journal overload - pcrs-uk.org...midlife cardiorespiratory fitness (crf) and the long-term risk of...

PCRS Respiratory Conference20th and 21st September 2019

Journal OverloadSteve HolmesGP, The Park Medical Practice, Shepton MalletPCRS Education lead and co-lead Primary Care Respiratory AcademyRCGP National Council

2019 PCRS Respiratory Conference

Declaration of Interests

● General practitioner, Park Medical Practice, Shepton Mallet

● Primary Care Respiratory Society (Education Lead, Executive and previous chair; Primary Care

Respiratory Academy co-lead)

● Somerset CCG Respiratory Lead and Chair, Somerset Respiratory Programme Board

• Education for Health (Trainer)

• RCGP (College Council, Severn Faculty Board, Essential Knowledge Update and clinical

expert, Lung Health Taskforce)

• Health Education England (Associate PostgraduateDean, GP Trainer in Somerset)

• NHS England (National Respiratory Specialist Commissioning Group)

• NHS England (Appraiser)

• National Institute for Health Research (Care out of hospital panel)

• Guideline involvement (Air Travel, Asthma, COPD, Mesothelioma, Pulse oximetry, Spirometry,

Tobacco Dependency)


Declarations of Interest (2)Conference / travel / lecture / projects / advisory board work (in the last five years) (personal / on

behalf of PCRS, BTS, BLF)

● Astra Zeneca

● Beximco

● Boehringer Ingelheim

● Chiesi

● Glaxo Smith Kline

● Johnson and Johnson

● Mylan

● Napp

● Novartis

● Nutricia

● Orion

● Pfizer

● Sandoz

● Teva

● Trudell Medical International

● University College, London

● Univ of Birmingham

● Univ of Cardiff

● Univ of Edinburgh

● Univ of Sheffield

● Univ of Southampton

● Univ of South Wales

● Bristol NSSG CCG

● East Lancashire CCG

● Heywood, Middleton, Rochdale CCG

● Rushcliffe CCG

● Mediconf

● MIMS

● Pulse

No tobacco shares No speaking / publications without complete autonomy on slides / phrasing


Taylor GMJ, Itani T, Thomas KH, Rai D, Jones T, Windmeijer F, et al. Prescribing Prevalence, Effectiveness, and Mental Health Safety of Smoking Cessation Medicines in Patients With Mental Disorders. Nicotine & Tobacco Research. 2019.


Best treatment for smokers with mental health problems

● 78457 smokers with mental health problem (aged more than 18 years)

● NRT (N = 59 340) or varenicline (N = 19 117)

● September 1, 2006 to December 31, 2015.

Results

● Smokers with mental health disorders

● less likely to be prescribed varenicline (compared to NRT) (31%)

● If prescribed varenicline 19% greater odds of quitting at 2 years (compared to NRT)

● Varenicline was associated with decreased or similar odds of worse mental health

● outcomes than NRT in patients both with and without mental disorders,

Conclusion

● “Varenicline was more effective than NRT for smoking cessation in patients with mental disorders”

Taylor GMJ, Itani T, Thomas KH, Rai D, Jones T, Windmeijer F, et al. Prescribing Prevalence, Effectiveness, and Mental Health Safety of Smoking Cessation Medicines in Patients With Mental Disorders. Nicotine & Tobacco Research. 2019.

Anthenelli


Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-

controlled clinical trial. The Lancet. 2016;387(10037):2507-20. Anthenelli

Varenicline can be used in patients with a history of mental illness

2019 PCRS Respiratory ConferenceNational Institute for Clinical Excellence. Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing.

London NICE; 2018 Dec 2018.


Did it make a difference?

● Method

● multicentre, open-label, randomized, controlled trial (diagnosis of COPD in their primary care clinical record consulted clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD)

● Results

● 653 patients randomised (all ascertained except 1; 97% followed up for 1m)

● Initial consultation 47.7% (CRP) v 69.7% (clinical alone))

● During first 4w of follow up - (59.1% v 79.7%)

● Two patients in the usual-care group died within 4 weeks after randomization (NS)

● Conclusions

● CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm.

Butler CC, Gillespie D, White P, Bates J, Lowe R, Thomas-Jones E, et al. C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations. N Engl J Med. 2019;381(2):111-20.


Midlife cardiorespiratory fitness (CRF) and the long-term risk of chronic obstructive pulmonary disease.

