Background-It is important to diagnose asthma at an early stage as early treatment may improve the prognosis in the long term. However, many patients do not present at an early stage of the condition so the physician may have diYculty with the diagnosis. A study was therefore undertaken to compare the proportion of patients who underpresented their respiratory symptoms with the proportion of underdiagnosed cases of asthma by the general practitioner (GP). A secondary aim was to investigate whether bad perception of dyspnoea by the patient was a determining factor in the underpresentation of asthma symptoms to the GP. Methods-A random sample of 1155 adult subjects from the general population in the eastern part of the Netherlands was screened for respiratory symptoms and lung function and the results were compared with the numbers of asthma related consultations registered in the medical files of the GP. In subjects with reduced lung function the ability to perceive dyspnoea was investigated during a histamine provocation test in subjects who did and did not report their symptoms to their GP. Results-Of the random sample of 1155 subjects 86 (7%) had objective airflow obstruction (forced expiratory volume in one second (FEV 1 ) below the reference value corrected for age, length, and sex minus 1.64SD on two occasions) and had symptoms suggestive of asthma. Of these 86 subjects only 29 (34%) consulted the GP, which indicates underpresentation by 66% of patients. Of all subjects with objective airflow obstruction who presented to their GP with respiratory symptoms, 23 (79%) were recorded in the medical files as having asthma, indicating underdiagnosis by the GP in 21% of cases. Of the subjects with objective airflow obstruction who visited the GP with respiratory symptoms 6% had bad perception of dyspnoea compared with 26% of those who did not present to the GP in spite of airflow obstruction ( 2 = 3.02, p = 0.08). Conclusions-Underpresentation to GPs of respiratory symptoms by asthmatic patients contributes significantly to the problem of underdiagnosis of asthma. Underdiagnosis by the GP seems to play a smaller role. Furthermore, there are indications that underpresentation of symptoms by the patient is at least partly explained by a worse perception of dyspnoea. (Thorax 2000;55:562-565)

The aim of this prospective study was to detect subjects in the general population with objective signs of chronic obstructive pulmonary disease (COPD) or asthma at an early stage. This was done by means of a two-stage protocol involving screening and a subsequent 2-yr monitoring of all subjects with positive results of screening. The study was done in 10 general practices located in the eastern part of the Netherlands. A random sample was taken from the general population aged 25 to 70 yr. All known COPD and asthma patients were excluded. A total of 1,749 subjects met the inclusion criteria: 1,155 subjects (66%) agreed to participate in the screening stage of the study. A total of 604 subjects (52.3%) showed symptoms or objective signs of COPD or asthma during the screening and were considered "positive." Of those with positive screening results, 384 subjects (64%) agreed to participate in the second, 2-yr monitoring stage of the study. The costs involved in detection were calculated for three different scenarios, as follows: (1) The detection of subjects with persistently decreased lung function or an increased level of bronchial hyperresponsiveness (BHR) during 6 mo of monitoring; (2) Scenario 1 plus the detection of subjects with a rapid decline in lung function with signs of BHR during 12 mo of monitoring; (3) Scenario 2 plus the detection of subjects with a moderate increase in the decline in lung function or signs of BHR during 24 mo of monitoring. The costs of lung function assessments, organization, transportation, and patient time were included. The costs were converted to United States dollars on the basis of purchasing power (1 United States dollar = 2.08 Netherlands guilders). During the second stage, 252 subjects were detected with objective signs of COPD or asthma at an early stage. Smoking status as a screening criterion was neither sensitive nor specific. Because there was no evidence of biased recruitment or selection during the program, the proportions of subjects found to have objective signs of COPD or asthma at an early stage could be extrapolated to the general population. Of the general population, 7.7% showed persistently reduced lung function or increased BHR. Another 12.5 % of the general population showed a rapid decline in lung function (> 80 ml/yr) in combination with signs of BHR, and a further 19.4% of the general population showed mild objective signs of COPD or asthma. The average costs per detected case varied from US$953 (Scenario 1) to US$469 (Scenario 3). In conclusion, detection of COPD or asthma at an early stage by means of a two-stage protocol was feasible at relatively little expense in comparison with other mass screening programs. Persistently decreased lung function or a rapid decline in lung function (Scenario 2) was observed in approximately 20% of the general adult population.

