Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE Study) (REDEFINE)

The purpose of this study is to evaluate the use of spirometry in identifying Diagnostic Error in COPD and Asthma patients.

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic lung diseases that are diagnosed in more than 30 million adults in the United States. However, diagnostic error (DE), is considered one of the most common and harmful of patient-safety problems by the Institute of Medicine, occur frequently with asthma and/or COPD and disproportionately affect minorities and the under-served. DE leads to lost opportunities to identify other chronic conditions, avoidable morbidity and mortality, unnecessary costs to patients and health systems, and poor quality of care. Shortness of breath or dyspnea, which is a common symptom in asthma and COPD, is also common for many other chronic conditions such as cardiovascular disease and obesity. A better understanding of the impact of DE and interventions to improve diagnostic accuracy in asthma and COPD are of particular importance for minorities and the under-served that are disproportionately affected by conditions leading to dyspnea. Spirometry is a simple, mobile, and essential test that is recommended by all major national and international guidelines for the diagnosis of asthma and COPD. However it is well known that spirometry is not routinely used in the ambulatory primary care setting and minorities and the underserved population are less likely to have spirometry leading to greater prevalence of DE. It has been estimated that 30-50% of people with an existing diagnosis of asthma and COPD were found to be misdiagnosed. Many of these patients misdiagnosed with asthma and/or COPD receive unnecessary respiratory pharmacotherapy which can pose serious risks including pneumonia, cardiovascular events, and mortality. In the setting of DE, these are considered avoidable and unnecessary respiratory pharmacotherapy use in minorities and the underserved that are already disproportionately affected by cardiovascular disease increases the risk of poorer outcomes. There is also DE in the diagnosis of asthma versus COPD, as these are both clinically distinct respiratory disorders with nuances in treatment recommendations. It is reported that African-Americans are considered to have increasing COPD mortality and are disproportionately affected by asthma death rates. However, as spirometry is not routinely performed and DE is prevalent in asthma and COPD, a component of these poor outcomes may be attributable to missed or delayed diagnoses of other chronic conditions or misdiagnosis within asthma and COPD. Barriers to the use of spirometry in primary care exist at provider and health systems levels. Previous studies show that primary care providers (PCPs) lack knowledge in existing guidelines and in implementing spirometry into primary care clinics. Beyond these barriers, PCPs struggle with logistical challenges such as time and workflow constraints with clinic visits lasting 15 minutes or less in patients with multiple chronic medical conditions. These predisposing and enabling factors explain why prior studies that included interventions to educate PCPs and incorporate spirometry by training personnel in primary care clinics have had limited results. A new paradigm to improve guideline based care for asthma and COPD which includes spirometry is needed and can lead to a better understanding of DE and improved patient safety and patient-centered outcomes. Health Promoters or Community health workers (CHWs) have been supplementing medical care by disseminating appropriate health care practices for underserved minority populations. However, studies which include diagnostic evaluations with spirometry for asthma and COPD have not been performed. The REDEFINE program (Reducing Diagnostic Error to Improve PatieNt SafEty in COPD and Asthma) will incorporate health promoters working collaboratively with PCPs to address identified barriers to guideline based care which includes spirometry for the diagnosis of asthma and COPD for patients at risk for DE. We propose a comparative effectiveness study to better understand the epidemiology of DE and to evaluate the effectiveness and economic impact of providing the REDEFINE program to an underserved, predominantly minority population with a diagnosis of asthma and/or COPD at risk for DE.

On the day of the outpatient visit, subjects will be advised to arrive 90 minutes prior to their clinic visit. The following will be performed. Subject demographic and contact information Co-morbid conditions Smoking history Medication history from patient and also from pharmacy used by subjects A respiratory exacerbation history in the past year Modified Medical Research Counsel (mMRC) dyspnea scale Quality of life measures Subjects will be advised to go to their clinics and be managed by their PCP thereafter. At the end of the 1 year followup, the patient will be scheduled for a pre and post BD spirometry and undergo the same spirometry protocol as the intervention group.

