance analysis (BIA), mid-upper arm circumference (MUAC) and mid-thigh circumference (MTC), peripheral muscle function by six-minute walking distance (6MWD) and handgrip strength (HGS), symptoms by the COPD Assessment Trial (CAT) and dyspnoea by the Medical Research Council dyspnoea scale and Borg scores; all at baseline and after 12 weeks. RESULTS: Ten out of 13 randomised patients completed the trial. The intervention group was superior to the control group with respect to 6MWD (97 ± 93 m, p = 0.04) at 12 weeks. No differences were observed between the groups in HGS, anthropometrics, symptom burden or dyspnoea. CONCLUSION: In patients with COPD attending rehabilitation, a high protein diet combined with physical exercise had a clinically relevant effect on walking distance. FUNDING: none. TRIAL REGISTRATION: NCT04888182.

A systematic review of blood eosinophils and continued treatment with inhaled corticosteroids in patients with COPD.

Inhaled corticosteroid (ICS) in patients with chronic obstructive pulmonary disease (COPD) has been debated for 20 years. In our systematic literature review and meta-analysis, we addressed the following: Should patients with COPD and a blood eosinophil count (EOS) of, respectively, a) < 150 cells/µl, b) 150-300 cells/µl, and c) > 300 cells/µl continue treatment with ICS? Protocol registered in PROSPERO (CRD42020178110) and funded by the Danish Health Authority. We searched Medline, Embase, CINAHL and Cochrane Central on 22nd July 2020 for randomized controlled trials (RCT) of ICS treatment in patients with COPD (≥40 years, no current asthma), which analyzed outcomes by EOS count and where >50% of patients used ICS prior. We used the GRADE method. Meta-analyzes for the outcomes were divided into EOS subgroups and analyzed for differences. We identified 11 RCTs with a total of 29,654 patients. A significant difference (p < 0.00001) between the three subgroups' reduction of risk of moderate to severe exacerbation was found. Rate ratios for EOS counts: <150 cells/µL was 0.88 (95%CI: 0.83, 0.94); 150-300 cells/µL was 0.80 (95%CI: 0.69, 0.94); >300 cells/µL was 0.57 (95%CI: 0.49, 0.66). Overall, the certainty of the effect estimates was low to very low due to risk of bias, unexplained heterogeneity, few RCTs, and wide confidence intervals. A clear correlation was demonstrated between effect of continued ICS treatment (number of exacerbations, lung function, and quality of life) and increasing EOS count. Our meta-analyses suggested that treatment with ICS seemed beneficial for everyone except patients with EOS count below 150 cells/µl.

Comparison of Characteristics Between ICS-Treated COPD Patients and ICS-Treated COPD Patients with Concomitant Asthma: A Study in Primary Care.

Background and Objective: Inhaled corticosteroids (ICS) for COPD has been much debated. Our aim was to identify characteristics associated with prescribing ICS for patients with COPD alone compared to those with concomitant asthma in general practice. Patients and Methods: Participating general practitioners (GPs) (n=144) recruited patients with COPD (ICPC 2nd ed. code R95) currently prescribed ICS (ACT code R03AK and R03BA). Data, if available, on demographics, smoking habits, spirometry, COPD medication, dyspnea score, and exacerbation history were retrieved from the medical records. Logistic regression analysis was used to identify possible differences in characteristics between patients with COPD alone compared to those having a concomitant diagnosis of asthma. Results: A total of 2.289 (45% males) COPD patients on ICS were recruited. Compared to patients with COPD alone (n=1.749), those with COPD and concomitant asthma (n=540) were younger (p<0.001), had higher BMI, higher FEV1/FVC ratio, higher blood eosinophil count and less life-time tobacco exposure (36 and 26 pack-years, respectively). Compared to COPD alone, logistic regression analysis showed that COPD with concomitant asthma was significantly associated to age (OR 0.94; CI 0.92 to 0.97; p<0.001), pack-years of smoking (OR 0.98; CI 0.97 to 0.99; p<0.001), %pred (OR 1.02; CI 1.00 to 1.03; p=0.005), and doctor-diagnosed depression (OR 2.59; CI 1.20 to 5.58; p=0.015). Conclusion: In COPD patients currently prescribed ICS, the presence of concomitant asthma was associated with being younger, having less tobacco exposure, more preserved lung function and a higher likelihood of doctor-diagnosed depression compared to COPD alone.

