NPJ Primary Care Respiratory Medicine最新文献

Past epidemiological studies demonstrated mixed findings on the association between diabetes and lung cancer. Given the possible links between diabetes, smoking, and respiratory diseases, this study aims to examine the interaction patterns among factors associated with the risk of lung cancer among diabetes patients. A territory-wide retrospective cohort study was performed using electronic health records of Hong Kong. Patients who received diabetes care in general outpatient clinics between 2010 and 2019 without cancer history were included and followed up until December 2019. Conditional inference survival tree was applied to examine the interaction patterns among factors associated with the risk of lung cancer. A total of 385,521 patients were included. During a median follow-up of 6.2 years, 3395 developed lung cancer. Age emerged as primary factor in differentiating the risk of lung cancer. Conditional on age ( ≤ 64 vs >64 years), smoking appeared as subsequent dominant risk factor within each subpopulation. Among old smokers aged >64 years characterized by long duration of diabetes (median: 6-8 years), chronic obstructive pulmonary disease (COPD) emerged as key risk factor. Six distinct subgroups of diabetes patients with different risk levels of lung cancer according to age, smoking, metformin use, and COPD status were identified. Findings of the study suggest the interaction patterns among age, smoking, and COPD on the risk of lung cancer among diabetes patients, providing targets for public health interventions.

An infection of SARS-CoV-1, the causative agent of Severe Acute Respiratory Syndrome (SARS), may be followed by long-term clinical sequala. We hypothesized a greater 20-year multimorbidity incidence in people hospitalized for SARS-CoV-1 infection than those for influenza during similar periods. We conducted a retrospective cohort study using a territory-wide public healthcare database in Hong Kong. All patients aged ≥15 hospitalized for SARS in 2003 or influenza in 2002 or 2004 with no more than one of 30 listed chronic disease were included. Demographics, clinical history, and medication use were adjusted for in the inverse-probability-of-treatment-weighted Poisson regression analyses. We identified 1255 hospitalizations for SARS-CoV-1 infection and 687 hospitalizations for influenza. Overall crude multimorbidity incident rates were 1.5 per 100 person-years among SARS patients and 5.6 among influenza patients. Adjusted multimorbidity incidence rate ratio (IRR) was estimated at 0.78 [95% confidence interval (CI), 0.70-0.86) for SARS patients compared with influenza patients. Analysis by follow-up period shows a potentially greater risk among SARS patients in the first year of follow-up (IRR 1.33, 95% CI 0.97-1.84), with the risk in influenza patients increasing in subsequent years. Subgroup analyses by age and sex showed consistent results with the main analysis that SARS-CoV-1 infection was not followed by a higher incidence of multimorbidity than influenza. Notable differences in the patterns of multimorbidity were identified between the two arms. To conclude, we found no evidence of a higher multimorbidity incidence after hospitalization for SARS than for influenza over the long-term.

Underdiagnosis and overdiagnosis commonly occur in Chronic Obstructive Pulmonary Disease (COPD) patients. We assessed diagnostic accuracy, clinical characteristics, healthcare utilization, and care plan registration for patients undergoing primary care. We conducted a cross-sectional, population-based study using a health record registry from four primary healthcare centers in Catalonia (Spain) for patients aged ≥15 years. The variables included sociodemographic characteristics, dyspnea, comorbidities, spirometry results, treatments, and healthcare use. Logistic regression models were used to analyze differences between patients with and without airflow limitation, and ordinal logistic regression models were used to examine the association between disease severity and healthcare use. Among the 2610 patients, 54% had spirometry data, 29.5% had confirmed airflow obstruction, and 24% were overdiagnosed according to the GOLD criteria. Patients without airflow obstruction were younger (OR: 0.98, 95% CI: 0.96-0.99) and more likely to be current smokers (OR: 1.44, 95% CI: 1.13-1.84). Airflow obstruction severity was significantly associated with increased use of emergency home ambulance use (OR: 1.7, 95% CI: 1.23-2.35), emergency department visits (OR: 1.48, 95% CI: 1.11-1.99), and hospital admission (OR: 1.8, 95% CI: 1.32-2.47), but not primary care visits and follow-up frequency. COPD is frequently overdiagnosed in primary healthcare settings. The severity of airflow obstruction is associated with increased healthcare utilization, including hospital admissions. Improved diagnostic accuracy and management may enhance COPD care and reduce healthcare costs.