In general practice, diagnosis of chronic obstructive pulmonary disease (COPD) is hampered by underpresentation. A substantial proportion of subjects experiencing respiratory complaints do not consult their general practitioner (GP). In this study, the relationship between disease-specific quality of life and presentation of respiratory symptoms to a GP is investigated. A random sample from the general population (undiagnosed subjects) was screened for symptoms and objective signs of COPD (n=1,155). The lung function of subjects with symptoms of COPD was monitored for 6 months. During this period, 48 new COPD patients with a persistently reduced lung function (forced expiratory volume in one second (FEV1) less than or equal to the predicted value minus 2 SD) were detected. A disease-specific quality-of-life questionnaire (chronic respiratory questionnaire (CRQ)) was administered and clinical and GP consultation data were collected. Multivariate analysis showed that quality-of-life impairments due to dyspnoea and fatigue and variability in lung function (bronchial hyperresponsiveness, reversibility and peak expiratory flow rate variability) were related to medical consultation. Only 31% of the newly detected patients reported that they had ever visited their GP for respiratory complaints. A similarly low percentage was found in the rest of the sample (26%). It is concluded that the mere presence of respiratory symptoms or a (gradually) reduced lung function is insufficient reason for patients to seek medical help. Subjects are more likely to consult their general practitioner once their quality of everyday life is affected or they experience variability in lung function.

In this randomized controlled economic evaluation we compared guided asthma self-management with usual asthma care according to guidelines for Dutch family physicians. Nineteen family practices were randomized, and 193 adults with stable asthma (98 self-management, 95 usual care) were included and monitored for 2 years. We hypothesized that introducing self-management would not compromise asthma control and cost would be equal to or lower than in usual care. Patient-specific cost data were collected, preference-based utilities were assessed, and incremental cost per quality-adjusted life year (QALY) and successfully treated week gained was calculated. Self-management patients gained 0.039 QALY (95% confidence interval [CI], 0.003 to 0.075) and experienced 81 (95% CI, 78 to 84) successfully treated weeks in 2 years' time; the corresponding figures for usual care were 0.024 (95% CI, -0.022 to 0.071) and 75 (95% CI, 72 to 78). Total costs were 1,084 euros(95% CI, 938 to 1,228) for self-management and 1,097 euros (95% CI, 933 to 1,260) for usual care. Self-management patients consumed 1,680 (95% CI, 1,538 to 1,822) puffs of budesonide, usual care patients 1,897 (95% CI, 1,679 to 2,115). Mean productivity cost due to limited activity days was 213 euros lower among self-management patients. When all costs were included, self-management was cost-effective on all outcomes. The probability that self-management was cost-effective relative to usual care in terms of QALYs was 52%. We conclude that guided self-management is a safe and efficient alternative approach compared with asthma treatment usually provided in Dutch primary care.

Background: A study was undertaken to determine the effectiveness of asthma self-management in general practice. Methods: Nineteen general practices were randomly allocated to usual care (UC) or self-management (SM). Asthma patients were included after confirmation of the GP diagnosis. Follow up was 2 years. Patients kept diary cards and visited the lung function laboratory every 6 months. Outcomes were number of successfully treated weeks, limited activity days, asthma specific quality of life, forced expiratory volume in 1 second (FEV 1 ), FEV 1 reversibility, concentration of histamine provoking a fall in FEV 1 of 20% or more (PC 20 histamine), and amount of inhaled steroids. Results: A total of 214 patients were included in the study (104 UC/110 SM; one third of the total asthma population in general practice); 62% were female. The mean percentage of successfully treated weeks per patient in the UC group was 72% (74/103 weeks) compared with 78% (81/105 weeks) in the SM group (p=0.003). The mean number of limited activity days was 1.2 (95% CI 0.5 to 1.9) in the SM group and 3.9 (95% CI 2.5 to 5.4) in the UC group. The estimated increase in asthma quality of life score was 0.10 points per visit in the UC group and 0.21 points per visit in the SM group (p=0.055). FEV 1 , FEV 1 reversibility, and PC 20 histamine did not change. There was a saving of 217 puffs of inhaled steroid per patient in favour of the SM group (p<0.05). Conclusion: Self-management lowers the burden of illness as perceived by patients with asthma and is at least as effective as the treatment usually provided in Dutch primary care. Self-management is a safe basis for intermittent treatment with inhaled corticosteroids.