Supervised pulmonary tele-rehabilitation versus pulmonary rehabilitation in severe COPD: a randomised multicentre trial.

RATIONALE: Pulmonary rehabilitation (PR) is an effective, key standard treatment for people with COPD. Nevertheless, low participant uptake, insufficient attendance and high drop-out rates are reported. Investigation is warranted of the benefits achieved through alternative approaches, such as pulmonary tele-rehabilitation (PTR). OBJECTIVE: To investigate whether PTR is superior to conventional PR on 6 min walk distance (6MWD) and secondarily on respiratory symptoms, quality of life, physical activity and lower limb muscle function in patients with COPD and FEV1 <50% eligible for routine hospital-based, outpatient PR. METHODS: In this single-blinded, multicentre, superiority randomised controlled trial, patients were assigned 1:1 to 10 weeks of groups-based PTR (60 min, three times weekly) or conventional PR (90 min, two times weekly). Assessments were performed by blinded assessors at baseline, end of intervention and at 22 weeks' follow-up from baseline. The primary analysis was based on the intention-to-treat principle. MEASUREMENTS AND MAIN RESULTS: The primary outcome was change in 6MWD from baseline to 10 weeks; 134 participants (74 females, mean±SD age 68±9 years, FEV1 33%±9% predicted, 6MWD 327±103 metres) were included and randomised. The analysis showed no between-group differences for changes in 6MWD after intervention (9.2 metres (95% CI: -6.6 to 24.9)) or at 22 weeks' follow-up (-5.3 metres (95% CI: -28.9 to 18.3)). More participants completed the PTR intervention (n=57) than conventional PR (n=43) (χ2 test p<0.01). CONCLUSION: PTR was not superior to conventional PR on the 6MWD and we found no differences between groups. As more participants completed PTR, supervised PTR would be relevant to compare with conventional PR in a non-inferiority design. Trial registration number ClinicalTrials.gov (NCT02667171), 28 January 2016.

Inspiratory muscle strength and walking capacity in patients with COPD.

Purpose: It has been suggested that patients with inspiratory muscle weakness could benefit from specific inspiratory muscle training (IMT). We aimed to examine the frequency of patients with inspiratory muscle weakness in a Danish hospital-based outpatient pulmonary rehabilitation program, and to evaluate the association between inspiratory muscle strength and peripheral muscle strength and walking capacity. Methods: Maximal Inspiratory Pressure (MIP) was assessed in 97 patients with COPD (39 men, 58 women, mean age years 70 ± 9, forced expiratory volume in 1 s ((FEV1) = 35 ± 10% pred.). The impact of MIP on knee-extension strength, walking distance, and symptom burden was evaluated using multiple linear regression analyses. Results: The MIP of the patients with COPD was 63 (95% CI 59; 67) cmH2O and it was significantly reduced compared to gender and age-matched reference values 76 (95% CI 73; 79) cmH2O (p < 0.001). Seven patients (7.2%) were under the lower limit of normal. MIP was negatively correlated with increasing age, female gender, decreasing knee-extension strength and lower FEV1% pred. Walking distance was associated with knee-extension strength and it was not associated with MIP. Conclusion: Maximal inspiratory pressure was reduced in patients with COPD but only a few patients had a weak MIP. Whilst MIP was associated with leg muscle strength, it was not associated with walking distance or symptoms.

Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis.

