A Delphi consensus to identify the key screening tests/questions for a digital neurological examination for epidemiological research.

BACKGROUND: Most neurological diseases have no curative treatment; therefore, focusing on prevention is key. Continuous research to uncover the protective and risk factors associated with different neurological diseases is crucial to successfully inform prevention strategies. eHealth has been showing promising advantages in healthcare and public health and may therefore be relevant to facilitate epidemiological studies. OBJECTIVE: In this study, we performed a Delphi consensus exercise to identify the key screening tests to inform the development of a digital neurological examination tool for epidemiological research. METHODS: Twelve panellists (six experts in neurological examination, five experts in data collection-two were also experts in the neurological examination, and three experts in participant experience) of different nationalities joined the Delphi exercise. Experts in the neurological examination provided a selection of items that allow ruling out neurological impairment and can be performed by trained health workers. The items were then rated by them and other experts in terms of their feasibility and acceptability. RESULTS: Ten tests and seven anamnestic questions were included in the final set of screening items for the digital neurological examination. Three tests and five anamnestic questions were excluded from the final selection due to their low ratings on feasibility. CONCLUSION: This work identifies the key feasible and acceptable screening tests and anamnestic questions to build an electronic tool for performing the neurological examination, in the absence of a neurologist.

eHealth tools to assess the neurological function for research, in absence of the neurologist - a systematic review, part I (software).

BACKGROUND: Neurological disorders remain a worldwide concern due to their increasing prevalence and mortality, combined with the lack of available treatment, in most cases. Exploring protective and risk factors associated with the development of neurological disorders will allow for improving prevention strategies. However, ascertaining neurological outcomes in population-based studies can be both complex and costly. The application of eHealth tools in research may contribute to lowering the costs and increase accessibility. The aim of this systematic review is to map existing eHealth tools assessing neurological signs and/or symptoms for epidemiological research. METHODS: Four search engines (PubMed, Web of Science, Scopus & EBSCOHost) were used to retrieve articles on the development, validation, or implementation of eHealth tools to assess neurological signs and/or symptoms. The clinical and technical properties of the software tools were summarised. Due to high numbers, only software tools are presented here. FINDINGS: A total of 42 tools were retrieved. These captured signs and/or symptoms belonging to four neurological domains: cognitive function, motor function, cranial nerves, and gait and coordination. An additional fifth category of composite tools was added. Most of the tools were available in English and were developed for smartphone device, with the remaining tools being available as web-based platforms. Less than half of the captured tools were fully validated, and only approximately half were still active at the time of data collection. INTERPRETATION: The identified tools often presented limitations either due to language barriers or lack of proper validation. Maintenance and durability of most tools were low. The present mapping exercise offers a detailed guide for epidemiologists to identify the most appropriate eHealth tool for their research. FUNDING: The current study was funded by a PhD position at the University of Groningen. No additional funding was acquired.

Effectiveness of a COVID-19 contact tracing app in a simulation model with indirect and informal contact tracing.

During the COVID-19 pandemic, contact tracing was used to identify individuals who had been in contact with a confirmed case so that these contacted individuals could be tested and quarantined to prevent further spread of the SARS-CoV-2 virus. Many countries developed mobile apps to find these contacted individuals faster. We evaluate the epidemiological effectiveness of the Dutch app CoronaMelder, where we measure effectiveness as the reduction of the reproduction number R. To this end, we use a simulation model of SARS-CoV-2 spread and contact tracing, informed by data collected during the study period (December 2020 - March 2021) in the Netherlands. We show that the tracing app caused a clear but small reduction of the reproduction number, and the magnitude of the effect was found to be robust in sensitivity analyses. The app could have been more effective if more people had used it, and if notification of contacts could have been done directly by the user and thus reducing the time intervals between symptom onset and reporting of contacts. The model has two innovative aspects: i) it accounts for the clustered nature of social networks and ii) cases can alert their contacts informally without involvement of health authorities or the tracing app.

Intensive out-of-hospital coaching for frequently hospitalized COPD patients: a before-after feasibility study.