On the day of the outpatient visit, subjects will be advised to arrive 90 minutes prior to their clinic visit in the same building as the clinic site. The following information will be collected and procedures will be performed: Subject demographic and contact information Co-morbid conditions Smoking history Medication history from patient and also from pharmacy used by subjects A respiratory exacerbation history in the past year Modified Medical Research Counsel (mMRC) dyspnea scale Quality of life measures Pre and post-bronchodilator using Albuterol (BD) spirometry

Initial visit for the intervention group, an initial demographics form and health questionnaires. To evaluate the breathing, a pre and post broncho dilator will be performed as well as a spirometry test.

The post broncho dilator spirometry test will be preformed after a breathing medication called Albuterol. Albuterol is used in standard practice for COPD and is commonly used during spirometry.

At the end of the 1 year followup, the patient will be scheduled for a pre and post BD spirometry test and undergo the same spirometry protocol as the intervention group.

Determine differences in healthcare visits which include all-cause and respiratory related, acute care outpatient visits, emergency department visits, and hospitalizations between groups

Inclusion Criteria: 1.Age >40 years of age 2. Use of a maintenance respiratory medication and one of the following in the past year: 3. Diagnosis of asthma and/or COPD 4. No spirometry test performed in the past 3 years 5. Past or current smoker or is exposed to tobacco Exclusion Criteria: Unable to perform adequate spirometry Non-English speaking Pregnancy Plans to move from the Chicago Area within the next year Seen by pulmonary specialist in the past 3 years Any terminal illness with a life expectancy of <6 months Life threatening (e.g. intensive care admission and/or use of mechanical ventilation) respiratory failure event in the past year.

Akinbami LJ, Liu X. Chronic obstructive pulmonary disease among adults aged 18 and over in the United States, 1998-2009. NCHS Data Brief. 2011 Jun;(63):1-8.

Centers for Disease Control and Prevention (CDC). Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001--2009. MMWR Morb Mortal Wkly Rep. 2011 May 6;60(17):547-52.

Ball JR, Balogh E. Improving Diagnosis in Health Care: Highlights of a Report From the National Academies of Sciences, Engineering, and Medicine. Ann Intern Med. 2016 Jan 5;164(1):59-61. doi: 10.7326/M15-2256. Epub 2015 Sep 29. No abstract available.

Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press (US); 2015 Dec 29. Available from http://www.ncbi.nlm.nih.gov/books/NBK338596/

Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. N Engl J Med. 2015 Dec 24;373(26):2493-5. doi: 10.1056/NEJMp1512241. Epub 2015 Nov 11. No abstract available.

Khullar D, Jha AK, Jena AB. Reducing Diagnostic Errors--Why Now? N Engl J Med. 2015 Dec 24;373(26):2491-3. doi: 10.1056/NEJMp1508044. Epub 2015 Sep 23. No abstract available.

Global Initiative for Asthma. Global strategy for asthma management and prevention. Bethesda, MD, USA: GINA;2015

Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, Marciniuk DD, Denberg T, Schunemann H, Wedzicha W, MacDonald R, Shekelle P; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91. doi: 10.7326/0003-4819-155-3-201108020-00008.

National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138. doi: 10.1016/j.jaci.2007.09.043. Erratum In: J Allergy Clin Immunol. 2008 Jun;121(6):1330.

Bolton CE, Ionescu AA, Edwards PH, Faulkner TA, Edwards SM, Shale DJ. Attaining a correct diagnosis of COPD in general practice. Respir Med. 2005 Apr;99(4):493-500. doi: 10.1016/j.rmed.2004.09.015. Epub 2004 Nov 11.

