Triage of frail elderly with reduced exercise tolerance in primary care (TREE). a clustered randomized diagnostic study

BMC Public Health

Frans H Rutten¹  Arno W Hoes¹  Johannes B Reitsma¹  Loes CM Bertens¹  Karel GM Moons¹  Yvonne van Mourik¹ 

[1] Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, PO box 85500, Stratenum 6.131, 3508, AB, Utrecht, the Netherlands

关键词: Screening;    Elderly;    Frail;    COPD;    Heart failure;    Breathlessness;    Dyspnoea;    Reduced exercise tolerance;   

Others  :  1163590
DOI  :  10.1186/1471-2458-12-385

 received in 2012-03-17, accepted in 2012-05-28,  发布年份 2012

【 摘 要 】

Background

Exercise reduced tolerance and breathlessness are common in the elderly and can result in substantial loss in functionality and health related quality of life. Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common underlying causes, but can be difficult to disentangle due to overlap in symptomatology. In addition, other potential causes such as obesity, anaemia, renal dysfunction and thyroid disorders may be involved.

We aim to assess whether screening of frail elderly with reduced exercise tolerance leads to high detection rates of HF, COPD, or alternative diagnoses, and whether detection of these diseases would result in changes in patient management and increase in both functionality and quality of life.

Methods/Design

A cluster randomized diagnostic trial. Primary care practices are randomized to the diagnostic-treatment strategy (screening) or care as usual.

Patient population: Frail (defined as having three or more chronic or vitality threatening diseases and/or receiving five or more drugs chronically during the last year) community-dwelling persons aged 65 years and older selected from the electronic medical files of the participating general practitioners. Those with reduced exercise tolerance or moderate to severe dyspnoea (≥2 score on the Medical Research Counsel dyspnoea scale) are included in the study.

The diagnostic screening in the intervention group includes history taking, physical examination, electrocardiography, spirometry, blood tests, and echocardiography. Subsequently, participants with new diagnoses will be managed according to clinical guidelines. Participants in the control arm receive care as usual. All participants fill out health status and other relevant questionnaires at baseline and after 6 months of follow-up.

Discussion

This study will generate information on the yield of screening for previously unrecognized HF, COPD and other chronic diseases in frail elderly with reduced exercise tolerance and/or exercise induced dyspnoea. The cluster randomized comparison will reveal whether this yield will result in subsequent improvements in functional health and/or health related quality of life.

Trial registration

ClinicalTrials.gov NCT01148719

【 授权许可】

   
2012 van Mourik et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Landahl S, Steen B, Svanborg A: Dyspnea in 70-year-old people. Acta Med Scand 1980, 207:225-230.
• [2]Mulrow CD, Lucey CR, Farnett LE: Discriminating causes of dyspnea through clinical examination. J Gen Intern Med 1993, 8:383-392.
• [3]Hogg K, Swedberg K, McMurray J: Heart failure with preserved left ventricular systolic function; epidemiology, clinical characteristics, and prognosis. J Am Coll Cardiol 2004, 43:317-327.
• [4]Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, Tavazzi L, Smiseth OA, Gavazzi A, Haverich A, et al.: Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 2005, 26:1115-1140.
• [5]Rutten FH, Cramer MJ, Lammers JW, Grobbee DE, Hoes AW: Heart failure and chronic obstructive pulmonary disease: An ignored combination? Eur J Heart Fail 2006, 8:706-711.
• [6]Rutten FH, Cramer MJ, Grobbee DE, Sachs AP, Kirkels JH, Lammers JW, Hoes AW: Unrecognized heart failure in elderly patients with stable chronic obstructive pulmonary disease. Eur Heart J 2005, 26:1887-1894.
• [7]Bednarek M, Maciejewski J, Wozniak M, Kuca P, Zielinski J: Prevalence, severity and underdiagnosis of COPD in the primary care setting. Thorax 2008, 63:402-407.
• [8]Geijer RM, Sachs AP, Hoes AW, Salome PL, Lammers JW, Verheij TJ: Prevalence of undetected persistent airflow obstruction in male smokers 40–65 years old. Fam Pract 2005, 22:485-489.
• [9]Remes J, Miettinen H, Reunanen A, Pyorala K: Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 1991, 12:315-321.
• [10]Wheeldon NM, MacDonald TM, Flucker CJ, McKendrick AD, McDevitt DG, Struthers AD: Echocardiography in chronic heart failure in the community. Q J Med 1993, 86:17-23.
• [11]Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, Fukuchi Y, Jenkins C, Rodriguez-Roisin R, Van WC, et al.: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2007, 176:532-555.
• [12]Schilling RS, Hughes JP, Dingwall-Fordyce I: Disagreement between observers in an epidemiological study of respiratory disease. Br Med J 1995, 1:65-68.
• [13]Campbell MJ: Cluster randomized trials in general (family) practice research. Stat Methods Med Res 2000, 9:81-94.
• [14]The Minimal Data Set http://www.nationaalprogrammaouderenzorg.nl/het-programma/minimale-data-set/ webcite
• [15]Aaronson NK, Muller M, Cohen PD, Essink-Bot ML, Fekkes M, Sanderman R, Sprangers MA, te VA, Verrips E: Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol 1998, 51:1055-1068.
• [16]McHorney CA, Ware JE, Raczek AE: The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 1993, 31:247-263.
• [17]Blackburn H, Keys A, Simonson E, Rautaharju P, Punsar S: The electrocardiogram in poplation studies A classification system. Circulation 1960, 21:1160-1175.
• [18]Redfield MM, Jacobsen SJ, Burnett JC, Mahoney DW, Bailey KR, Rodeheffer RJ: Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemie. JAMA 2003, 289:194-202.
• [19]Bailie GR, Uhlig K, Levey AS: Clinical practice guidelines in nephrology: evaluation, classification, and stratification of chronic kidney disease. Pharmacotherapy 2005, 25(4):491-502.
• [20]Brooks RG, Jendteg S, Lindgren B, Persson U, Bjork S: EuroQol: health-related quality of life measurement. Results of the Swedish questionnaire exercise. Health Policy 1991, 18:37-48.
• [21]Weinberger M, Samsa GP, Schmader K, Greenberg SM, Carr DB, Wildman DS: Comparing proxy and patients’ perceptions of patients’ functional status: results from an outpatient geriatric clinic. J Am Geriatr Soc 1992, 40:585-588.
• [22]Rutten FH, Moons KG, Cramer MJ, Grobbee DE, Zuithoff NP, Lammers JW, Hoes AW: Recognising heart failure in elderly patients with stable chronic obstructive pulmonary disease in primary care: cross sectional diagnostic study. BMJ 2005, 331:1379.
• [23]Oostenbrink JB, Koopmanschap MA, Rutten FF: Standardisation of costs: the Dutch Manual for costing in economic evaluations. PharmacoEconomics 2002, 20:443-454.