The feasibility and impact of implementing a computer-guided consultation to target health inequality in Asthma.

Greater Manchester has a greater prevalence and worse asthma outcomes than the national average. This study aims to evaluate a digital approach to primary care asthma management and in particular the initial impact of implementing Clinical Decision Support System software in the form of a computer-guided consultation (CGC) in the setting of primary care asthma reviews in deprived areas of Greater Manchester. The CGC (LungHealth Ltd) is an intelligent decision support system ensuring accurate guideline-based staging of asthma and assessment of asthma control with the software subsequently prompting guideline-standard management. Patients on asthma registers in Greater Manchester Primary Care Networks were identified and underwent remote review by nursing staff using the CGC linked directly to the GP clinical system. Three-hundred thirty-eight patients (mean age 59 (SD 17) years; 60% Female) were reviewed. The CGC reported the patient's asthma control to be "Good" in 22%, "Partial" in 6% and "Poor" in 72%. ACT scores were significantly higher in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. The number of steroid courses and hospital admissions in the previous 12 months was significantly lower in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. Nineteen percent were found not to have a personalised asthma management plan during CGC review, which was alerted by the CGC and subsequently, all but 3 patients had this created on review completion (McNemar's test; p < 0.001). 5% were found not to have been prescribed regular inhaled steroid therapy resulting in the operator being alerted by the CGC in all cases. Overall, 44% underwent alteration in asthma therapy following the CGC review with 82% of these representing treatment escalation. An end-to-end digital service solution is feasible for Asthma within primary care and the utilisation of a CGC when conducting primary care asthma reviews increases implementation of guideline-level management thus addressing healthcare inequality while enabling identification of "high risk" asthma patients and guiding appropriate therapy escalation and de-escalation.

Reduced risk of emergency admission for colorectal cancer associated with the introduction of bowel cancer screening across England: a retrospective national cohort study.

AIM: We wanted to find out if roll-out of the bowel cancer screening programme (BCSP) across England was associated with a reduced risk of emergency hospital admission for people presenting with colorectal cancer (CRC) during this period. METHOD: This is a retrospective cohort study of 27 763 incident cases of CRC over a 1-year period during the roll-out of screening across parts of England. The primary outcome was the number of emergency (unplanned) hospital admissions during the diagnostic pathway. The primary exposure was to those living in an area where the BCSP was active at the time of diagnosis. Patients were categorized into three exposure groups: BCSP not active (reference group), BCSP active < 6 months or BCSP active ≥ 6 months. RESULTS: The risk of emergency admission for CRC in England was associated with increasing age, female gender, comorbidity and social deprivation. After adjusting for these factors in logistic regression, the odds ratio (OR) for emergency admission in patients diagnosed ≥ 6 months after the start-up of local screening was 0.83 (CI 0.76-0.90). The magnitude of risk reduction was greatest for cases of screening age (OR 0.75; CI 0.63-0.90) but this effect was apparent also for cases outside the 60-69-year age group (OR 0.85; CI 0.77-0.94). Living in an area with active BCSP conferred no reduction in risk of emergency admission for people diagnosed with oesophagogastric cancer during the same period. CONCLUSION: The start-up of bowel cancer screening in England was associated with a substantial reduction in the risk of emergency admission for CRC in people of all ages. This suggests that the roll-out of the programme had indirect benefits beyond those related directly to participation in screening.

Commissioning for COPD care: a new, recordable metric that supports the patient interest.

BACKGROUND: Healthcare metrics have been used to drive improvement in outcome and delivery in UK hospital stroke and cardiac care. This model is attractive for chronic obstructive pulmonary disease (COPD) care because of disease frequency and the burden it places on primary, secondary and integrated care services. METHODS: Using 'hospital episode statistics' (UK 'coding'), we examined hospital 'bed days/1000 population' in 150 UK Primary Care Trusts (PCTs) during 2006-07 and 2007-08. Data were adjusted for COPD prevalence. We looked at year-on-year consistency and factors which influenced variation. RESULTS: There were 248 996 COPD admissions during 2006-08. 'Bed days/1000 PCT population' was consistent between years (r = 0.87; P < 0.001). There was a >2-fold difference in bed days between the best and worst performing PCTs which was primarily a consequence of variation in emergency admission rate (P < 0.001) and proportion of emergency admissions due to COPD (P < 0.001) and to only a lesser extent length of hospital stay (P < 0.001). CONCLUSIONS: Bed days/1000 population appears a useful annual metric of COPD care quality. Good COPD care keeps patients active and out of hospital and requires co-ordinated action from both hospital and community services, with an important role for integrated care. This metric demonstrates that current care is highly variable and offers a measurable target to commission against.