Damarla M, Celli BR, Mullerova HX, Pinto-Plata VM. Discrepancy in the use of confirmatory tests in patients hospitalized with the diagnosis of chronic obstructive pulmonary disease or congestive heart failure. Respir Care. 2006 Oct;51(10):1120-4.

Han MK, Kim MG, Mardon R, Renner P, Sullivan S, Diette GB, Martinez FJ. Spirometry utilization for COPD: how do we measure up? Chest. 2007 Aug;132(2):403-9. doi: 10.1378/chest.06-2846. Epub 2007 Jun 5.

Lee TA, Bartle B, Weiss KB. Spirometry use in clinical practice following diagnosis of COPD. Chest. 2006 Jun;129(6):1509-15. doi: 10.1378/chest.129.6.1509.

Mapel DW, Picchi MA, Hurley JS, Frost FJ, Petersen HV, Mapel VM, Coultas DB. Utilization in COPD: patient characteristics and diagnostic evaluation. Chest. 2000 May;117(5 Suppl 2):346S-53S. doi: 10.1378/chest.117.5_suppl_2.346s.

Miravitlles M, de la Roza C, Naberan K, Lamban M, Gobartt E, Martin A. Use of spirometry and patterns of prescribing in COPD in primary care. Respir Med. 2007 Aug;101(8):1753-60. doi: 10.1016/j.rmed.2007.02.019. Epub 2007 Apr 19.

Mularski RA, Asch SM, Shrank WH, Kerr EA, Setodji CM, Adams JL, Keesey J, McGlynn EA. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest. 2006 Dec;130(6):1844-50. doi: 10.1378/chest.130.6.1844.

Walters JA, Hansen E, Mudge P, Johns DP, Walters EH, Wood-Baker R. Barriers to the use of spirometry in general practice. Aust Fam Physician. 2005 Mar;34(3):201-3.

O'Dowd LC, Fife D, Tenhave T, Panettieri RA Jr. Attitudes of physicians toward objective measures of airway function in asthma. Am J Med. 2003 Apr 1;114(5):391-6. doi: 10.1016/s0002-9343(03)00007-x.

Ghattas C, Dai A, Gemmel DJ, Awad MH. Over diagnosis of chronic obstructive pulmonary disease in an underserved patient population. Int J Chron Obstruct Pulmon Dis. 2013;8:545-9. doi: 10.2147/COPD.S45693. Epub 2013 Nov 12.

Prieto-Centurion V, Rolle AJ, Au DH, Carson SS, Henderson AG, Lee TA, Lindenauer PK, McBurnie MA, Mularski RA, Naureckas ET, Vollmer WM, Joese BJ, Krishnan JA; CONCERT Consortium. Multicenter study comparing case definitions used to identify patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2014 Nov 1;190(9):989-95. doi: 10.1164/rccm.201406-1166OC.

Han MK, Postma D, Mannino DM, Giardino ND, Buist S, Curtis JL, Martinez FJ. Gender and chronic obstructive pulmonary disease: why it matters. Am J Respir Crit Care Med. 2007 Dec 15;176(12):1179-84. doi: 10.1164/rccm.200704-553CC. Epub 2007 Aug 2.

Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis of COPD. Chest. 2001 Jun;119(6):1691-5. doi: 10.1378/chest.119.6.1691.

Franks P, Clancy CM, Naumburg EH. Sex, access, and excess. Ann Intern Med. 1995 Oct 1;123(7):548-50. doi: 10.7326/0003-4819-123-7-199510010-00012. No abstract available.

Ohar J, Fromer L, Donohue JF. Reconsidering sex-based stereotypes of COPD. Prim Care Respir J. 2011 Dec;20(4):370-8. doi: 10.4104/pcrj.2011.00070.

Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ. Misdiagnosis of COPD and asthma in primary care patients 40 years of age and over. J Asthma. 2006 Jan-Feb;43(1):75-80. doi: 10.1080/02770900500448738.