Background: This study assesses whether out-of-hospital coaching of re-hospitalized, severe COPD patients by specialized respiratory nurses is feasible in terms of cost-effectiveness, implementation, and recipient acceptability. The coaching was aimed at improving patients' health management abilities, motivation for healthy behavior, strengthening the professional and informal care network, stimulating physiotherapy treatment and exercise training, improving knowledge on symptom recognition and medication use, and providing safety and support. Methods: Cost-effectiveness of 6 months of out-of-hospital coaching was assessed based on a before-after intervention design, with real-life data and one-year follow-up. A total of 170 patients were included. Primary (questionnaires, meeting reports) and secondary data (insurance reimbursement data) were collected in one province in the Netherlands. The implementing and recipient acceptability was assessed based on the number of successfully delivered coaching sessions, questionnaire response rate, Patient Reported Experience Measure, and interviews with coaches. Results: Post-intervention, the COPD-related hospitalization rate was reduced by 24%, and patients improved in terms of health status, anxiety, and nutritional status. Patients with a high mental burden and a poor score for health impairment and wellbeing at the start of the intervention showed the greatest reduction in hospitalizations. The coaching service was successfully implemented and considered acceptable by recipients, based on patient and coach satisfaction and clinical use of patient-reported measures. Conclusion: The study demonstrates the value of coaching patients out-of-hospital, with a strong link to primary care, but with support of hospital expertise, thereby adding to previous studies on disease- or self-management support in either primary or secondary care settings. Patients benefit from personal attention, practical advice, exercise training, and motivational meetings, thereby improving health status and reducing the likelihood of re-hospitalization and its associated costs.

Overcoming the Digital Divide for Older Patients With Respiratory Disease: Focus Group Study.

BACKGROUND: The need for and adoption of eHealth programs are growing worldwide. However, access can be limited among patients with low socioeconomic backgrounds, often resulting in a so-called "digital divide" due to a mismatch between eHealth and target populations that can gain benefit. This digital divide can result in unsuccessful eHealth implementations, which is of critical importance to health care. OBJECTIVE: This study evaluated the opinions of elderly patients with asthma and chronic obstructive pulmonary disease (COPD) about an existing pharmacy-based personalized patient web portal that provides medication overview and information on associated diagnoses. The aim was to obtain insights on the common barriers of elderly people when using health-related websites, which can help to improve accessibility. METHODS: This was a cross-sectional qualitative study of a patient panel of the Groningen Research Institute for Asthma and COPD in primary care. Participants were required to be older than 55 years, be Dutch speaking, have no prior experience with the study website, and be diagnosed with a chronic respiratory illness. Two focus groups were created, and they completed a 45-minute session for testing the website and a 120-minute session for semistructured interviews. The focus group sessions were recorded, transcribed verbatim, and analyzed by content analysis. RESULTS: We enrolled 11 patients (9 women) with a mean age of 66 (SD 9) years. Of these, 5 had asthma, 3 had COPD, 2 had asthma-COPD overlap syndrome, and 1 had bronchiectasis. Participants were generally positive about the website, especially the areas providing disease-related information and the medication overview. They appreciated that the website would enable them to share this information with other health care providers. However, some difficulties were reported with navigation, such as opening a new tab, and others reported that the layout of the website was difficult either because of visual impairments or problems with navigation. It was also felt that monitoring would only be relevant if it is also checked by health care professionals as part of a treatment plan. Participants mentioned few privacy or safety concerns. CONCLUSIONS: It is feasible to develop websites for elderly patients; however, developers must take the specific needs and limitations of elderly people into account (eg, navigation problems, poor vision, or poor hand-eye coordination). The provision of information appears to be the most important aspect of the website, and as such, we should endeavor to ensure that the layout and navigation remain basic and accessible. Patients are only motivated to use self-management applications if they are an integrated part of their treatment. The usability of the website can be improved by including older people during development and by implementing design features that can improve accessibility in this group.

The Adoption of a COVID-19 Contact-Tracing App: Cluster Analysis.