● Recruitment started in 1970-1971

● Estimated risk of incident COPD was 21% lower in participants with normal CRF (HR 0.79, 95% CI 0.63 to 0.99) and 31 % lower with high CRF (HR 0.69, 95% CI 0.52 to 0.91).

● Compared with low CRF, the risk of death from COPD was 35% lower in participants with normal CRF (HR 0.65, 95% CI 0.46 to 0.91) and 62% lower in participants with high CRF (HR 0.38, 95% CI 0.23 to 0.61).

● Test for reverse causation did not alter the results.

Hansen GM, Marott JL, Holtermann A, Gyntelberg F, Lange P, Jensen MT. Midlife cardiorespiratory fitness and the long-term risk of chronic obstructive pulmonary disease. Thorax. 2019;74(9):843-8.


Vanfleteren LEGW, Andersson AE, Fabbri LM. COPD: What’s in a Name?: Mismatch of Diagnostic Labels and Required Physiologic Features. CHEST. 2019;156(2):195-6.


Clinical significance of symptoms in smokers with preserved pulmonary function

Method

● Observational study of 2736 people (current / former smokers / controls)

● Performed CAT score / spirometry / evaluated exacerbations

Results

● Symptoms in 50% of current / former smokers with normal preserved pulmonary function (limitation of activity)

● Mean rate of respiratory exacerbations higher (x4) than asymptomatic or controls

● No association with emphysema on HRCT

● 42% treated with bronchodilators (23% inhaled glucocorticoids)

Woodruff PG, Barr RG, Bleecker E, Christenson SA, Couper D, Curtis JL, et al. Clinical Significance of Symptoms in Smokers with Preserved Pulmonary Function. New England Journal of Medicine. 2016;374(19):1811-21.


Are we overdiagnosing? - Overdiagnosis of COPD in Subjects With Unobstructed Spirometry: A BOLD Analysis.

● Overdiagnosis and prevalence of spirometrically defined false positive COPD

● 23 populations, 20 countries (BOLD study 2003 – 2012)

Method

● False positive was if diagnosed but postbronchodilators spirometry FEV1/FVC > LLN)

● Second analysis using fixed ratio (FEV1/ FVC <0.7) …(. For those following GOLD and NICE ☺)

Results

● 16177 participants 919 (5.7%) diagnosed with COPD

● 569 61.9% had unobstructed spirometry (55.3% when using fixed ratio criterion)

● Site specific prevalence of false positive COPD was 1.9% in low – medium income countries to 4.9% (high income countries)

● More likely diagnosed in ● Women

● Higher education

● Former or current smoker

● Presence of wheeze, cough and phlegm

● Diagnosis already of asthma

Sator L, Horner A, Studnicka M, Lamprecht B, Kaiser B, McBurnie MA, et al. Overdiagnosis of COPD in Subjects With Unobstructed Spirometry: A BOLD Analysis. Chest. 2019;156(2):277-88.


We must be doing better in UK (Airway Flow Obstruction)

● Data in Care and Health Information Analytics (CHIA) database -

● 14,378 patients with diagnosed COPD (mean ± SD age 68.8 ± 10.7 years)

● FEV1/FVC% was recorded in 12,491 (86.9%) patients: median (IQR) 5 (3, 7) measurements.

● 6550 (52.4%) had persistent AFO,

● 4507 (36.1%) variable AFO

● 1434 (11.5%) absent AFO.

● 13.13% had no record of spirometry in their notes

Josephs L, Culliford D, Johnson M, Thomas M. COPD overdiagnosis in primary care: a UK observational study of consistency of airflow obstruction. npj Primary Care Respiratory Medicine. 2019;29(1):33.


So who were more likely to have variable / absent AFO

● Female

● Non smoker

● Higher BMI,

● More co-morbidities,

● Treatment: Diagnosed with COPD – but absent AFO

● 57% received LABA (50% in those with no asthma diagnosed either)

● 60% had ICS (49% in those without asthma)

Josephs L, Culliford D, Johnson M, Thomas M. COPD overdiagnosis in primary care: a UK observational study of consistency of airflow obstruction. npj Primary Care Respiratory Medicine. 2019;29(1):33.


Artificial Intelligence in the respiratory world

● 6000 spirometry interpretations by 120 pulmonologists (88 senior, 32 more junior)

● Pattern accuracy 74.4%

● Diagnostic accuracy 44.6% (+-8.7)

● Centre 39-51%

● Individual 24-62%

● Senior 45% / Junior 43.6% (NS) - not related to age / clinical experience!