Abramson MJ, Schattner RL, Sulaiman ND, Del Colle EA, Aroni R, Thien F. Accuracy of asthma and COPD diagnosis in Australian general practice: a mixed methods study. Prim Care Respir J. 2012 Jun;21(2):167-73. doi: 10.4104/pcrj.2011.00103.

Melbye H, Drivenes E, Dalbak LG, Leinan T, Hoegh-Henrichsen S, Ostrem A. Asthma, chronic obstructive pulmonary disease, or both? Diagnostic labeling and spirometry in primary care patients aged 40 years or more. Int J Chron Obstruct Pulmon Dis. 2011;6:597-603. doi: 10.2147/COPD.S25955. Epub 2011 Nov 17.

Griffiths C, Feder G, Wedzicha J, Foster G, Livingstone A, Marlowe GS. Feasibility of spirometry and reversibility testing for the identification of patients with chronic obstructive pulmonary disease on asthma registers in general practice. Respir Med. 1999 Dec;93(12):903-8. doi: 10.1016/s0954-6111(99)90057-4.

Sichletidis L, Chloros D, Spyratos D, Chatzidimitriou N, Chatziiliadis P, Protopappas N, Charalambidou O, Pelagidou D, Zarvalis E, Patakas D. The validity of the diagnosis of chronic obstructive pulmonary disease in general practice. Prim Care Respir J. 2007 Apr;16(2):82-8. doi: 10.3132/pcrj.2007.00016.

Walters JA, Walters EH, Nelson M, Robinson A, Scott J, Turner P, Wood-Baker R. Factors associated with misdiagnosis of COPD in primary care. Prim Care Respir J. 2011 Dec;20(4):396-402. doi: 10.4104/pcrj.2011.00039.

Buffels J, Degryse J, Liistro G, Decramer M. Differential diagnosis in a primary care population with presumed airway obstruction: a real-life study. Respiration. 2012;84(1):44-54. doi: 10.1159/000332836. Epub 2011 Nov 15.

Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM; SMART Study Group. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest. 2006 Jan;129(1):15-26. doi: 10.1378/chest.129.1.15. Erratum In: Chest. 2006 May;129(5):1393.

Lee TA, Pickard AS, Au DH, Bartle B, Weiss KB. Risk for death associated with medications for recently diagnosed chronic obstructive pulmonary disease. Ann Intern Med. 2008 Sep 16;149(6):380-90. doi: 10.7326/0003-4819-149-6-200809160-00004.

Singh S, Loke YK, Furberg CD. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2008 Sep 24;300(12):1439-50. doi: 10.1001/jama.300.12.1439. Erratum In: JAMA. 2009 Mar 25;301(12):1227-30.

Van den Bruel A, Gailly J, Neyt M. Does tiotropium lower exacerbation and hospitalization frequency in COPD patients: results of a meta-analysis. BMC Pulm Med. 2010 Sep 21;10:50. doi: 10.1186/1471-2466-10-50.

Ogale SS, Lee TA, Au DH, Boudreau DM, Sullivan SD. Cardiovascular events associated with ipratropium bromide in COPD. Chest. 2010 Jan;137(1):13-9. doi: 10.1378/chest.08-2367. Epub 2009 Apr 10.

Macie C, Wooldrage K, Manfreda J, Anthonisen N. Cardiovascular morbidity and the use of inhaled bronchodilators. Int J Chron Obstruct Pulmon Dis. 2008;3(1):163-9. doi: 10.2147/copd.s1516.

Ringbaek T, Viskum K. Is there any association between inhaled ipratropium and mortality in patients with COPD and asthma? Respir Med. 2003 Mar;97(3):264-72. doi: 10.1053/rmed.2003.1423.

Guite HF, Dundas R, Burney PG. Risk factors for death from asthma, chronic obstructive pulmonary disease, and cardiovascular disease after a hospital admission for asthma. Thorax. 1999 Apr;54(4):301-7. doi: 10.1136/thx.54.4.301.