BACKGROUND: Pulmonary rehabilitation (PR), delivered as a supervised multidisciplinary program including exercise training, is one of the cornerstones in the chronic obstructive pulmonary disease (COPD) management. We performed a systematic review and meta-analysis to assess the effect on mortality of a supervised early PR program, initiated during or within 4 weeks after hospitalization with an acute exacerbation of COPD compared with usual post-exacerbation care or no PR program. Secondary outcomes were days in hospital, COPD related readmissions, health-related quality of life (HRQoL), exercise capacity (walking distance), activities of daily living (ADL), fall risk and drop-out rate. METHODS: We identified randomized trials through a systematic search using MEDLINE, EMBASE and Cocharne Library and other sources through October 2017. Risk of bias was assessed regarding randomization, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases using the Cochrane Risk of Bias tool. RESULTS: We included 13 randomized trials (801 participants). Our meta-analyses showed a clinically relevant reduction in mortality after early PR (4 trials, 319 patients; RR = 0.58 (95% CI: [0.35 to 0.98])) and at the longest follow-up (3 trials, 127 patients; RR = 0.55 (95% CI: [0.12 to 2.57])). Early PR reduced number of days in hospital by 4.27 days (1 trial, 180 patients; 95% CI: [- 6.85 to - 1.69]) and hospital readmissions (6 trials, 319 patients; RR = 0.47 (95% CI: [0.29 to 0.75])). Moreover, early PR improved HRQoL and walking distance, and did not affect drop-out rate. Several of the trials had unclear risk of bias in regard to the randomization and blinding, for some outcome there was also a lack of power. CONCLUSION: Moderate quality of evidence showed reductions in mortality, number of days in hospital and number of readmissions after early PR in patients hospitalized with a COPD exacerbation. Long-term effects on mortality were not statistically significant, but improvements in HRQoL and exercise capacity appeared to be maintained for at least 12 months. Therefore, we recommend early supervised PR to patients with COPD-related exacerbations. PR should be initiated during hospital admission or within 4 weeks after hospital discharge.

[Treatment of stable chronic obstructive pulmonary disease].

In 2012, The Danish Society of Respiratory Medicine gave birth to their most recent guideline regarding chronic obstructive pulmonary disease (COPD). Much has happened since, and in late 2017 an update has been published. Chapters have been deleted, and new ones added. The major alteration has been in the section concerning treatment with inhalation medication - now aiming at an easy stepwise up-titration of long-acting medicine as well as a guide of how to down-titrate inhaled corticosteroids. This review mainly focuses on how to treat stable COPD according to The Danish Society of Respiratory Medicine.

Use of prophylactic Saccharomyces boulardii to prevent Clostridium difficile infection in hospitalized patients: a controlled prospective intervention study.

Clostridium difficile infection (CDI) is a common complication to antibiotic use. Saccharomyces boulardii has shown effect as a prophylactic agent. We aimed to evaluate the efficacy of S. boulardii in preventing CDI in unselected hospitalized patients treated with antibiotics. We conducted a 1 year controlled prospective intervention study aiming to prescribe Sacchaflor (S. boulardii 5 × 109, Pharmaforce ApS) twice daily to hospitalized patients treated with antibiotics. Comparable departments from three other hospitals in our region were included as controls. All occurrences of CDI in patients receiving antibiotics were reported and compared to a baseline period defined as 2 years prior to intervention. Results were analyzed using run chart tests for non-random variation in CDI rates. In addition, odds ratios for CDI were calculated. S. boulardii compliance reached 44% at the intervention hospital, and 1389 patients were treated with Sacchaflor. Monthly CDI rates dropped from a median of 3.6% in the baseline period to 1.5% in the intervention period. S. boulardii treatment was associated with a reduced risk of CDI at the intervention hospital: OR = 0.06 (95% CI 0.02-0.16). At two control hospitals, CDI rates did not change. At one control hospital, the median CDI rate dropped from 3.5 to 2.4%, possibly reflecting the effects of simultaneous multifaceted intervention against CDI at that hospital. The results from this controlled prospective interventional study indicate that S. boulardii is effective for the prevention of CDI in an unselected cohort of mainly elderly patients from departments of internal medicine.

Oral prednisolone for 4 days does not increase exercise tolerance in men with COPD.

