The self-management abilities test (SMAT): a tool to identify the self-management abilities of adults with bronchiectasis

Bronchiectasis is an increasingly common chronic respiratory disease which requires a high level of patient engagement in self-management. Whilst the need for self-management has been recognised, the knowledge and skills needed to do so— and the extent to which patients possess these—has not been well-specified. On one hand, understanding the gaps in people’s knowledge and skills can enable better targeting of self-management supports. On the other, clarity about what they do know can increase patients’ confidence to self-manage. This study aims to develop an assessment of patients’ ability to self-manage effectively, through a consensus-building process with patients, clinicians and policymakers. The study employs a modified, online three-round Delphi to solicit the opinions of patients, clinicians, and policymakers (N = 30) with experience of bronchiectasis. The first round seeks consensus on the content domains for an assessment of bronchiectasis self-management ability. Subsequent rounds propose and refine multiple-choice assessment items to address the agreed domains. A group of ten clinicians, ten patients and ten policymakers provide both qualitative and quantitative feedback. Consensus is determined using content validity ratios. Qualitative feedback is analysed using the summative content analysis method. Overarching domains are General Health Knowledge, Bronchiectasis-Specific Knowledge, Symptom Management, Communication, and Addressing Deterioration, each with two sub-domains. A final assessment tool of 20 items contains two items addressing each sub-domain. This study establishes that there is broad consensus about the knowledge and skills required to self-manage bronchiectasis effectively, across stakeholder groups. The output of the study is an assessment tool that can be used by patients and their healthcare providers to guide the provision of self-management education, opportunities, and support.

Development and validation of a prediction index for recent mortality in advanced COPD patients

The primary barrier to initiating palliative care for advanced COPD patients is the unpredictable course of the disease. We enroll 752 COPD patients into the study and validate the prediction tools for 1-year mortality using the current guidelines for palliative care. We also develop a composite prediction index for 1-year mortality and validate it in another cohort of 342 patients. Using the current prognostic models for recent mortality in palliative care, the best area under the curve (AUC) for predicting mortality is 0.68. Using the Modified Medical Research Council dyspnea score and oxygen saturation to define the combined dyspnea and oxygenation (DO) index, we find that the AUC of the DO index is 0.84 for predicting mortality in the validated cohort. Predictions of 1-year mortality based on the current palliative care guideline for COPD patients are poor. The DO index exhibits better predictive ability than other models in the study.

Effectiveness of individualized inhaler technique training on low adherence (LowAd) in ambulatory patients with COPD and asthma

To analyze whether there is improvement in adherence to inhaled treatment in patients with COPD and asthma after an educational intervention based on the teach-to-goal method. This is a prospective, non-randomized, single-group study, with intervention and before-after evaluation. The study population included 120 patients (67 females and 53 males) diagnosed with asthma (70.8%) and COPD (29.1%). The level of adherence (low and optimal) and the noncompliance behavior pattern (erratic, deliberate and unwitting) were determined by the Test of the adherence to Inhalers (TAI). This questionnaire allows you to determine the level of adherence and the types of noncompliance. Low Adherence (LowAd) was defined as a score less than 49 points. All patients received individualized educational inhaler technique intervention (IEITI). Before the IEITI, 67.5% of the patients had LowAd. Following IEITI, on week 24, LowAd was 55% (p = 0.024). Each patient can present one or more types of noncompliance. The most frequent type was forgetting to use the inhaler (erratic), 65.8%. The other types were deliberate: 43.3%, and unwitting: 57.5%. All of them had decreased on the final visit: 51.7% (p = 0.009), 25.8% (p = 0.002), 39.2% (p = 0.002). There were no significant differences in adherence between asthma and COPD patients at the start of the study. The only predicting factor of LowAd was the female gender. An individualized educational intervention, in ambulatory patients with COPD and asthma, in real-world clinical practice conditions, improves adherence to the inhaled treatment.

Validity of urges to smoke measures in predicting smoking relapse during treatment in primary care

In the context of smoking cessation treatment in primary care, identifying patients at the highest risk of relapse is relevant. We explored data from a primary care trial to assess the validity of two simple urges to smoke questions in predicting long-term relapse and their diagnostic value. Of 295 patients who received behavioural support and varenicline, 180 were abstinent at week 9. In this subgroup, we measured time spent with urges to smoke (TSU) and strength of urges to smoke (SUT; both scales 1 to 6 = highest). We used separate regression models with TSU or SUT as predictor and relapse from week 9–26 or week 9–52 as an outcome. We also calculated the sensitivity (SP), specificity and positive predictive values (PPV) of TSU and SUT in correctly identifying patients who relapsed at follow-up. The adjusted odds ratios (aOR) for predicting relapse from week 9–26 were 1.74 per point increase (95% CI = 1.05–2.89) for TSU and 1.59 (95% CI = 1.11–2.28) for SUT. The aORs for predicting relapse from week 9–52 were 2.41 (95% CI = 1.33–4.37) and 1.71 (95% CI = 1.14–2.56), respectively. Applying a cut-point of ≥3 on TSU resulted in SP = 97.1 and PPV = 70.0 in week 9–26, and SP = 98.8 and PPV = 90.0 in week 9–52. Applying a cut-point of ≥4 on SUT resulted in SP = 99.0 and PPV = 85.7 in week 9–26, and SP = 98.8 and PPV = 85.7 in week 9–52. Both TSU and SUT were valid predictors of long-term relapse in patients under smoking cessation treatment in primary care. These simple questions may be useful to implement in primary care.Trial registration: Dutch Trial Register (NTR3067).