Use of mortality within 30 days of a COPD hospitalisation as a measure of COPD care in UK hospitals.

Mortality rate has been proposed as a metric of hospital chronic obstructive pulmonary disease (COPD) care in light of variation seen in national COPD audits. Using Hospital Episode Statistics (hospital 'coding') we examined 30-day mortality after COPD hospitalisation in 150 UK hospitals during 2006-2007 and 2007-2008. Mean and median 30-day mortalities were similar each year but the coefficient of variation was >20% and hospitals could change from a low or high quartile to the median by chance. We could not detect any reasons for hospitals being at the extremes. 30-day mortality after COPD hospitalisation is a complex variable and unlikely to be useful as a primary annual COPD metric.

Admissions to hospital with exacerbations of chronic obstructive pulmonary disease: Effect of age related factors and service organisation.

BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) have a high rate of mortality which gets worse with advancing age. It is unknown whether this is due to age related deficiencies in process of care. A study was undertaken in patients with COPD exacerbations admitted to UK hospitals to assess whether there were age related differences in the process of care that might affect outcome, and whether different models of care affected process and outcome. METHODS: 247 hospital units audited activity and outcomes (inpatient death, death within 90 days, length of stay (LOS), readmission within 90 days) for 40 consecutive COPD exacerbation admissions in autumn 2003. Logistic regression methods were used to assess relationships between process and outcome at p < 0.001. RESULTS: 7514 patients (36% aged > or = 75 years) were included. Patients aged > or = 75 years were less likely to have blood gases documented, to have FEV1 recorded, or to be given systemic corticosteroids. Those admitted under care of the elderly (CoE) physicians were less likely to enter early discharge schemes or to receive non-invasive ventilation when acidotic. Overall inpatient and 90 day mortality was 7.4% and 15.3%, respectively. Inpatient and 90 day adjusted odds mortality rates for those aged > or = 85 years (versus < or = 65 years) were 3.25 and 2.54, respectively. Mortality was unaffected by admitting physician (CoE v general v respiratory). Age predicted LOS but not readmission. Age related deficiencies in process of care did not predict inpatient or 90 day mortality, readmission, or LOS. CONCLUSIONS: Management of COPD exacerbations varies with age in UK hospitals. Inpatient and 90 day mortality is approximately three times higher in very elderly patients with a COPD exacerbation than in younger patients. Age related deficiencies in the process of care were not associated with mortality, but it is likely that they represent poorer quality of care and patient experience. Recommended standards of care should be applied equally to elderly patients with an exacerbation of COPD.

UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation.

BACKGROUND: Acute chronic obstructive pulmonary disease (COPD) exacerbations use many hospital bed days and have a high rate of mortality. Previous audits have shown wide variability in the length of stay and mortality between units not explained by patient factors. This study aimed to explore associations between resources and organisation of care and patient outcomes. METHODS: 234 UK acute hospitals each prospectively identified 40 consecutive acute COPD admissions, documenting process of care and outcomes from a retrospective case note audit. Units also completed a resources and organisation of care proforma. RESULTS: Data for 7529 patients were received. Inpatient mortality was 7.4% and mortality at 90 days was 15.3%; the readmission rate was 31.4%. Mean length of stay for discharged patients was 8.7 days (median 6 days). Wide variation was observed in all outcomes between hospitals. Both inpatient mortality (odds ratio (OR) 0.67, CI 0.50 to 0.90) and 90 day mortality (OR 0.75, CI 0.60 to 0.94) were associated with a staff ratio of four or more respiratory consultants per 1000 hospital beds. The length of stay was reduced in units with more respiratory consultants, better organisation of care scores, an early discharge scheme, and local COPD management guidelines. CONCLUSIONS: Units with more respiratory consultants and better quality organised care have lower mortality and reduced length of hospital stay. This may reflect unit resource richness. Dissemination of good organisational practice and recruitment of more respiratory specialists offers the potential for improved outcomes for hospitalised COPD patients.

Stroke unit care and outcome: results from the 2001 National Sentinel Audit of Stroke (England, Wales, and Northern Ireland).