BACKGROUND: During the COVID-19 pandemic, there was limited adoption of contact-tracing apps (CTAs). Adoption was particularly low among vulnerable people (eg, people with a low socioeconomic position or of older age), while this part of the population tends to have lesser access to information and communication technology and is more vulnerable to the COVID-19 virus. OBJECTIVE: This study aims to understand the cause of this lagged adoption of CTAs in order to facilitate adoption and find indications to make public health apps more accessible and reduce health disparities. METHODS: Because several psychosocial variables were found to be predictive of CTA adoption, data from the Dutch CTA CoronaMelder (CM) were analyzed using cluster analysis. We examined whether subgroups could be formed based on 6 psychosocial perceptions (ie, trust in the government, beliefs about personal data, social norms, perceived personal and societal benefits, risk perceptions, and self-efficacy) of (non)users concerning CM in order to examine how these clusters differ from each other and what factors are predictive of the intention to use a CTA and the adoption of a CTA. The intention to use and the adoption of CM were examined based on longitudinal data consisting of 2 time frames in October/November 2020 (N=1900) and December 2020 (N=1594). The clusters were described by demographics, intention, and adoption accordingly. Moreover, we examined whether the clusters and the variables that were found to influence the adoption of CTAs, such as health literacy, were predictive of the intention to use and the adoption of the CM app. RESULTS: The final 5-cluster solution based on the data of wave 1 contained significantly different clusters. In wave 1, respondents in the clusters with positive perceptions (ie, beneficial psychosocial variables for adoption of a CTA) about the CM app were older (P<.001), had a higher education level (P<.001), and had higher intention (P<.001) and adoption (P<.001) rates than those in the clusters with negative perceptions. In wave 2, the intention to use and adoption were predicted by the clusters. The intention to use CM in wave 2 was also predicted using the adoption measured in wave 1 (P<.001, ß=-2.904). Adoption in wave 2 was predicted by age (P=.022, exp(B)=1.171), the intention to use in wave 1 (P<.001, exp(B)=1.770), and adoption in wave 1 (P<.001, exp(B)=0.043). CONCLUSIONS: The 5 clusters, as well as age and previous behavior, were predictive of the intention to use and the adoption of the CM app. Through the distinguishable clusters, insight was gained into the profiles of CM (non)intenders and (non)adopters. TRIAL REGISTRATION: OSF Registries osf.io/cq742; https://osf.io/cq742.

eHealth tools to assess neurological function: a systematic review protocol for a mapping exercise.

INTRODUCTION: Population-based epidemiological studies investigating risk/protective factors are outlining prevention strategies for neurological conditions that often do not have effective treatment. However, ascertaining neurological outcomes can be a time consuming and expensive process, often requiring specialised personnel and/or equipment. Thus, collecting neurological data on a large scale has been an ongoing challenge for clinicians and researchers alike. The development of new technology and the emergence of several opportunities to adapt it to the health research and practice (eHealth) can be a promising solution to this problem. Several neurological eHealth tools have been developed, with many others being currently planned. METHODS AND ANALYSIS: We propose a systematic review mapping the available eHealth tools for assessing the different aspects of neurological function. The search aims at identifying studies published in peer-reviewed journals, which focused on the development or implementation of eHealth for assessing neurological signs or symptoms. Four engine databases are being considered (PubMed, EBSCOhost, Web of Science and Scopus), and data extraction will follow a process aimed at classifying them by their characteristics and purposes. ETHICS AND DISSEMINATION: This mapping exercise will be made available to researchers in order to aid them in successfully ascertaining neurological outcomes in large population-based epidemiological studies. Given the nature of this study, no ethical clearance was needed to conduct the review.

Evaluation of a Digital Self-management Platform for Patients With Chronic Illness in Primary Care: Qualitative Study of Stakeholders' Perspectives.