One of the primary objectives in management of chronic obstructive pulmonary disease (COPD) is preventing decrease in lung function and reducing the annual number of acute exacerbations of COPD (AECOPD). An oral course of systemic corticosteroids is a commonly used treatment in AECOPD. We hypothesize that this treatment also increases exercise performance and decreases muscle fatigue. In a randomized double-blinded, parallel, placebo-controlled trial, we investigated 14 men (8 on prednisolone 37.5 mg vs. 6 on placebo) with severe and very severe COPD. For 5 consecutive days, the patients performed a submaximal endurance test measuring time to exhaustion (TTE, primary endpoint), spirometry, maximal inspiratory and expiratory pressure and maximal isometric contraction of the quadriceps femoris muscle (maximum voluntary contraction (MVC)). At visits 2, 3 and 4, a fatigue protocol was carried out after 40 minutes of cycling at 40% of maximal effort. No differences between groups were found for TTE, lung function or maximal inspiratory or expiratory pressure, however, patients on prednisolone showed significant increased MVC: median 5.15 [3.35; 9.15] against placebo: -2 [-5.57; 3.95] ( p = 0.03). This finding indicates an impact of corticosteroids on muscle groups being exposed to submaximal endurance.

Interorganisational Integration: Healthcare Professionals' Perspectives on Barriers and Facilitators within the Danish Healthcare System.

INTRODUCTION: Despite many initiatives to improve coordination of patient pathways and intersectoral cooperation, Danish health care is still fragmented, lacking intra- and interorganisational integration. This study explores barriers to and facilitators of interorganisational integration as perceived by healthcare professionals caring for patients with chronic obstructive pulmonary disease within the Danish healthcare system. METHODS: Seven focus groups were conducted in January through July 2014 with 21 informants from general practice, local healthcare centres and a pulmonary department at a university hospital in the Capital Region of Denmark. RESULTS AND DISCUSSION: Our results can be grouped into five influencing areas for interorganisational integration: communication/information transfer, committed leadership, patient engagement, the role and competencies of the general practitioner and organisational culture. Proposed solutions to barriers in each area hold the potential to improve care integration as experienced by individuals responsible for supporting and facilitating it. Barriers and facilitators to integrating care relate to clinical, professional, functional and normative integration. Especially, clinical, functional and normative integration seems fundamental to developing integrated care in practice from the perspective of healthcare professionals.

Symptoms and quality of life in patients with chronic obstructive pulmonary disease treated with aclidinium in a real-life setting.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a progressive disease with symptoms that can have a major impact on patients' physical health. The aim of this study was to evaluate quality of life (QoL), symptom severity and dyspnoea in COPD patients treated with aclidinium up to 24 weeks. METHODS: In this prospective non-interventional multicentre study (198 centres in Sweden, Denmark, and Norway), COPD patients (age ≥40 years) who started treatment with aclidinium (initial therapy, change of treatment, or add-on therapy) could be included. Health-related QoL was obtained by COPD assessment test (CAT). Symptoms were evaluated on a 6-point Likert scale. The modified Medical Research Council (mMRC) Dyspnoea Scale was used as a simple grading system to assess the level of dyspnoea/shortness of breath from0 to 4. Patients on treatment with aclidinium who completed baseline and at least one follow-up visit (week 12 or 24) were included in the study population. RESULTS: Overall, 1,093 patients were enrolled (mean 69 years, 54% females), one-third had ≥1 exacerbation the year prior to baseline. At enrolment, 48% were LAMA naïve. Mean (standard deviation, SD) CAT score decreased from 16.9 (7.7) at baseline to 14.3 (7.3) at week 24 (p<0.01) with a decrease in all individual CAT items (p<0.05). Mean difference in morning and night-time symptoms from baseline to week 24 was -0.60 (SD 2.51) and -0.44 (SD 2.48), respectively (both p<0.001). Mean (SD) mMRC Dyspnoea Scale changed from 1.6 (1.0) at baseline to 1.5 (1.0) at week 24 (p<0.001). CONCLUSION: In this observational study of a Nordic real-life COPD population, treatment with aclidinium was associated with a clinically important improvement in QoL and morning and night-time symptoms, most pronounced in the LAMA naïve group. However, there is still room for improvement in the management of symptomatic COPD patients.