● University 44.1% Non-university 45.2%

● AI (taking 0.2 seconds) – trained with 1500 cases

● Pattern accuracy 100%

● Accuracy 82% (esp COPD, neuromuscular, ILD and normal)

Topalovic M, Das N, Burgel P-R, Daenen M, Derom E, Haenebalcke C, et al. Artificial intelligence outperforms pulmonologists in the interpretation of pulmonary function tests. European Respiratory Journal. 2019;53(4):1801660.

2019 PCRS Respiratory ConferenceHoare S, Kelly MP, Barclay S. Home care and end-of-life hospital admissions: a retrospective interview study in English primary

and secondary care. British Journal of General Practice. 2019;69(685):e561-e9.


We know this as clinicians – but do commissioners know and want things to change?

● “Challenges in home care provision led to hospital admissions. Home end-of-life care depended on substantial input from family and professional carers, both of which were under-resourced.

● Where either care was insufficient to meet the needs of patients, home was no longer deemed to be desirable by healthcare staff and hospital care was sought.”

Hoare S, Kelly MP, Barclay S. Home care and end-of-life hospital admissions: a retrospective interview study in English primary and secondary care. British Journal of General Practice. 2019;69(685):e561-e9.


Postma DS, Brightling C, Baldi S, Van den Berge M, Fabbri LM, Gagnatelli A, et al. Exploring the relevance and extent of small airways dysfunction in asthma (ATLANTIS): baseline data from a prospective cohort study. Lancet Respir Med. 2019;7(5):402-16.


Small airways disease – important for the future

● SAD is a complex and silent signature of asthma that is likely to be directly or indirectly captured by combinations of physiological tests, such as spirometry, body plethysmography, impulse oscillometry, and multiple breath nitrogen washout.

● SAD is present across patients with all severities of asthma, but it is particularly prevalent in severe disease.

● The clinical classification of SAD into two groups (a milder and a more severe group) by use of impulse oscillometry and spirometry, which are easy to use, is meaningful given its association with GINA severity stages, asthma control, quality of life, and exacerbations.

Postma DS, Brightling C, Baldi S, Van den Berge M, Fabbri LM, Gagnatelli A, et al. Exploring the relevance and extent of small airways dysfunction in asthma (ATLANTIS): baseline data from a prospective cohort study. Lancet Respir Med. 2019;7(5):402-16.

2019 PCRS Respiratory ConferencePanagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019;366:l4185.


● Design - Systematic review and meta-analysis.

● Results

● 7313 records identified, 70 studies involving

● 337 025 patients were included in the meta-analysis.

● Prevalence for preventable patient harm was 6% (95% CI interval 5% to 7%).

● Pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death.

● Drugs accounted for 25% of these

● More severe problems in intensive care / surgery

Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019;366:l4185.

2019 PCRS Respiratory ConferenceSalisbury H. Helen Salisbury: Do we need integration? BMJ. 2019;366:l4614.

2019 PCRS Respiratory ConferenceStewart D, McCambridge J. Alcohol complicates multimorbidity in older adults. BMJ. 2019;365:l4304.


Faculty of Pain Medicine. Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain. Available on line at: https://wwwfpmacuk/faculty-of-pain-medicine/opioids-aware. 2019.

https://wwwfpmacuk/faculty-of-pain-medicine/opioids-aware.

2019 PCRS Respiratory ConferenceWilding JPH, Mooney V, Pile R. Should obesity be recognised as a disease? BMJ. 2019;366:l4258.


Pros…..and we still blame our patients

● Obesity has rapidly increased in prevalence and now affects 29% of the population in England.

● Metabolic complications include type 2 diabetes, fatty liver disease, and hormone dependent cancers; mechanical complications of joint pain, arthritis, increased obstetric risk, and sleep apnoea are common, and obesity may adversely affect mental health, partly because of stigmatisation

● Studies in twins show that 40-70% of the variability in weight is inherited

● More than 200 gene variations influence weight

● Most of these genes, including those with variants that cause early onset obesity, are expressed in the brain and involved in appetite regulation

● Environmental factors (social / financial / some environments are obesogenic)

Wilding JPH, Mooney V, Pile R. Should obesity be recognised as a disease? BMJ. 2019;366:l4258.


Con -

● “Good morning, doc. As you can see, I have been entirely successful in my pre-emptive strike against anorexia!”