BACKGROUND: Population aging and multimorbidity has led to increasing chronic care needs associated with new challenges in managing growing costs, rising health care professional workloads, and the adoption of rigorous guidelines. These issues could all benefit from greater digitalization and a more patient-centered approach to chronic care, a situation brought to the fore by the COVID-19 pandemic. Little is known about real-life use in primary care. OBJECTIVE: This study aimed to explore the views, thoughts, usability, and experiences concerning a recently introduced digital self-care platform for chronic conditions in 3 Dutch primary care practices. METHODS: We conducted an explorative study combining questionnaires and interviews among patients and general practitioners from 3 general practices that used the digital platform. Questionnaires were sent to patients in each practice to seek the views and experiences of both patient nonusers (n=20) and patient users (n=58) of the platform, together with standardized questionnaires about illness perception and quality of life. In addition, patients (n=15) and general practitioners (n=4) who used the platform took part in semistructured interviews. We transcribed interviews verbatim and performed qualitative content analysis using a deductive approach. The results of the questionnaires were analyzed with descriptive analysis. RESULTS: Among patients who had not actively used the platform but had received an explanation, only 35% (7/20) would recommend its use due to concerns over communication and handling. However, this percentage increased to 76.3% (45/59) among the people who actively used the platform. Interviews with patients and general practitioners who used the platform uncovered several key benefits, including reduced time requirements, reduced workload, improved care quality, and improved accessibility due to the greater patient-centeredness and use of different communication tools. In addition, the self-management tool led to greater patient autonomy and empowerment. Although users considered the platform feasible, usable, and easy to use, some technical issues remained and some patients expressed concerns about the reduction in human contact and feedback. CONCLUSIONS: The overall experience and usability of the platform was good. Support for the online self-management platform for chronic care increased when patients actively used the tool and could experience or identify important advantages. However, patients still noted several areas for improvement that need to be tackled in future iterations. To ensure benefit in the wider population, we must also evaluate this platform in cohorts with lower digital and health literacy.

Pharmacology, particle deposition and drug administration techniques of intranasal corticosteroids for treating allergic rhinitis.

This review presents an overview of the available literature regarding intranasal corticosteroids (INCs) for the treatment of allergic rhinitis (AR). Various treatment options exist for AR including INCs, antihistamines and leucotriene antagonists. INCs are considered to be the most effective therapy for moderate-to-severe AR, as they are effective against nasal and ocular symptoms and improve quality of life. Their safety has been widely observed. INCs are effective and safe for short-term use. Local adverse events are observed but generally well-tolerated. The occurrence of (serious) systemic adverse events is unlikely but cannot be ruled out. There is a lack of long-term safety data. INC may cause serious eye complications. The risk of INCs on the hypothalamic-pituitary-adrenal axis, on bone mineral density reduction or osteoporosis and on growth in children, should be considered during treatment. Pharmacological characteristics of INCs (e.g. the mode of action and pharmacokinetics) are well known and described. We sought to gain insight into whether specific properties affect the efficacy and safety of INCs, including nasal particle deposition, which the administration technique affects. However, advances are lacking regarding the improved understanding of the effect of particle deposition on efficacy and safety and the effect of the administration technique. This review emphasizes the gaps in knowledge regarding this subject. Advances in research and health care are necessary to improve care for patients with AR.

Prioritising primary care respiratory research needs: results from the 2020 International Primary Care Respiratory Group (IPCRG) global e-Delphi exercise.

Respiratory diseases remain a significant cause of global morbidity and mortality and primary care plays a central role in their prevention, diagnosis and management. An e-Delphi process was employed to identify and prioritise the current respiratory research needs of primary care health professionals worldwide. One hundred and twelve community-based physicians, nurses and other healthcare professionals from 27 high-, middle- and low-income countries suggested 608 initial research questions, reduced after evidence review by 27 academic experts to 176 questions covering diagnosis, management, monitoring, self-management and prognosis of asthma, COPD and other respiratory conditions (including infections, lung cancer, tobacco control, sleep apnoea). Forty-nine questions reached 80% consensus for importance. Cross-cutting themes identified were: a need for more effective training of primary care clinicians; evidence and guidelines specifically relevant to primary care, adaption for local and low-resource settings; empowerment of patients to improve self-management; and the role of the multidisciplinary healthcare team.