The impact of birth weight on the level of lung function and lung function decline in the general adult population. The Inter99 study.

BACKGROUND: Previous studies have reported an association between low birth weight and low adult lung function, but findings have not been consistent. The aim of this study was to investigate whether birth weight is associated with both the level and the decline in adult lung function in general population. METHODS: The Danish Inter99 study is a population-based intervention study in adults aged 30-60 years, providing information on birth weight and lung function on 4428 participants. Of these, 2931 participants performed spirometry at baseline and at five-year follow-up. Multiple linear regression models were used to examine the association between birth weight and forced expiratory volume in first second (FEV1) and forced vital capacity (FVC) and age-related decline in these variables. Analyses were conducted stepwise including sex, age, adult height, abdominal circumference, birth height, mother's age at birth, parity, prematurity, multiple pregnancy, socioeconomic and lifestyle factors and lung symptoms as covariates. RESULTS: Birth weight was positively associated with spirometric variables. For a 1 kg increase in birth weight, FEV1 increased by 86 ml (CI95%: 34-139) and FVC by 88 ml (CI95%: 27-148). No significant trend was found with regard to the FEV1/FVC ratio. In longitudinal analyses, there was a 0.2% (CI95%: 0.04-0.3) lower decline in FEV1/FVC ratio per year for every 1 kg increase in birth weight, whereas we found no significant association between birth weight and decline in FEV1 and FVC. CONCLUSION: Low birth weight was significantly associated with lower adult FEV1 and FVC but not with the decline in these variables during a 5-year observation. Although FEV1/FVC ratio was not related to birth weight, persons with low birth weight experienced a steeper decline on this index. In general, the magnitude of the association between birth weight and adult lung function was modest.

Observational study to characterise 24-hour COPD symptoms and their relationship with patient-reported outcomes: results from the ASSESS study.

BACKGROUND: Few studies have investigated the 24-hour symptom profile in patients with COPD or how symptoms during the 24-hour day are inter-related. This observational study assessed the prevalence, severity and relationship between night-time, early morning and daytime COPD symptoms and explored the relationship between 24-hour symptoms and other patient-reported outcomes. METHODS: The study enrolled patients with stable COPD in clinical practice. Baseline night-time, early morning and daytime symptoms (symptom questionnaire), severity of airflow obstruction (FEV1), dyspnoea (modified Medical Research Council Dyspnoea Scale), health status (COPD Assessment Test), anxiety and depression levels (Hospital Anxiety and Depression Scale), sleep quality (COPD and Asthma Sleep Impact Scale) and physical activity level (sedentary, moderately active or active) were recorded. RESULTS: The full analysis set included 727 patients: 65.8% male, mean ± standard deviation age 67.2 ± 8.8 years, % predicted FEV1 52.8 ± 20.5%. In each part of the 24-hour day, >60% of patients reported experiencing ≥1 symptom in the week before baseline. Symptoms were more common in the early morning and daytime versus night-time (81.4%, 82.7% and 63.0%, respectively). Symptom severity was comparable for each period assessed. Overall, in the week before baseline, 56.7% of patients had symptoms throughout the whole 24-hour day (3 parts of the day); 79.9% had symptoms in ≥2 parts of the 24-hour day. Symptoms during each part of the day were inter-related, irrespective of disease severity (all p < 0.001). Early morning and daytime symptoms were associated with the severity of airflow obstruction (p < 0.05 for both). Night-time, early morning and daytime symptoms were all associated with worse dyspnoea, health status and sleep quality, and higher anxiety and depression levels (all p < 0.001 versus patients without symptoms in each corresponding period). In each part of the 24-hour day, there was also an association between symptoms and a patient's physical activity level (p < 0.05 for each period). CONCLUSIONS: More than half of patients experienced COPD symptoms throughout the whole 24-hour day. There was a significant relationship between night-time, early morning and daytime symptoms. In each period, symptoms were associated with worse patient-reported outcomes, suggesting that improving 24-hour symptoms should be an important consideration in the management of COPD.