Singh S, Loke YK, Enright PL, Furberg CD. Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials. BMJ. 2011 Jun 14;342:d3215. doi: 10.1136/bmj.d3215.

Martin-Merino E, Garcia-Rodriguez LA, Masso-Gonzalez EL, Roehrborn CG. Do oral antimuscarinic drugs carry an increased risk of acute urinary retention? J Urol. 2009 Oct;182(4):1442-8. doi: 10.1016/j.juro.2009.06.051. Epub 2009 Aug 15.

Armitage JN, Sibanda N, Cathcart PJ, Emberton M, van der Meulen JH. Mortality in men admitted to hospital with acute urinary retention: database analysis. BMJ. 2007 Dec 8;335(7631):1199-202. doi: 10.1136/bmj.39377.617269.55. Epub 2007 Nov 8.

Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, Yates JC, Vestbo J; TORCH investigators. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007 Feb 22;356(8):775-89. doi: 10.1056/NEJMoa063070.

Ernst P, Gonzalez AV, Brassard P, Suissa S. Inhaled corticosteroid use in chronic obstructive pulmonary disease and the risk of hospitalization for pneumonia. Am J Respir Crit Care Med. 2007 Jul 15;176(2):162-6. doi: 10.1164/rccm.200611-1630OC. Epub 2007 Mar 30.

Kardos P, Wencker M, Glaab T, Vogelmeier C. Impact of salmeterol/fluticasone propionate versus salmeterol on exacerbations in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2007 Jan 15;175(2):144-9. doi: 10.1164/rccm.200602-244OC. Epub 2006 Oct 19.

Ferguson GT, Anzueto A, Fei R, Emmett A, Knobil K, Kalberg C. Effect of fluticasone propionate/salmeterol (250/50 microg) or salmeterol (50 microg) on COPD exacerbations. Respir Med. 2008 Aug;102(8):1099-108. doi: 10.1016/j.rmed.2008.04.019. Epub 2008 Jul 9.

Wedzicha JA, Calverley PM, Seemungal TA, Hagan G, Ansari Z, Stockley RA; INSPIRE Investigators. The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide. Am J Respir Crit Care Med. 2008 Jan 1;177(1):19-26. doi: 10.1164/rccm.200707-973OC. Epub 2007 Oct 4.

Joo MJ, Au DH, Fitzgibbon ML, Lee TA. Inhaled corticosteroids and risk of pneumonia in newly diagnosed COPD. Respir Med. 2010 Feb;104(2):246-52. doi: 10.1016/j.rmed.2009.10.002. Epub 2009 Oct 30.

Yawn BP, Li Y, Tian H, Zhang J, Arcona S, Kahler KH. Inhaled corticosteroid use in patients with chronic obstructive pulmonary disease and the risk of pneumonia: a retrospective claims data analysis. Int J Chron Obstruct Pulmon Dis. 2013;8:295-304. doi: 10.2147/COPD.S42366. Epub 2013 Jun 27.

McKeever T, Harrison TW, Hubbard R, Shaw D. Inhaled corticosteroids and the risk of pneumonia in people with asthma: a case-control study. Chest. 2013 Dec;144(6):1788-1794. doi: 10.1378/chest.13-0871.

Lee TA, Weiss KB. Fracture risk associated with inhaled corticosteroid use in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004 Apr 1;169(7):855-9. doi: 10.1164/rccm.200307-926OC. Epub 2004 Jan 7.

Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation. 2005 Mar 15;111(10):1233-41. doi: 10.1161/01.CIR.0000158136.76824.04.

Cooper R, Cutler J, Desvigne-Nickens P, Fortmann SP, Friedman L, Havlik R, Hogelin G, Marler J, McGovern P, Morosco G, Mosca L, Pearson T, Stamler J, Stryer D, Thom T. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation. 2000 Dec 19;102(25):3137-47. doi: 10.1161/01.cir.102.25.3137.