Effectiveness of Telemonitoring for Respiratory and Systemic Symptoms of Asthma and COPD: A Narrative Review.

Asthma and chronic obstructive pulmonary diseases (COPD) are highly prevalent chronic lung diseases that require ongoing self-management, which itself is often suboptimal. Therefore, telemonitoring has been used to help patients measure their symptoms, share data with healthcare providers and receive education and feedback to improve disease management. In this study, we conducted a narrative review of recent evidence on the effectiveness of telemonitoring for asthma and COPD in adults. Of the thirteen identified studies, eleven focused on COPD and two focused on asthma. All studies were reviewed, and effects were compared between intervention and care as usual groups. Of the study interventions, seven showed a positive outcome on at least one outcome measure, and six had no significant results on any of the outcome measures. All of the interventions with a positive outcome included an educational component, while only one of the six interventions without positive outcomes included an educational component. We conclude that telemonitoring interventions for asthma and COPD seem more effective if they included an educational component regarding different aspects of self-management.

Expectations and Perceptions of Dutch Pharmacy Staff Regarding a New Framework for Continence Care: A Focus Group Study.

Based on complaints that patients with urinary incontinence were not receiving the correct medical aids, the Dutch Ministry of Health, Wellbeing, and Sports requested further exploration. This resulted in a new framework based on considering individual activities of daily living when providing continence products. We aimed to explore the expectations of pharmacy staff regarding this new framework for continence care in the Netherlands and to establish the facilitators and barriers associated with that care. In total, 15 participants from 7 different pharmacies participated in 2 focus groups. Data analysis was by thematic content analysis. Pharmacy employees were positive about the idea of considering individual daily activities when providing continence products in the new framework, but they did have some reservations about the feasibility of implementation in daily practice. Barriers to optimal continence care included low reimbursement for patients with incontinence, especially with non-standard needs, and poor communication between the various stakeholders in continence care. Efforts must be extended to review the current reimbursement system and to change the policies and information provided by stakeholders in continence care, before the new framework will make a real impact in clinical practice.

Rational selection of inhalation devices in the treatment of chronic obstructive pulmonary disease by means of the System of Objectified Judgement Analysis (SOJA).

OBJECTIVES: The large number of available medicines and devices makes it almost impossible to have sufficient knowledge of each individual medicine and device, especially for general practitioners. This may lead to suboptimal treatment, more exacerbations, hospitalisations and higher treatment costs. Reducing the number of medicines and devices, based on rational criteria, allows physicians and pharmacists to build experience with a more limited set of medicines and to standardise the inhalation instructions. METHODS: In this study inhalers are compared by means of the System of Objectified Judgement Analysis (SOJA) method. The following selection criteria were applied: uniformity in device, number of steps per inhalation, risk of errors, hygienic aspects, feedback mechanism, and risk of inhalation with an empty inhaler. RESULTS: Substantial differences were seen in the overall scores, with the Ellipta device showing the highest score, followed by Diskus/Accuhaler, Genuair and Nexthaler. Several devices require more or less identical techniques, such Ellipta and Diskus/Accuhaler as well as Genuair and Novolizer. When patients use these devices in combination this increases their uniformity, because additional medicines become available for the devices: starting therapy with Diskus or Novolizer and follow-up with Ellipta or Genuair. The resistance of Respimat and Breezhaler is lower than that of other devices, which makes these devices suitable for patients who cannot generate sufficient inhalation flow. CONCLUSIONS: A substantial reduction of inhalers, combined with optimal and standardised instructions, should improve the care of patients with chronic obstructive pulmonary disease.

The Quality of Instructional YouTube Videos for the Administration of Intranasal Spray: Observational Study.