Acute respiratory infections in an adult refugee population: an observational study

The presence of acute infectious respiratory diseases (ARD) is one of the main reasons why recently arrived refugees seek medical help. This paper investigates the incidence rates of acute respiratory diseases in an adult refugee population as well as associated sociodemographic factors and drug treatments. We conducted a retrospective observational study of deidentified medical records. The data were collected between 2015 and 2019 in the health care centers of two large German initial reception centers for refugees. Multivariable analyses controlling for sociodemographics were carried out using generalized estimating equations. Out of 10,431 eligible residents, 6965 medical encounters of 2840 adult patients were recorded over 30 months. Of all the adult patients, 34.4% sought medical help for a respiratory symptom or diagnosis at least once. Older patients and patients from Sub-Saharan Africa sought help less often. The occurrence of ARD showed a typical distribution over the course of the year. Facility occupancy was not associated with ARD occurrence. Acute respiratory symptoms are a leading cause for adult refugee patients to seek medical care. The doctor contact rates due to ARD were consistently two to three times higher among refugees than among German residents.

Implementing asthma management guidelines in public primary care clinics in Malaysia

Implementing asthma guideline recommendations is challenging in low- and middle-income countries. We aimed to explore healthcare provider (HCP) perspectives on the provision of recommended care. Twenty-six HCPs from six public primary care clinics in a semi-urban district of Malaysia were purposively sampled based on roles and experience. Focus group discussions were guided by a semi-structured interview guide and analysed thematically. HCPs had access to guidelines and training but highlighted multiple infrastructure-related challenges to implementing recommended care. Diagnosis and review of asthma control were hampered by limited access to spirometry and limited asthma control test (ACT) use, respectively. Treatment decisions were limited by poor availability of inhaled combination therapy (ICS/LABA) and free spacer devices. Imposed Ministry of Health programmes involving other non-communicable diseases were prioritised over asthma. Ministerial policies need practical resources and organisational support if quality improvement programmes are to facilitate better management of asthma in public primary care clinics.

Influence of the first wave of COVID-19 on asthma inhaler prescriptions

In the beginning of the COVID-19 pandemic, there were major concerns regarding the huge demand for asthma inhalers. Using the primary-care medical records for 614,700 asthma patients between January and June 2020, we found that there was a substantial increase in inhalers solely in March 2020. Patients significantly associated with receiving higher inhaled corticosteroid prescriptions were younger, of higher socioeconomic status, and had milder asthma.

COVID-19 assessment in family practice—A clinical decision rule based on self-rated symptoms and contact history

The study aimed to evaluate the diagnostic accuracy of contact history and clinical symptoms and to develop decision rules for ruling-in and ruling-out SARS-CoV-2 infection in family practice. We performed a prospective diagnostic study. Consecutive inclusion of patients coming for COVID-PCR testing to 19 general practices. Contact history and self-reported symptoms served as index test. PCR testing of nasopharyngeal swabs served as reference standard. Complete data were available from 1141 patients, 605 (53.0%) female, average age 42.2 years, 182 (16.0%) COVID-PCR positive. Multivariable logistic regression showed highest odds ratios (ORs) for “contact with infected person” (OR 9.22, 95% CI 5.61–15.41), anosmia/ageusia (8.79, 4.89–15.95), fever (4.25, 2.56–7.09), and “sudden disease onset” (2.52, 1.55–4.14). Patients with “contact with infected person” or “anosmia/ageusia” with or without self-reported “fever” had a high probability of COVID infection up to 84.8%. Negative response to the four items “contact with infected person, anosmia/ageusia, fever, sudden disease onset” showed a negative predictive value (NPV) of 0.98 (95% CI 0.96–0.99). This was present in 446 (39.1%) patients. NPV of “completely asymptomatic,” “no contact,” “no risk area” was 1.0 (0.96–1.0). This was present in 84 (7.4%) patients. To conclude, the combination of four key items allowed exclusion of SARS-CoV-2 infection with high certainty. With the goal of 100% exclusion of SARS-CoV-2 infection to prevent the spread of SARS-CoV-2 to the population level, COVID-PCR testing could be saved only for patients with negative response in all items. The decision rule might also help for ruling-in SARS-CoV-2 infection in terms of rapid assessment of infection risk.