● “Labelling obesity as a disease risks reducing autonomy, disempowering and robbing people of the intrinsic motivation that is such an important enabler of change.”

● It encourages fatalism, promoting the fallacy that genetics are destiny.

Wilding JPH, Mooney V, Pile R. Should obesity be recognised as a disease? BMJ. 2019;366:l4258.


Should we be switching to cheaper inhalers?

● (Switch – without being seen)

● Methods: Asthma and COPD patients (UK primary care health records 2000 – 2016)

● A self-controlled case series was used to estimate incidence rate ratios (IRR); comparing outcome rates during the risk period, 3 months after the exposure (financially motivated switch), and control periods (preswitch and postrisk period).

● Four outcomes were assessed: disease exacerbation, general practitioner consultation, non-specific respiratory events and adverse-medication events.

Bloom CI, Douglas I, Olney J, D'Ancona G, Smeeth L, Quint JK. Cost saving of switching to equivalent inhalers and its effect on health outcomes. Thorax. 2019:thoraxjnl-2018-212957


Results (1)

● 569 901 asthma and 171 231 COPD regular inhaler users

● 2% of those with asthma and 6% with COPD had been switched

● Inhaler switches between a brand-to-generic inhaler, and all other switches (brand-to-brand, generic-to-generic, generic-to-brand), were associated with reduced exacerbations (brand-to-generic: IRR=0.75, 95% CI 0.64 to 0.88; all other: IRR=0.79, 95% CI 0.71 to 0.88)

● Gender, age, therapeutic class, inhaler device and inhaler-technique checks did not significantly modify this association (p>0.05).

● The rate of consultations, respiratory-events and adverse-medication events did not change significantly (consultations: IRR=1.00, 95% CI 0.99 to 1.01; respiratory-events: IRR=0.96, 95% CI 0.95 to 0.97; adverse-medication-events: IRR=1.05, 95% CI 0.96 to 1.15)



Results (2)

● Adherence significantly increased post-switch (median MPR: pre-switch=54%, post-switch=62%; p<0.001).

● Switching patients, in the cohort of regular inhaler users, to the cheapest equivalent inhaler, could have saved around £6 million annually.

● Conclusion

● Switching to an equivalent inhaler in patients with asthma or COPD appeared safe and did not negatively affect patient’s health or healthcare utilisation.



Keeley D, Partridge MR. Emergency MDI and spacer packs for asthma and COPD. The Lancet Respiratory Medicine. 2019;7(5):380-2.Keeley D. Everyone with asthma should have a metered dose inhaler and a spacer. BMJ. 2018;360.

2019 PCRS Respiratory Conferencewang qingsong: china pavilion, venice biennale 2013

https://www.designboom.com/art/wang-qingsong-china-pavilion-venice-artbiennale-2013/


British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 158 British Guidelines for the Management of Asthma. Guideline. 2019.


Global Initiative for Asthma Committee. Global Strategy for Asthma Management and Prevention (2019 Update) Available from: www.gina.org. GINA; 2019.

http://www.gina.org./

2019 PCRS Respiratory Conference NICE CG115 COPD; GOLD 2018 Report.

NICE and GOLD Fundamentals of COPD care - agreement

Offer treatment and support to stop smoking

Offer pneumococcal and influenza vaccines

Offer pulmonary rehabilitation if indicated

Co-develop a personalised self-management plan

Optimise treatment for comorbidities

These treatments and plans should be revisited at every

review

National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guideline NG115. 2018


Lets work through GOLD (only)

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD (2019). 2018.


So what does this GOLD mean after diagnosis?


LAMA / LABA


Others to check out

● BTS Bronchiectasis in Adults (Jan 2019)

● NICE Acute cough – antimicrobial guidance (Feb 2019)

● Inhaler choice decision support tool (April 2019)

Later this year

● NICE Bronchiolitis guideline update

● NICE Community acquired pneumonia – anti microbial prescribing

● NICE Indoor air pollution guideline

● BTS Clinical statement on air travel for people with respiratory disease


European Sex Toy League Table (2019)

https://www.theatlas.com/charts/SyG2QUi_g

2019 PCRS Respiratory Conferencewang qingsong: china pavilion, venice biennale 2013

https://www.designboom.com/art/wang-qingsong-china-pavilion-venice-artbiennale-2013/


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journal overload - pcrs-uk.org...midlife cardiorespiratory fitness (crf) and the long-term risk of...

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