BACKGROUND: Allergic rhinitis is a common disorder affecting both children and adults. Recommended treatment consists of intranasal corticosteroid spray administration, but only few patients administer the nasal spray in the correct technical manner. A wrong administration technique may result in side effects and affect the efficacy and adherence, thus making accurate administration instructions indispensable. Unfortunately, information about intranasal drug administration is generally not explained accurately, thereby leading to confusion among patients and inaccuracy in the self-administration of drugs. OBJECTIVE: In this study, we analyzed instructional videos available on YouTube for the administration of nasal sprays for allergic rhinitis. Our aim was to determine if the videos provided instructions in accordance with the standardized nationwide patient protocol in the Netherlands for intranasal spray administration. METHODS: Instructional videos for the administration of aqueous formulations of nasal spray for allergic rhinitis were found on YouTube. All videos were reviewed by 2 researchers and scored using the instructions from the Dutch standardized protocol. Correct instructions were given a score of 1, while incorrect or missing instructions were given a score of 0. The interrater reliability using Cohen ĸ was used to determine the differences in the scores between the researchers. RESULTS: We identified 33 YouTube videos made by different health care professionals and pharmaceutical companies around the world. None of the videos displayed all the steps correctly, while 5 of the 33 (15%) videos displayed over 75% of the steps correctly. The median score of the correctly displayed steps was 11 out of 19 (range 2-17, IQR 6). The interrater reliability using Cohen ĸ was statistically significant (range 0.872-1.00, P<.001). The steps "neutral position of the head," "breathing out through the mouth," and "periodically cleaning with water" scored the lowest and were incorrectly displayed in 28 (85%), 28 (85%), and 30 (91%) of the 33 videos, respectively. CONCLUSIONS: The findings of our study revealed that only few instructional videos on YouTube provided correct instructions for the administration of nasal sprays to patients. The inaccuracy of the instructions for nasal spray administration in the majority of the videos may lead to confusion in patients and incorrect use of nasal sprays. In the future, it is important to make evidence-based instructional videos that show patients the correct technique of nasal spray administration. TRIAL REGISTRATION: Not applicable.

Prevalence of Asthma Characteristics in COPD Patients in a Dutch Well-Established Asthma/COPD Service for Primary Care.

Purpose: Primary care COPD guidelines indicate that COPD patients with asthma characteristics should be treated as having asthma. This study aims to describe the prevalence of asthma characteristics in patients with a pulmonologist-confirmed working diagnosis of COPD or ACO. Patients and Methods: This retrospective cross-sectional study used real-life data (collected between 2007 and 2017) from a Dutch asthma/COPD-service, a structured web-based system in which pulmonologists support general practitioners in their diagnosis of patients with suspicion of obstructive lung disease. The prevalence of asthma characteristics (history of asthma, atopy, symptoms, and reversibility) and blood eosinophil (Eos) counts were assessed in patients with a working diagnosis of COPD or ACO. Results: Of the 14,141 patients, ≥40 years in the dataset, 4475 (31.6%) were diagnosed with asthma, 3532 (25.0%) with COPD, and 1276 (9.0%) with ACO. Asthma characteristics were present in 65.6% (n=1956) of the COPD and 90.9% (n=1059) of the ACO patients. Eos counts of ≥ 300 cells per µL were found in 35.7% (n=924) of the COPD patients and 35.3% (n=341) of the ACO patients. Conclusion: In this group of COPD and ACO patients remotely diagnosed by pulmonologists, a substantial proportion would be considered to have asthma characteristics according to the guidelines. This may explain the high number of inhaled corticosteroid (ICS) prescriptions found in primary care COPD patients. Prospective studies are necessary to identify patients who may or may not benefit from ICS containing treatment. Hence, personalized care in primary care can be optimized.

Wrong inhalation technique is associated to poor asthma clinical outcomes. Is there room for improvement?

PURPOSE OF REVIEW: The long-term goals of asthma management are to control symptoms and to reduce the risk of exacerbations. Inhaled medication is the cornerstone of pharmacological treatment for asthma; therefore, good inhalation technique is the key for asthma management. However, up to 70% of asthma patients do not use their inhalers correctly. There is evidence on how poor inhalation technique is associated to poor asthma control. The purpose of this review is to present the most recent research in this field to help clinicians understand the importance of proper inhalers use and the possible interventions to optimize patients' inhalation technique. RECENT FINDINGS: New evidence on how poor inhaler technique and specific critical errors are significantly associated to poor asthma control and exacerbations and how this negative impact could be improved by optimizing device selection, enhancing shared decision-making and giving more importance to education, both for patients and healthcare professionals. New devices and additional tools might help patients to achieve the correct inhaler technique and could form the basis of simplified educational interventions. SUMMARY: There is an urgent need for specific interventions including new educational strategies to minimize the negative effects of wrong inhalation technique in asthma clinical outcomes.