Fractional exhaled nitric oxide (FeNO) testing is used in primary care in some areas of the UK to aid asthma diagnosis but is used less frequently for managing asthma. A randomised controlled trial (RCT) is investigating whether an intervention, including FeNO testing and a clinical algorithm, improves outcomes for patients with asthma. This study was conducted to explore potential for implementation of the intervention. The study aim was to explore views of those with a vested interest in implementing the FeNO intervention into primary care asthma reviews. In-depth, semi-structured interviews were conducted online with individuals, including those with experience in policymaking, healthcare management, National Health Service commissioning, as healthcare professionals (HCPs) with extended roles, and patients and advocates. Inductive thematic analysis was conducted for nineteen interviews. Findings suggest complex interplay of barriers, contextual issues and facilitators. Overall, participants perceived FeNO-informed asthma management would enhance care, if used appropriately and flexibly according to context, for example planning implementation alongside remote reviews. Easier, equitable access to funded FeNO equipment would be needed for national implementation. Participants suggested motivation of all involved in future implementation may be increased by guidelines recommending FeNO, and by use of financial incentives and champions sharing best practice examples. In conclusion, financial obstacles were reiterated as a primary barrier to FeNO use. Despite barriers, facilitating implementation by harnessing prominent cost-benefits could persuade decision makers and clinicians. Findings lay early foundations for development of an implementation strategy.

In asthma and chronic obstructive pulmonary disease (COPD) incorrect use of inhalers is still common. The aim of the study was to detect whether education improves inhalation skills and whether the type of education influenced the educational effect depending on the device. A systematic review and meta-analysis for errors during inhalation before and after education was performed. The selected data allowed for education assessment of dry powder (DPIs) and pressurised metered dose (pMDI/MDIs) inhalers in a meta-analysis. Education reduced critical errors (risk ratio [RR], 0.28, 95% confidence interval [CI]: 0.17, 0.47, P < 0.00001) and any incorrect use events for DPI (RR = 0.38, 95% CI: 0.21, 0.70, P = 0.002) and pMDI/MDIs, (RR = 0.16, 95% CI: 0.11, 0.23, P < 0.00001). Education improves patient's inhalation skills regardless of the device. The educational effect for pMDI/MDIs depends on the type of educational approach which has not been demonstrated for DPIs.

The asthma diagnosis jigsaw puzzle is a clinical practice and teaching concept conceived in clinical practice and refined through an expert multidisciplinary consensus process by academics and clinicians with an interest in primary respiratory care. The concept incorporates guidance to facilitate the effective diagnosis of adults or children with asthma in primary care where misdiagnosis is common. The jigsaw puzzle metaphor teaches a problem-solving approach to diagnosis, introducing the concept of diagnosis over time and in no particular sequence. Puzzle pieces can be collected from the domains of presentation, history, symptoms and physical examination, as well as objective tests. The clinician's challenge is to complete the diagnostic jigsaw puzzle testing the likelihood of a picture which can be recognised as asthma. This approach aligns with symptom-based pattern-recognition approaches taught to primary care clinicians which gets easier and more reliable with experience. Relational continuity, or informational continuity through the patient record, is integral to the process of puzzle completion. Where non-fitting puzzle pieces are encountered, alternative or additional diagnoses should be considered and/or referral to secondary care pursued. As a metaphor, 'puzzle completion' may be used within clinical communication encounters, addressing the importance of partnership working ('completing the puzzle together'), uncertainty (deciding 'which pieces fit') and changes in symptoms over time (enabling the 'puzzle picture to become clearer'). Adaptation of this teaching concept has started through translation of educational resources, including puzzle pieces. Supporting case vignettes developed locally will contextualise the jigsaw puzzle teaching concept. The Asthma Diagnosis Jigsaw Puzzle teaching concept has been piloted in North Macedonia and is also developed for educational workshops by primary care health educators in Malaysia, India and Uganda.