BACKGROUND AND PURPOSE: Stroke unit care is one of the most powerful interventions available to help stroke patients. There are limited data available to assess the impact of stroke units in routine clinical practice outside randomized clinical trials. This article uses data from the 2001 to 2002 National Stroke Audit to assess the effectiveness of stroke unit care in England, Wales, and Northern Ireland in delivering effective processes of care and in reducing case fatality and disability. METHODS: An observational study of the organization, structure, process of care, and outcomes for stroke in 2001. Case fatality after stroke in England was compared using data from the audit and routinely collected data from the Department of Health. 240 hospitals (196 Trusts) from England, Wales, and Northern Ireland took part in the 2001 to 2002 National Stroke Audit, a response rate of >95%. These sites assessed a total of 8200 patients using the Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: The availability of stroke unit care varies hugely across the country. Case fatality after stroke was higher in Trusts with least availability of stroke unit care. These differences persisted after control for case mix. The process of care was better for patients managed on stroke units compared with other settings. Overall, the risk of death for patients who received stroke unit care was estimated to be approximately 75% that of the risk for those having no stroke unit care (95% CI, 60 to 90). CONCLUSIONS: Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland reduces case fatality by approximately 25%, which is in line with the figures obtained from systematic analysis of stroke unit trial data.

A prospective study of the practical issues of local involvement in national audit of COPD.

RATIONALE, AIMS AND OBJECTIVES: Variation in quality of local services is of great concern to the government and public. National audit is an important means of providing data of comparative performance but is hampered at local level by poor methodology including audit design, standard setting and data collection tools. A pilot audit of the hospital care of patients admitted with acute chronic obstructive pulmonary disease (COPD) was performed in preparation for a national audit programme and was designed and supported by experts. It was hoped to overcome these barriers. We report a prospective evaluation of the practical issues involved in local participation of hospital audit of COPD care within a national framework. METHODS: Hospitals were recruited to the study by random selection and voluntary participation. A clinical audit study was completed over an 8-week period immediately followed by a survey of clinicians and audit staff to identify positive and negative issues of participation and the process required to achieve a successful outcome. RESULTS: Forty-one hospitals were invited to participate, 26 (63%) accepted, and four others volunteered to meet the target of 30 enrolled centres. Reasons cited for non-participation were of inadequate resources amongst either clinicians or audit departments or prior engagement in other national or local audit schemes. Following completion of the audit most (81%) participating units reported it was a useful exercise and were willing to be involved in future audits. Negative aspects of involvement included the lack of dedicated time and manpower for audit, poor information technology and inadequate systems for identifying patient diagnoses either at admission or at discharge and incomplete case note entries. Methodological issues such as study design and data collection tools were not cited as important barriers to participation. CONCLUSION: There is local willingness to be involved in national audit of hospital care of COPD and central provision of expert design of methods and tools may reduce some audit barriers. Nevertheless, priority must be given to improving resources identified to support audit and in improving methods and systems for data capture. These issues appear to be important in most units and represent a potentially serious barrier to achieving widespread local involvement in a national audit programme of COPD care and may also apply to other national audits designed to provide comparative assessment of National Health Service services.

National clinical sentinel audit of evidence-based prescribing for older people.

OBJECTIVES: To audit the performance of hospitals in evidence-based prescribing. SETTING: All hospitals in England were invited to participate. The audit was completed in 62 hospitals. SUBJECTS: Prescribing and clinical data were collected on 100 consecutive medical inpatients aged >/= 65 years at each site, enabling evaluation of eight prescribing indicators before and after intervention. The data were collected using a specifically designed database. INTERVENTIONS: The results of the first audit were available immediately from the software and a national report with locally identifiable information was returned to hospitals. Hospitals were encouraged to design and deliver their own intervention strategy. A questionnaire was sent to all hospitals to document prioritization of indicators. RESULTS: Generic names were used for 36 061 (82.6%) in 1999 and 39 188 (86.4)% in 2000. In 1999, 50% (3074) of patients had documentation of allergy status. This increased to 60% (3684) in 2000. For 21.2% of patients prescribed paracetamol in 1999 and 18.1% in 2000, the prescription was written such that it was possible to exceed the maximum recommended dose of 4 g in 24 hours. Long-acting hypoglycaemic drugs were prescribed to 29 patients in 1999 and 20 patients in 2000. Anti-thrombotics were used appropriately for 54% (520/966) of patients in atrial fibrillation in the first audit and 57% (579/1019) in the second audit. The appropriate use of aspirin increased from 91% (595/651) to 94% (725/772) and the appropriate use of benzodiazepines dropped from 49% (537/1088) to 47% (460/966) between the audits. For three indicators, the allocating of a high priority translated into a bigger improvement between the audits. CONCLUSIONS: Local ownership of data and the quality improvement process, and provision of national benchmarking data did not result in a significant improvement in prescribing in the second audit.