Assessing the Needs and Perspectives of Patients With Asthma and Chronic Obstructive Pulmonary Disease on Patient Web Portals: Focus Group Study.

BACKGROUND: As accessibility to the internet has increased in society, many health care organizations have developed patient Web portals (PWPs), which can provide a range of self-management options to improve patient access. However, the available evidence suggests that they are used inefficiently and do not benefit patients with low health literacy. Asthma and chronic obstructive pulmonary disease (COPD) are common chronic diseases that require ongoing self-management. Moreover, patients with COPD are typically older and have lower health literacy. OBJECTIVE: This study aimed to obtain and present an overview of patients' perspectives of PWPs to facilitate the development of a portal that better meets the needs of patients with asthma and COPD. METHODS: We performed a focus group study using semistructured interviews in 3 patient groups from the north of the Netherlands who were recruited through the Dutch Lung Foundation. Each group met 3 times for 2 hours each at a 1-week interval. Data were analyzed with coding software, and patient descriptors were analyzed with nonparametric tests. The consolidated criteria for reporting qualitative research were followed when conducting the study. RESULTS: We included 29 patients (16/29, 55% male; mean age 65 [SD 10] years) with COPD (n=14), asthma-COPD overlap (n=4), asthma (n=10), or other respiratory disease (n=1). There was a large variation in the internet experience; some patients hardly used the internet (4/29, 14%), whereas others used internet >3 times a week (23/29, 79%). In general, patients were positive about having access to a PWP, considering access to personal medical records as the most important option, though only after discussion with their physician. A medication overview was considered a useful option. We found that communication between health care professionals could be improved if patients could use the PWP to share information with their health care professionals. However, as participants were worried about the language and usability of portals, it was recommended that language should be adapted to the patient level. Another concern was that disease monitoring through Web-based questionnaire use would only be useful if the results were discussed with health care professionals. CONCLUSIONS: Participants were positive about PWPs and considered them a logical step. Today, most patients tend to be better educated and have internet access, while also being more assertive and better informed about their disease. A PWP could support these patients. Our participants also provided practical suggestions for implementation in current and future PWP developments. The next step will be to develop a portal based on these recommendations and assess whether it meets the needs of patients and health care providers.

Associations between chronic comorbidity and exacerbation risk in primary care patients with COPD.

BACKGROUND: COPD often coexists with chronic conditions that may influence disease prognosis. We investigated associations between chronic (co)morbidities and exacerbations in primary care COPD patients. METHOD: Retrospective cohort study based on 2012-2013 electronic health records from 179 Dutch general practices. Comorbidities from patients with physician-diagnosed COPD were categorized according to International Classification of Primary Care (ICPC) codes. Chi-squared tests, uni- and multivariable logistic, and Cox regression analyses were used to study associations with exacerbations, defined as oral corticosteroid prescriptions. RESULTS: Fourteen thousand six hundred three patients with COPD could be studied (mean age 67 (SD 12) years, 53% male) for two years. At baseline 12,826 (88%) suffered from ≥1 comorbidities, 3263 (22%) from ≥5. The most prevalent comorbidities were hypertension (35%), coronary heart disease (19%), and osteoarthritis (18%). Several comorbidities showed statistically significant associations with frequent (i.e., ≥2/year) exacerbations: heart failure (odds ratio [OR], 95% confidence interval: 1.72; 1.38-2.14), blindness & low vision (OR 1.46; 1.21-1.75), pulmonary cancer (OR 1.85; 1.28-2.67), depression 1.48; 1.14-1.91), prostate disorders (OR 1.50; 1.13-1.98), asthma (OR 1.36; 1.11-1.70), osteoporosis (OR 1.41; 1.11-1.80), diabetes (OR 0.80; 0.66-0.97), dyspepsia (OR 1.25; 1.03-1.50), and peripheral vascular disease (OR 1.20; 1.00-1.45). From all comorbidity categories, having another chronic respiratory disease beside COPD showed the highest risk for developing a new exacerbation (Cox hazard ratio 1.26; 1.17-1.36). CONCLUSION: Chronic comorbidities are highly prevalent in primary care COPD patients. Several chronic comorbidities were associated with having frequent exacerbations and increased exacerbation risk.

