Speaker
Shawn Aaron, MD
Professor
University of Ottawa
Keywords
Respiratory Symptoms; Guideline-Directed Care; Standard Care; Phone Recruitment; Randomized Controlled Trial
Key Points
- Up to 70% of individuals with asthma or Chronic Obstructive Pulmonary Disease (COPD) remain undiagnosed. The 2007 – 2012 U.S. National Health and Nutritional Examination survey of randomly selected American adults found obstructive lung disease in 13% of the sample, 71% of whom had never been diagnosed.
- Inspired by an encounter with a patient who had undiagnosed asthma, Dr. Aaron and his team developed three research questions for the Undiagnosed COPD and Asthma in the Population, or UCAP, study: 1) Can we find adults with undiagnosed asthma or COPD in the community? 2) Are they sick? 3) Can we treat them early to improve health outcomes?
- They used a case-finding approach to identify symptomatic individuals with undiagnosed cases of either disease. Case-finding evaluates subgroups of people at increased risk of a disease; in this case, they looked at adults with undiagnosed respiratory symptoms.
- To identify that sample, the team called over 1.1 million Canadian residents. After initial screening of the 50,000 contacts who indicated that there was someone in the household with respiratory symptoms, 2,857 of 4,272 eligible participants underwent testing with spirometry. A fifth of the sample had undiagnosed asthma or COPD.
- Compared to a healthy age- and sex-matched control group, the adults with undiagnosed COPD or asthma had lower quality of life, worse symptoms and health status, and significant work impairment.
- To determine whether early diagnosis of previously undiagnosed symptomatic asthma or COPD, and subsequent treatment, improves health outcomes, the team randomly assigned the participants diagnosed with asthma or COPD to the intervention or to usual care.
- All participants and participants’ primary care providers (PCPs) were given a copy of their interpreted spirometry report with their diagnosis. The intervention group received treatment from a pulmonologist and an asthma/COPD educator; the control group received usual care from their PCP.
- Guideline-directed treatment of undiagnosed COPD or asthma by a pulmonologist and an educator was found to improve healthcare utilization, symptoms, quality of life and lung function more than usual care.
- In practice, not all patients can or will be treated by a lung specialist. The trial results indicated that the health of people with asthma or COPD will still improve if they are diagnosed and receive the usual care.
Discussion Themes
Cold-calling, though ultimately effective, was an expensive and inefficient screening and recruitment method. In the future, the team will attempt to drive people with respiratory symptoms to the study website by advertising in the community and on social media.
The research team considered a few iterations of the control arm, including a design in which the control group was informed of their diagnosis later on in the trial. They decided to compare guideline-directed treatment to usual care after reviewing the ethical considerations and the potential for inappropriate randomization.
Case-finding in a sample of people living in asthma or COPD “hotspots,” or in other high-risk populations, could increase the efficiency of the method but narrow the applicability of the findings.
Volunteer bias likely impacted the diversity of the sample; a disproportionate number of the volunteers were white (97%) and older, with an average age of 63.
In this Friday’s PCT Grand Rounds, Jody Cioliono will present 
In this Friday’s PCT Grand Rounds, Dr. Melanie Meersch-Dini of University Hospital Münster (Germany) will present 
In this Friday’s PCT Grand Rounds, Dr. Justin Ezekowitz of University of Alberta will present “SODIUM-HF: Should Our Patients Consume Less Dietary Sodium?” 