These results demonstrate marked differences in persistence between AHT classes, with the highest persistence for ARBs and lowest for diuretics. Women were less persistent with their AHT compared to men. This low persistence leads to suboptimal treatment with a potential for substantial clinical consequences. Especially in women, more attention paid to AHT persistence patterns could improve their cardiovascular outcome.

In a two-stage detection program, subjects with signs of obstructive airway disease were selected from a random sample of the general population. Subjects (n = 82) were randomly assigned to either fluticasone propionate 250 microg twice a day or placebo twice a day via pMDI in a 1-yr, double-blind trial if they met criteria for persistent airway obstruction, increased bronchial hyperresponsiveness, or a rapid decline in FEV(1). Main outcome measures were postbronchodilator FEV(1), quality-adjusted life years (QALYs), and direct medical cost. Secondary measures were prebronchodilator FEV(1), PC(20), health-related quality of life (CRQ), symptom-free weeks, episode-free weeks, exacerbations, and indirect cost. Subgroup analysis was based on reversibility of obstruction. Analysis revealed a significant gain in postbronchodilator FEV(1) (98 ml/yr; p = 0.01) in favor of fluticasone. Only subjects with reversible obstruction showed an improvement in PC(20) (1.4 doubling dose; p = 0.03). Early treatment resulted in 2.7 QALYs gained per 100 treated subjects (p = 0.17) and in a clinically relevant improvement in dyspnea (CRQ; p < 0.03). The incremental cost effectiveness ratios were US$13,016/QALY for early treatment and US$33,921/QALY for the combination of detection and treatment. The incremental cost for one additional subject with a clinically relevant difference in dyspnea was US$1,674. In conclusion, early intervention with fluticasone resulted in significant health gains at relatively low financial cost.

The burdens of chronic obstructive airway diseases among the elderly in Europe, and worldwide, are increasing. Although asthma is common in all ages, the main airway disease affecting the elderly is chronic obstructive pulmonary disease (COPD). The aim of this paper is to review the prevalence and incidence of COPD on the basis of population studies. As the prevalence estimates of asthma are probably well known, only the incidence and remission of asthma will be discussed. The underdiagnosis of obstructive airway diseases is huge. A Dutch programme for early detection of obstructive airway disease among the elderly has, thus, been included in the presentation.A prerequisite for fighting COPD is to acquire data on illnesses and death. COPD has only recently been defined by cut-off points of spirometric outcomes, which is why measures of the prevalence of COPD have been distorted by use of a large number of different diagnostic terms and lung function criteria. The prevalence of clinicallyrelevant COPD has been estimated in several community studies to 4-6% in adult population samples, with a considerable increase by age, particularly among smokers. The incidence of COPD not only increases heavily with age and smoking, but also occupational exposure to dust, gas and damp. Precise estimates of the incidence of COPD or spirometric airflow limitation are not available.Demographic changes will result in a further substantial increase of chronic obstructive airway disorders, mainly chronic obstructive pulmonary disease, among the elderly. The increasing burden of chronic obstructive pulmonary disease has to come to the awareness of the public, governments, health authorities, and industry. Eur Respir J 2003; 21: Suppl. 40, 3s-9s.