AQuA weekly update

This week’s news:

Event: Academic Health Science Networks: Who, What and Why?
24 April 2013
Secondary Care Toolkit for COPD from NHS Improvement Lung available here….
25 April 2013
The Kings Fund explain the top ten priorities for commissioners….
26 April 2013
Developing a specification for lifestyle weight management services. Best practice guidance for tier 2 services” from the Department of Health dated March 2013, find it here…
26 April 2013
The Cardiovascular Disease Outcomes Strategy has been published recently..take a look
26 April 2013
End of Life Care profiles added to our benchmarking section…
26 April 2013
GP outcomes indicators added to our benchmarking section
26 April 2013
New End of Life Care resources available
26 April 2013
New Spirometry guide…
29 April 2013
New materials added to our CKD pack, see what they are in the discussion forum
29 April 2013

A.G. Mathioudakis comments: Chronic bronchitis: an objective diagnosis of exclusion

The authors of the above article published would like to thank A.G. Mathioudakis and co-workers for their interest and comments regarding our recently published article in the July issue of the European Respiratory Journal [1].

A.G. Mathioudakis and co-workers raise a concern regarding the term of “chronic bronchitis phenotype” and the actual diagnosis. They also comment that the phenotype could include patients with tuberculosis, lung cancer, asthma, bronchiectasis and heart failure, and that these diagnoses were not sufficiently investigated in our study. We agree with the position that the phenotype includes patients with other conditions and, in this way, the term was addressed in our study [1]. The self-reported comorbidity (asthma, tuberculosis and lung cancer) of the subjects with spirometric diagnosis of chronic obstructive pulmonary disease (COPD) is clearly shown in table 3 of our article (description of subjects with COPD, by chronic bronchitis) [1]. However, we think that the problem is that A.G. Mathioudakis and co-workers did not understand the type of study PLATINO (Proyecto Latinoamericano de Investigación en Obstrucción Pulmonar) is. This study is a well-known population-based study on COPD and not a study of a selected COPD population, so it is not possible to conduct additional analyses to rule out, for example, congestive heart failure in this type of study. In addition, we think that it is important to highlight the existing proposal for defining COPD phenotypes as “a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes (symptoms, exacerbations, response to therapy, rate of disease progression, or death).” This more focused definition allows classification of patients into distinct prognostic and therapeutic subgroups for both clinical and research purposes [2]. This definition is not restricted exclusively to selected COPD samples (there is no limit for its use in unselected populations), so it can also be used to study COPD phenotypes in a population-based sample and this is the case of our study. We presented the association of chronic bronchitis symptoms (a single attribute of the disease) in the PLATINO COPD population with the severity of airway obstruction, subjects’ perceptions of their general health status, physical activity limitation and exacerbations (relation to clinically meaningful outcomes).

A.G. Mathioudakis and co-workers also made a comment regarding the low prevalence of the chronic bronchitis phenotype and suggest that this could be associated with the use of post-bronchodilator forced expiratory volume in 1 s/forced vital capacity ratio <0.70 to define COPD and the possible over-diagnosis of stage I COPD patients with low symptom prevalence. Unfortunately, it seems that A.G. Mathioudakis and co-workers have not reviewed the supplementary material of our study, which shows all analyses performed using the lower limit of normal (LLN) to define COPD [1]. Interestingly, supplemental tables 1 and 2 showed the parallel analysis using the LLN to define COPD, and the proportion of persons in both groups was quite similar to that found with the use of the fixed ratio [1]. Supplemental table 3 (description of subjects with COPD), and supplemental figures 1 and 2 (Global Initiative for Chronic Obstructive Lung Disease severity distribution of COPD subjects by chronic bronchitis and general health status assessed in COPD and non-COPD subjects, respectively) also showed the analyses using the LLN definition with similar findings [1].

Finally, we think that the data presented in our article helps to better understand the prevalence of the chronic bronchitis phenotype in an unselected COPD population using different criteria for defining COPD, and the association of this phenotype with some important outcomes (reduced pulmonary function, more respiratory symptoms and exacerbations, worse health status, and more physical activity limitation).

see link


Map of Medicine – how can it help your practice?

Respiratory viruses during winter can strain the NHS with an influx of patients, as well as more staff illness. In most cases, rest, increased fluid intake, and paracetamol are sufficient. However, winter can be much more serious for people with pre-existing conditions, such as COPD.  Total excess winter mortality is between 20,000 and 50,000 annually in England and Wales, principally from respiratory, cardiovascular or cerebrovascular diseases.  Older age, female gender and a history of respiratory disease confer greater vulnerability.
Optimising management of chronic conditions is a process, not an event, and clinicians can be supported in this by using the Map of Medicine.   The following care maps are accredited by the Royal College of Physicians (RCP) and offer evidence-based, practice-informed guidance for the on-going management of chronic conditions:

  • ‘Chronic obstructive pulmonary disease (COPD)’ – covers management in both primary and secondary care, and includes treatment of acute exacerbations of breathlessness, which can occur in response to viral infection
  • ‘Cardiovascular disease (CVD) risk management’ – gives information on primary and secondary prevention of cardiac disease
  • ‘Stroke and transient ischaemic attack (TIA)’ – includes information on the secondary prevention of cerebrovascular events

The Map and the RCP bring together evidence and practice to support clinical decisions at the point of care. The Map can be customised to reflect local needs by clinicians looking to support clinical decision-making. Over 150 organisations have ‘localised’ more than 1,300 care pathways. Local additions to the care maps for these chronic conditions range from signposting services, for example local telehealth initiatives and social care packages, to providing information on topics such as factors to consider when deciding where exacerbations of COPD should be managed, and which teams are responsible for delivering care.

Click here to see how the Map could help your organisation.