Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
Department of Medicine, University of California, San Francisco, CA, USA.
BMC Pulm Med. 2024 Sep 2;24(1):433. doi: 10.1186/s12890-024-03239-8.
Research studies typically quantify acute respiratory exacerbation episodes (AECOPD) among people with chronic obstructive pulmonary disease (COPD) based on self-report elicited by survey questionnaire. However, AECOPD quantification by self-report could be inaccurate, potentially rendering it an imprecise tool for identification of those with exacerbation tendency.
Determine the agreement between self-reported and health records-documented quantification of AECOPD and their association with airway inflammation.
We administered a questionnaire to elicit the incidence and severity of respiratory exacerbations in the three years preceding the survey among current or former heavy smokers with or without diagnosis of COPD. We then examined electronic health records (EHR) of those with COPD and those without (tobacco-exposed persons with preserved spirometry or TEPS) to determine whether the documentation of the three-year incidence of moderate to very severe respiratory exacerbations was consistent with self-report using Kappa Interrater statistic. A subgroup of participants also underwent bronchoalveolar lavage (BAL) to quantify their airway inflammatory cells. We further used multivariable regressions analysis to estimate the association between respiratory exacerbations and BAL inflammatory cell composition with adjustment for covariates including age, sex, height, weight, smoking status (current versus former) and burden (pack-years).
Overall, a total of 511 participants completed the questionnaire, from whom 487 had EHR available for review. Among the 222 participants with COPD (70 ± 7 years-old; 96% male; 70 ± 38 pack-years smoking; 42% current smoking), 57 (26%) reported having any moderate to very severe AECOPD (m/s-AECOPD) while 66 (30%) had EHR documentation of m/s-AECOPD. However, 42% of those with EHR-identified m/s-AECOPD had none by self-report, and 33% of those who reported m/s-AECOPD had none by EHR, suggesting only moderate agreement (Cohen's Kappa = 0.47 ± 0.07; P < 0.001). Nevertheless, self-reported and EHR-identified m/s-AECOPD events were both associated with higher BAL neutrophils (ß ± SEM: 3.0 ± 1.1 and 1.3 ± 0.5 per 10% neutrophil increase; P ≤ 0.018) and lymphocytes (0.9 ± 0.4 and 0.7 ± 0.3 per 10% lymphocyte increase; P ≤ 0.041). Exacerbation by either measure combined was associated with a larger estimated effect (3.7 ± 1.2 and 1.0 ± 0.5 per 10% increase in neutrophils and lymphocytes, respectively) but was not statistically significantly different compared to the self-report only approach. Among the 184 TEPS participants, there were fewer moderate to very severe respiratory exacerbations by self-report (n = 15 or 8%) or EHR-documentation (n = 9 or 5%), but a similar level of agreement as those with COPD was observed (Cohen's Kappa = 0.38 ± 0.07; P < 0.001).
While there is modest agreement between self-reported and EHR-identified m/s-AECOPD, events are missed by relying on either method alone. However, m/s-AECOPD quantified by self-report or health records is associated with BAL neutrophilia and lymphocytosis.
研究通常根据问卷调查中自我报告的方式来量化慢性阻塞性肺疾病（COPD）患者的急性呼吸加重事件（AECOPD）。然而，基于自我报告的 AECOPD 量化可能不够准确，从而使其成为识别有加重倾向人群的不精确工具。
确定自我报告和健康记录中记录的 AECOPD 量化之间的一致性，并评估其与气道炎症的相关性。
我们对目前或曾经的重度吸烟者进行问卷调查，以了解他们在调查前三年中呼吸加重的发生率和严重程度，这些吸烟者要么患有 COPD，要么没有（有或无 COPD 的吸烟暴露者，保留了肺功能或 TEPS）。然后，我们检查了 COPD 患者和无 COPD 患者（有或无 COPD 的吸烟暴露者，保留了肺功能或 TEPS）的电子健康记录（EHR），以使用 Kappa 评分统计量确定过去三年中度至重度呼吸加重事件的记录是否与自我报告一致。一个亚组参与者还接受了支气管肺泡灌洗（BAL）以量化其气道炎症细胞。我们还进一步使用多变量回归分析来估计呼吸加重与 BAL 炎症细胞组成之间的关联，同时调整了年龄、性别、身高、体重、吸烟状态（当前与既往）和吸烟量（包年）等混杂因素。
总体而言，共有 511 名参与者完成了问卷调查，其中 487 名参与者有 EHR 可供审查。在 222 名 COPD 患者中（70±7 岁；96%为男性；70±38 包年吸烟；42%为当前吸烟者），57 名（26%）报告有任何中度至重度 AECOPD（m/s-AECOPD），而 66 名（30%）有 EHR 记录 m/s-AECOPD。然而，42%的 EHR 确定的 m/s-AECOPD 患者自我报告中没有，33%的自我报告有 m/s-AECOPD 的患者 EHR 中没有，表明只有中度的一致性（Cohen's Kappa=0.47±0.07；P<0.001）。然而，自我报告和 EHR 确定的 m/s-AECOPD 事件均与 BAL 中性粒细胞（ß±SEM：3.0±1.1 和 1.3±0.5 每增加 10%中性粒细胞；P≤0.018）和淋巴细胞（0.9±0.4 和 0.7±0.3 每增加 10%淋巴细胞；P≤0.041）的增加相关。通过任何一种方法确定的加重事件都与更大的估计效应相关（分别为 3.7±1.2 和 1.0±0.5 每增加 10%的中性粒细胞和淋巴细胞），但与仅通过自我报告的方法相比，并无统计学意义上的差异。在 184 名 TEPS 参与者中，自我报告（n=15 或 8%）或 EHR 记录（n=9 或 5%）的中度至重度呼吸加重事件较少，但观察到与 COPD 患者相似的一致性（Cohen's Kappa=0.38±0.07；P<0.001）。
虽然自我报告和 EHR 确定的 m/s-AECOPD 之间存在适度的一致性，但单独依靠任何一种方法都会遗漏事件。然而，自我报告或健康记录中确定的 m/s-AECOPD 与 BAL 中性粒细胞增多和淋巴细胞增多相关。