Development of a diagnostic decision tree for obstructive pulmonary diseases based on real-life data.

The aim of this study was to develop and explore the diagnostic accuracy of a decision tree derived from a large real-life primary care population. Data from 9297 primary care patients (45% male, mean age 53±17 years) with suspicion of an obstructive pulmonary disease was derived from an asthma/chronic obstructive pulmonary disease (COPD) service where patients were assessed using spirometry, the Asthma Control Questionnaire, the Clinical COPD Questionnaire, history data and medication use. All patients were diagnosed through the Internet by a pulmonologist. The Chi-squared Automatic Interaction Detection method was used to build the decision tree. The tree was externally validated in another real-life primary care population (n=3215). Our tree correctly diagnosed 79% of the asthma patients, 85% of the COPD patients and 32% of the asthma-COPD overlap syndrome (ACOS) patients. External validation showed a comparable pattern (correct: asthma 78%, COPD 83%, ACOS 24%). Our decision tree is considered to be promising because it was based on real-life primary care patients with a specialist's diagnosis. In most patients the diagnosis could be correctly predicted. Predicting ACOS, however, remained a challenge. The total decision tree can be implemented in computer-assisted diagnostic systems for individual patients. A simplified version of this tree can be used in daily clinical practice as a desk tool.

Morning and night symptoms in primary care COPD patients: a cross-sectional and longitudinal study. An UNLOCK study from the IPCRG.

COPD symptoms show a diurnal variability. However, morning and night variability has generally not been taken into consideration in disease management plans. The aims of this study were to cross-sectionally assess morning and night symptom prevalence and correlation with health status and disease severity in COPD, and to determine to what extent they could predict longitudinal outcomes, exacerbations and health status. A further aim is to explore whether the CCQ is able to depict this morning/night symptomatology. We included 2,269 primary care COPD patients (58% male, 49% current smokers, with a mean age of 65±11 years) from a Dutch Asthma/COPD service. Spirometry, patient history, the Clinical COPD Questionnaire(CCQ) and the Asthma Control Questionnaire(ACQ) were assessed; we used the latter to evaluate morning (question 2) and night symptoms (question 1). A total of 1159 (51.9%) patients reported morning symptoms (ACQ question 2>0) and 879 (39.4%) had night complaints (ACQ question 1>0). Patients with morning/night symptoms were mostly smokers and had on average poorer lung function, higher CCQ scores and used more rescue inhalers (P<0.0001). Patients using long-acting muscarinic antagonists (LAMAs) had less night symptoms, showing a possible favourable effect. Only a small proportion of stable or slightly unstable patients (CCQ total scores <2) had severe morning symptoms (ACQ 2⩾4: n=19, 1.1%) or severe night symptoms (ACQ 1⩾4: n=11, 0.7%). Night symptoms seemed to predict future exacerbations; however, baseline exacerbations were the strongest predictors (n=346, OR:4.13, CI: 2.45-6.95, P<0.000). Morning symptoms increased the odds of poor health status at follow-up (n=346, OR:12.22, CI:4.76-31.39, P<0.000). Morning and night symptoms in COPD patients are common, and they are associated with poor health status and predicted future exacerbations. Our study showed that patients with morning/night symptoms have higher scores in CCQ, and therefore we do not really miss patients with high morning/night symptomatology when we only measure CCQ. Severe morning symptoms predicted worsening of COPD health status.