Ski CF, King-Shier KM, Thompson DR. Gender, socioeconomic and ethnic/racial disparities in cardiovascular disease: a time for change. Int J Cardiol. 2014 Jan 1;170(3):255-7. doi: 10.1016/j.ijcard.2013.10.082. Epub 2013 Nov 1.

Akinbami LJ, Moorman JE, Bailey C, Zahran HS, King M, Johnson CA, Liu X. Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010. NCHS Data Brief. 2012 May;(94):1-8.

Morbidity & Mortality: 2012 Chart Book on Cardiovascular, Lung, and Blood Diseases. In: National Heart Lung and Blood Institute, ed2012

Dransfield MT, Bailey WC. COPD: racial disparities in susceptibility, treatment, and outcomes. Clin Chest Med. 2006 Sep;27(3):463-71, vii. doi: 10.1016/j.ccm.2006.04.005.

Barr RG, Celli BR, Martinez FJ, Ries AL, Rennard SI, Reilly JJ Jr, Sciurba FC, Thomashow BM, Wise RA. Physician and patient perceptions in COPD: the COPD Resource Network Needs Assessment Survey. Am J Med. 2005 Dec;118(12):1415. doi: 10.1016/j.amjmed.2005.07.059.

Caramori G, Bettoncelli G, Tosatto R, Arpinelli F, Visona G, Invernizzi G, Novelletto BF, Papi A, Adcock IM, Ciaccia A. Underuse of spirometry by general practitioners for the diagnosis of COPD in Italy. Monaldi Arch Chest Dis. 2005 Mar;63(1):6-12. doi: 10.4081/monaldi.2005.651.

Kaminsky DA, Marcy TW, Bachand M, Irvin CG. Knowledge and use of office spirometry for the detection of chronic obstructive pulmonary disease by primary care physicians. Respir Care. 2005 Dec;50(12):1639-48.

Foster JA, Yawn BP, Maziar A, Jenkins T, Rennard SI, Casebeer L. Enhancing COPD management in primary care settings. MedGenMed. 2007 Jul 31;9(3):24.

Stange KC, Zyzanski SJ, Jaen CR, Callahan EJ, Kelly RB, Gillanders WR, Shank JC, Chao J, Medalie JH, Miller WL, Crabtree BF, Flocke SA, Gilchrist VJ, Langa DM, Goodwin MA. Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians. J Fam Pract. 1998 May;46(5):377-89.

Lusuardi M, De Benedetto F, Paggiaro P, Sanguinetti CM, Brazzola G, Ferri P, Donner CF. A randomized controlled trial on office spirometry in asthma and COPD in standard general practice: data from spirometry in Asthma and COPD: a comparative evaluation Italian study. Chest. 2006 Apr;129(4):844-52. doi: 10.1378/chest.129.4.844.

Walters JA, Hansen EC, Johns DP, Blizzard EL, Walters EH, Wood-Baker R. A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of COPD. Thorax. 2008 May;63(5):408-14. doi: 10.1136/thx.2007.082859. Epub 2007 Nov 16.

Walker PP, Mitchell P, Diamantea F, Warburton CJ, Davies L. Effect of primary-care spirometry on the diagnosis and management of COPD. Eur Respir J. 2006 Nov;28(5):945-52. doi: 10.1183/09031936.06.00019306. Epub 2006 Jul 26.

Pacheco E, Sohn AJ, Wells C, Sharp LK, Madrid S, Lee TA, Chen YF, Yawn BP, Garcia D, Shim K, Quesada N, Joo MJ. Design of the Reducing Diagnostic Error to Improve Patient Safety (REDEfINE) in COPD and asthma study: A cluster randomized comparative effectiveness trial. Contemp Clin Trials. 2022 Dec;123:106971. doi: 10.1016/j.cct.2022.106971. Epub 2022 Oct 22.

Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2016