A confidential study of deaths after emergency medical admission: issues relating to quality of care.

In this retrospective pilot study we examine the feasibility of establishing a confidential enquiry into why some patients die after emergency admission to hospital. After excluding those who died in the first hour or who were admitted for palliative care, pairs of physicians were able to collect quantitative and qualitative data on 200 consecutive deaths. Both physicians reported shortfalls of care in 14 patients and one of the pair in 25 patients whose deaths would not have been the expected outcome. In 25, the shortfalls of care may have contributed to their deaths. Major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. They occurred mostly in those admitted at night. It is possible that establishing the correct diagnosis and starting appropriate treatment may have been delayed in 64% of the 200 patients. The headline figures appear worse than some previous external assessment studies but this study did concentrate on those in whom problems were more likely. Nevertheless, the frequency is too high to be overlooked. In this feasibility study we have demonstrated that it is practicable for local staff to collect and assess data in hospitals and that the types of problems identified are relevant to anyone planning how to organise emergency care. A larger definitive study should be performed.

Evidence for a link between mortality in acute COPD and hospital type and resources.

BACKGROUND: The 1997 BTS/RCP national audit of acute care of chronic obstructive pulmonary disease (COPD) found wide variations in mortality between hospitals which were only partially explained by known audit indicators of outcome. It was hypothesised that some of the unexplained variation may result from differences in hospital type, organisation and resources. This pilot study examined the hypothesis as a factor to be included in a future national audit programme. METHODS: Thirty hospitals in England and Wales were randomly selected by geographical region and hospital type (teaching, large district general hospital (DGH), small DGH). Data on process and outcome of care (death and length of stay) were collected retrospectively at 90 days on all prospectively identified COPD admissions over an 8 week period. Each centre completed a questionnaire relating to organisation and resources available for the care of COPD patients. RESULTS: Eleven teaching hospitals, nine large DGHs, and 10 small DGHs provided data on 1274 cases. Mortality was high (14%) with wide variation between centres (IQR 9-19%). Small DGHs had a higher mortality (17.5%) than teaching hospitals (11.9%) and large DGHs (11.2%). When corrected for confounding factors, an excess of deaths in small DGHs was still observed (OR 1.56 (CI 1.04 to 2.35)) v teaching hospitals. Analysis of resource and organisational factors suggested higher mortality was associated with fewer doctors (OR 1.5) and with fewer patients being under the care of a specialist physician (OR 1.8). Small DGHs had fewest resources. CONCLUSION: Significant differences in mortality may exist between hospital types. The findings justify further study in a proposed national audit.

National sentinel clinical audit of evidence-based prescribing for older people: methodology and development.

RATIONALE, AIMS AND OBJECTIVES: This national clinical audit aimed to develop and implement a methodology to assess the appropriateness of prescribing for patients over the age of 65 in hospitals, general practice and nursing homes. METHODS: Organizations providing health care in the National Health Service in these three sectors were recruited into multi-disciplinary and inter-organizational local coalition teams. Prescription data and relevant clinical data were collected electronically on a customized database. The appropriateness of prescribing for specific conditions among the patients sampled was assessed by simple computerized algorithms, and users were provided with feedback to stimulate discussion and change. Use of the software tool was demonstrated to be feasible and its data reliable. Participants were re-audited, after a period of nationally guided and locally driven intervention, to evaluate levels of change. Local efforts to stimulate change and barriers to change were collected qualitatively. RESULTS AND CONCLUSIONS: The investigation revealed encouraging results and demonstrated the ability of audit to improve the quality of clinical services in given circumstances, although a multiplicity of questions relating to cost and methodology remain to be addressed.

Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: The 1997 BTS/RCP national audit of acute chronic obstructive pulmonary disease (COPD) in terms of process of care has previously been reported. This paper describes from the same cases the outcomes of death, readmission rates within 3 months of initial admission, and length of stay. Identification of the main pre-admission predictors of outcome may be used to control for confounding factors in population characteristics when comparing performance between units. METHODS: Data on 74 variables were collected retrospectively using an audit proforma from patients admitted to UK hospitals with acute COPD. Important prognostic variables for the three outcome measures were identified by relative risk and logistic regression was used to place these in order of predictive value. RESULTS: 1400 admissions from 38 acute hospitals were collated. 14% of cases died within 3 months of admission with variation between hospitals of 0-50%. Poor performance status, acidosis, and the presence of leg oedema were the best significant independent predictors of death. Age above 65, poor performance status, and lowest forced expiratory volume in 1 second (FEV(1)) tertile were the best predictors of length of stay (median 8 days). 34% of patients were readmitted (range 5-65%); lowest FEV(1) tertile, previous admission, and readmission with five or more medications were the best predictors for readmission. CONCLUSIONS: Important predictors of outcome have been identified and formal recording of these may assist in accounting for confounding patient characteristics when making comparisons between hospitals. There is still wide variation in outcome between hospitals that remains unexplained by these factors. While some of this variance may be explained by incomplete recording of data or patient factors as yet unidentified, it seems likely that deficiencies in the process of care previously identified are responsible for poor outcomes in some units.

Audit of acute admissions of COPD: standards of care and management in the hospital setting.

Despite publication of several management guidelines for COPD, relatively little is known about standards of care in clinical practice. Data were collected on the management of 1400 cases of acute admission with Chronic Obstructive Pulmonary Disease in 38 UK hospitals to compare clinical practice against the recommended British Thoracic Society standards. Variation in the process of care between the different centres was analysed and a comparison of the management by respiratory specialists and nonrespiratory specialists made. There were large variations between centres for many of the variables studied. A forced expiratory volume in one second measurement was found in only 53% of cases. Of the investigations recommended in the acute management arterial blood gases were performed in 79% (interhospital range 40-100%) of admissions and oxygen was formally prescribed in only 64% (range 9-94%). Of those cases with acidosis and hypercapnia 35% had no further blood gas analysis and only 13% received ventilatory support. Long-term management was also deficient with 246 cases known to be severely hypoxic on admission yet two-thirds had no confirmation that oxygen levels had returned to levels above the requirements for long-term oxygen therapy. Only 30% of current smokers had cessation advice documented. To conclude, the median standards of care observed fell below those recommended by the guidelines. The lowest levels of performance were for patients not under the respiratory specialists, but specialists also have room for improvement. The substantial variation in the process of care between hospitals is strong evidence that it is possible for other centres with poorer performance to improve their levels of care.

Relationship between anxiety, depression, and morbidity in adult asthma patients.

BACKGROUND: Symptoms of disease reported by patients reflect the effects of the disease process within the individual and the person's physical and mental ability to tolerate or otherwise cope with the limitations on their functioning. This study examines the relationship between asthma symptoms, disease severity, and psychological status in patients being managed in routine primary healthcare settings. METHODS: One hundred and fourteen subjects from four GP practices, two inner city and two suburban, were studied. Symptoms were assessed by means of the Asthma Quality of Life questionnaire (AQLQ) and a locally devised Q score, and psychological status with the Hospital Anxiety and Depression (HAD) scale. Spirometric values and details of current asthma treatment (BTS asthma guidelines treatment step) were recorded as markers of asthma severity. RESULTS: Symptoms as measured by AQLQ correlated with peak expiratory flow (r(S) = 0.40) and with BTS guidelines treatment step (r(S) = 0.25). Similarly, the Q score correlated with peak expiratory flow (r(S) = 0.44) and with BTS guidelines treatment step (r(S) = 0.42). Similar levels of correlation of forced expiratory volume in one second (FEV(1)) with symptoms were reported. HAD anxiety and depression scores also correlated to a similar extent with these two symptom scores, but there was hardly any correlation with lung function. Logistic regression analysis showed that HAD scores help to explain symptom scores over and above the effects of lung function and BTS guidelines treatment step. Symptoms, depression, and anxiety were higher for inner city patients while little difference was observed in objective measures of asthma. CONCLUSIONS: Asthma guidelines suggest that changing levels of symptoms should be used to monitor the effectiveness of treatment. These data suggest that reported symptoms may be misleading and unreliable because they may reflect non-asthma factors that cannot be expected to respond to changes in asthma treatment.

Reliability and validity of the Intercollegiate Stroke Audit Package.