Instruments to assess integrated care: a systematic review.

INTRODUCTION: Although several measurement instruments have been developed to measure the level of integrated health care delivery, no standardised, validated instrument exists covering all aspects of integrated care. The purpose of this review is to identify the instruments concerning how to measure the level of integration across health-care sectors and to assess and evaluate the organisational elements within the instruments identified. METHODS: An extensive, systematic literature review in PubMed, CINAHL, PsycINFO, Cochrane Library, Web of Science for the years 1980-2011. Selected abstracts were independently reviewed by two investigators. RESULTS: We identified 23 measurement instruments and, within these, eight organisational elements were found. No measurement instrument covered all organisational elements, but almost all studies include well-defined structural and process aspects and six include cultural aspects; 14 explicitly stated using a theoretical framework. CONCLUSION AND DISCUSSION: This review did not identify any measurement instrument covering all aspects of integrated care. Further, a lack of uniform use of the eight organisational elements across the studies was prevalent. It is uncertain whether development of a single 'all-inclusive' model for assessing integrated care is desirable. We emphasise the continuing need for validated instruments embedded in theoretical contexts.

A qualitative study of integrated care from the perspectives of patients with chronic obstructive pulmonary disease and their relatives.

BACKGROUND: Disease management programmes have been developed for chronic obstructive pulmonary disease (COPD) to facilitate the integration of care across healthcare settings. The purpose of the present study was to examine the experiences of COPD patients and their relatives of integrated care after implementation of a COPD disease management programme. METHODS: Seven focus groups and five individual interviews were held with 34 patients with severe or very severe COPD and two focus groups were held with eight of their relatives. Data were analysed using inductive content analysis. RESULTS: Four main categories of experiences of integrated care emerged: 1) a flexible system that provides access to appropriate healthcare and social services and furthers patient involvement; 2) the responsibility of health professionals to both take the initiative and follow up; 3) communication and providing information to patients and relatives; 4) coordination and professional cooperation. Most patients were satisfied with their care and raised few criticisms. However, patients with more unstable and severe disease tended to experience more problems. CONCLUSIONS: Participant suggestions for optimizing the integration of healthcare included assigning patients a care coordinator, telehealth solutions for housebound patients and better information technology to support interprofessional cooperation. Further studies are needed to explore these and other possible solutions to problems with integrated care among COPD patients. A future effort in this field should be informed by detailed knowledge of the extent and relative importance of the identified problems. It should also be designed to address variable levels of severity of COPD and relevant comorbidities and to deliver care in ways appropriate to the respective healthcare setting. Future studies should also take health professionals' views into account so that interventions may be planned in the light of the experiences of all those involved in the treatment of COPD patients.

Meta-analysis of routine blood tests as predictors of mortality in COPD.

OBJECTIVE: The purpose of this study was to examine whether routine blood tests can be useful in predicting mortality in COPD patients. METHODS: Eligible studies were found through a search conducted in the PubMed and Embase databases, the Cochrane Library, and the Web of Knowledge. Twelve studies were included for the meta-analysis of five biochemical markers. Pooled odds ratios (ORs), matching 95% confidence intervals (CIs), and p-values for each of the biochemical markers were calculated using the random effect model. RESULTS: The following four examined biochemical markers were shown to be associated with mortality in patients suffering from COPD: anemia (OR=2.62, 95% CI: 1.60; 4.29, p=0.01), hypoalbuminemia (OR=2.90, 95% CI: 1.56; 5.40, p=0.0008), elevated NT-proBNP (OR=7.54, 95% CI: 4.04; 14.10, p<0.00001), and elevated cardiac troponin T (OR=3.10, 95% CI: 1.11; 8.25, p=0.03). hs-CRP was not found to be associated with increased mortality. CONCLUSION: In this study, we found that anemia, hypoalbuminemia, elevated NT-proBNP, and elevated cardiac troponin T were associated with increased mortality in patients suffering from COPD.