Breathlessness is highly prevalent in low and middle-income countries (LMICs). Low-cost, non-drug, breathlessness self-management interventions are effective in high-income countries. However, health beliefs influence acceptability and have not been explored in LMIC settings. Review with stakeholder engagement to co-develop explanatory programme theories for whom, if, and how breathlessness self-management might work in community settings in India. Iterative and systematic searches identified peer-reviewed articles, policy and media, and expert-identified sources. Data were extracted in terms of contribution to theory (high, medium, low), and theories developed with stakeholder groups (doctors, nurses and allied professionals, people with lived experiences, lay health workers) and an International Steering Group (RAMESES guidelines (PROSPERO42022375768)). One hundred and four data sources and 11 stakeholder workshops produced 8 initial programme theories and 3 consolidated programme theories. (1) Context: breathlessness is common due to illness, environment, and lifestyle. Cultural beliefs shape misunderstandings about breathlessness; hereditary, part of aging, linked to asthma. It is stigmatised and poorly understood as a treatable issue. People often use rest, incense, or tea, while avoiding physical activity due to fear of worsening breathlessness. Trusted voices, such as healthcare workers and community members, can help address misconceptions with clear, simple messages. (2) Breathlessness intervention applicability: nonpharmacological interventions can work across different contexts when they address unhelpful beliefs and behaviours. Introducing concepts like "too much rest leads to deconditioning" aligns with cultural norms while promoting beneficial behavioural changes, such as gradual physical activity. Acknowledging breathlessness as a medical issue is key to improving patient and family well-being. (3) Implementation: community-based healthcare workers are trusted but need simple, low-cost resources/skills integrated into existing training. Education should focus on managing acute episodes and daily breathlessness, reducing fear, and encouraging behavioural change. Evidence-based tools are vital to gain support from policymakers and expand implementation. Breathlessness management in India must integrate symptom management alongside public health and disease treatment strategies. Self-management interventions can be implemented in an LMIC setting. However, our novel methods indicate that understanding the context for implementation is essential so that unhelpful health beliefs can be addressed at the point of intervention delivery.

This study evaluates the impact of using a Clinical Decision Support System software in the form of a computer-guided consultation (CGC) when conducting Chronic Obstructive Pulmonary Disease (COPD) reviews in primary care. 5221 patients on the COPD register underwent CGC review with 21.1% found not to have COPD. Previously unrecognised cardiac disease was highlighted by the CGC in 7% of confirmed COPD cases. CGC review resulted in the number of patients possessing a self-management plan rising from 62-85%. 13% were found to have sub-optimal inhaler technique during CGC review with the CGC prompting correction in all cases. Only 26% of patients identified by the CGC as appropriate for Pulmonary Rehabilitation (PR) referral had previously attended a PR program. The integration of technology in the form of clinical decision support system software results in greater implementation of guideline-level care representing a scalable solution when performing COPD reviews.

Management of long-term conditions is a significant challenge in contemporary health care as people often require support for both physical and psychological symptoms. Assessing the competence of healthcare professionals delivering psychologically informed interventions informs decisions about future implementation. This is a comprehensive intervention fidelity assessment nested within a randomised controlled trial. We developed a bespoke intervention fidelity assessment framework to assess the competence of primary care respiratory nurses, physiotherapists and occupational therapists delivering a cognitive behavioural intervention for people with COPD. A total of 180 (representing 15% of trial cases) intervention audio files, from 36 intervention arm participants, were coded. The intervention was delivered with acceptable adherence for most components. Therapeutic competency was achieved and comparable with previous research studies. Interpersonal skills and focus had higher competency whilst guided discovery and application of appropriate change techniques was lower but still adequate. Skills improved over time and with an increased number of clients. With proper training and supervision, primary care respiratory nurses, physiotherapists and occupational therapists can deliver cognitive behavioural interventions with acceptable therapeutic competency but questioning and change techniques may need particular focus in training and greater practice.