The aim of this study was to assure the validity and reliability of the Intercollegiate Stroke Audit Package as used in the National Sentinel Audit of Stroke. The Intercollegiate Working Party for Stroke, which included most stakeholders, including patients, devised the audit standards. These were submitted to a formal consensus (modified Delphi) survey before the audit questions were developed and piloted for validity and reliability. Following the pilot, Help Booklets were developed to promote the involvement of all disciplines as auditors in the national sentinel audit of stroke and ensure inter-rater reliability. During the national audit each Trust was asked to double rate the first five cases with auditors of different disciplines working independently. A total of 886 case notes were double-rated in 184 separate sites (median 5, range 1-5 per site). Trusts used auditors from different disciplines in 77% of cases. After excluding the 'No answer' cases the kappa score for items ranged from 0.49 to 0.87 (median 0.70, IQR 0.63-0.78). Very good agreement was found for seven of the 45 items, good agreement for 30 items, and moderate agreement for eight items. This large study, across a range of hospital sites and involving many disciplines, demonstrates that careful piloting of audit tools, with use of clear instructions to auditors, promotes the reliability of data.

Capsaicin induced cough in cryptogenic fibrosing alveolitis.

BACKGROUND: Cough is a common and troublesome symptom in cryptogenic fibrosing alveolitis (CFA) but the mechanisms responsible are not known. The cough threshold to inhaled capsaicin is increased in asthma and chronic obstructive pulmonary disease (COPD) where lung volumes are increased, but the relationship between cough response and symptom intensity has not been studied in CFA where lung volumes are reduced. METHODS: Capsaicin challenge tests were performed on 15 subjects with proven CFA and 96 healthy controls. Symptoms, as assessed by daily diary card cough score and by visual analogue scale (VAS), were related to the capsaicin sensitivity (C5) and compared with lung volumes. Volume restriction was produced in a group of 12 normal healthy subjects by a plastic shell tightly strapped to the chest wall. Capsaicin challenge tests were performed in these subjects, both strapped and unstrapped, to determine whether volume restriction altered the cough reflex. RESULTS: The median C5 response in normal subjects was more than 500 microM compared with 15.6 microM in those with CFA (p<0.001). The C5 response of the CFA patients was not related to symptoms of cough (whether measured by diary card or by VAS), nor was it related to percentage predicted total lung capacity (TLC) or forced vital capacity (FVC). Volume restriction of normal subjects with chest strapping successfully restricted lung volumes to levels similar to that of the CFA patients but did not change the sensitivity to capsaicin. CONCLUSIONS: The cough reflex measured using capsaicin is markedly increased in patients with CFA. This increase is not the result of alterations in the deposition of inhaled particles of capsaicin brought about by volume restriction. It could be related to reduced lung compliance leading to sensitisation of rapidly adapting receptors, other mechanical changes, or to destruction of pulmonary C fibres secondary to interstitial inflammation. The capsaicin test may be a useful method of objectively monitoring cough propensity in CFA.

Capsaicin responsiveness and cough in asthma and chronic obstructive pulmonary disease.

BACKGROUND: Chronic cough is associated with an increased sensitivity to inhaled capsaicin in a number of conditions but there are no data for patients with more severe asthma or chronic obstructive pulmonary disease (COPD). Moreover, the relationships between the capsaicin response (expressed as the concentration of capsaicin provoking five coughs, C5), self-reported cough, and routine medication is not known. METHODS: The cough response to capsaicin in 53 subjects with asthma, 56 subjects with COPD, and 96 healthy individuals was recorded and compared with a number of subjective measures of self-reported cough, measures of airway obstruction, and prescribed medication. In asthmatic subjects the relationships between the cough response to capsaicin and mean daily peak flow variability and non-specific bronchial hyperresponsiveness to histamine were also examined. RESULTS: Subjects with asthma (median C5 = 62 mM) and COPD (median C5 = 31 mM) were similarly sensitive to capsaicin and both were more reactive than normal subjects (median C5 >500 mM). Capsaicin sensitivity was related to symptomatic cough as measured by the diary card score in both asthma and COPD (r = -0.38 and r = -0.44, respectively), but only in asthma and not COPD when measured using a visual analogue score (r = -0.32 and r = -0.05, respectively). Capsaicin sensitivity was independent of the degree of airway obstruction and in asthmatics was not related to PEF variability or PC(20) for histamine. The response to capsaicin was not related to treatment with inhaled corticosteroids but was increased in those using anticholinergic agents in both conditions. CONCLUSIONS: These data suggest that an increased cough reflex, as measured by capsaicin responsiveness, is an important contributor to the presence of cough in asthma and COPD, rather than cough being simply secondary to excessive airway secretions. The lack of any relationship between capsaicin responsiveness and airflow limitation as measured by the FEV(1) suggests that the mechanisms producing cough are likely to be different from those causing airways obstruction, at least in patients with COPD.