Less health care use with lung specialist-directed treatment in undiagnosed COPD, asthma

Key takeaways:

• Disease-specific quality of life and symptoms improved in undiagnosed COPD/asthma with either pulmonologist- or primary care-directed treatment.
• Greater improvements were seen with specialist direction.

SAN DIEGO — Receiving treatment from a lung specialist for undiagnosed COPD or asthma lowered annual respiratory illness-related health care usage, according to research presented at the American Thoracic Society International Conference.

Data from this study were also simultaneously published in The New England Journal of Medicine.

“If we find [people with undiagnosed COPD/asthma] and then we provide them with guideline-directed treatment of undiagnosed COPD or asthma by pulmonologist/educator, we improve their health care utilization, we improve their symptoms, their quality of life and their lung function over 1 year, and that improvement is even greater than that provided by usual care,” Shawn D. Aaron, MD, senior scientist and lung specialist at The Ottawa Hospital and professor at University of Ottawa, said during his presentation.

In a multicenter, randomized, controlled trial, Aaron and colleagues evaluated 508 adults with undiagnosed COPD or asthma on spirometry to compare health care utilization for respiratory illness among those who received an evaluation from a pulmonologist and an asthma-COPD educator (intervention; n = 253; mean age, 63.4 years; 64% men) vs. those who received usual care from a primary care practitioner (n = 255; mean age, 62.8 years; 58% men).

Adults in the intervention group started guideline-based care per the instruction of the pulmonologist and asthma-COPD educator, according to researchers.

Researchers also assessed changes in baseline FEV₁, disease-specific quality of life using St. George Respiratory Questionnaire (SGRQ) scores and symptom burden using COPD assessment test (CAT) scores at 1 year between the two groups.

Notably, both groups had comparable demographics and clinical characteristics at baseline.

Of the two groups, researchers observed that a greater proportion of adults receiving the intervention started a new treatment for asthma or COPD in the assessment period than those receiving usual care (92% vs. 60%).

Some aids provided to those in the intervention group included exercise advice (61%), pharmacologic treatment for smoking cession (53% of current smokers in the group), action plans (35%), weight loss advice (22%) and pulmonary rehabilitation referrals (8%).

Researchers noted that withdrawals/deaths prior to the end of the assessment period occurred in both the intervention group (n = 16) and the usual care group (n = 24).

In the intervention group, the annualized rate of health care utilization for respiratory illness was 0.53 events per person-year, whereas in the usual care group, this rate was higher at 1.12 events per person-year (IRR = 0.48; 95% CI, 0.36-0.63; P < .001).

Compared with the usual care group, the intervention group also had lower rates for other visit types, such as:

• hospitalizations (0.021 vs. 0.03 per person-year; IRR = 0.71; 95% CI, 0.17-2.99);
• ED visits (0.069 vs. 0.075 per person-year; IRR = 0.92; 95% CI, 0.46-1.87);
• primary care visits (0.36 vs. 0.91 per person-year; IRR = 0.39; 95% CI, 0.29-0.53); and
• specialist visits (0.085 vs. 0.096 per person-year; IRR = 0.89; 95% CI, 0.45-1.76).

Between baseline and the 1-year mark, researchers observed a larger improvement in quality of life via SGRQ scores among adults who received the intervention (–10.2 points) vs. usual care (–6.8 points).

The intervention group also had more improvement in CAT scores than the usual care group from baseline to 1 year (–3.8 points vs. –2.6 points).

“Even the control group, who were only randomized to regular care by a primary care practitioner, had SGRQ improvement and CAT score improvements over 1 year that were greater than the [minimal clinically important difference],” Aaron said. “The good news is that as long as you find a patient, diagnose their symptoms and put them on a path to see any health care provider, they will improve their quality of life relative to their baseline.”

Notably, the intervention group had higher odds than the usual care group for achieving a minimum decrease of 4 points on the SGRQ (OR = 1.38; 95% CI, 0.95-2), as well as for achieving a minimum decrease of 2 points on the CAT (OR = 1.57; 95% CI, 1.08-2.27).

This pattern continued when researchers assessed changes in baseline prebronchodilator FEV₁, with larger 1-year improvements seen among those receiving the intervention compared with those receiving usual care (+119 mL vs. +22 mL).

In both groups, two adults died. Sudden cardiac arrest was the reason behind two of the deaths. Other reasons included lung cancer and liver failure.

Between the two groups, researchers observed a comparable number of serious adverse events (intervention, five events; usual care, seven events) and adverse events (intervention, 24 events; usual care, 16 events).

When discussing study limitations, Aaron noted that keeping knowledge of a COPD/asthma diagnosis from individuals in the usual care/control group “would have been unethical.”

“There’s no getting around the fact that patients may have been more likely to see their physicians after they’ve received their diagnosis,” he said during his presentation. “Before they were suffering at home and not going to see doctors, but once we told them they had asthma or COPD, many of them in the control group ran to see a doctor. Maybe that’s why their outcomes improved in the control group ... because they were getting treatment, but we couldn’t avoid that.”

References:

• Aaron SD, et al. N Eng J Med. 2024;doi:10.1056/NEJMoa2401389.
• World-first trial shows benefits of finding, treating undiagnosed asthma and COPD. https://www.eurekalert.org/news-releases/1044550. Published May 19, 2024. Accessed May 19, 2024.