Early Diagnosis and Treatment of COPD and Asthma - A Randomized, Controlled Trial.

Journal

The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562

Informations de publication

Date de publication:
19 May 2024
Historique:
medline: 20 5 2024
pubmed: 20 5 2024
entrez: 20 5 2024
Statut: aheadofprint

Résumé

Many persons with chronic obstructive pulmonary disease (COPD) or asthma have not received a diagnosis, so their respiratory symptoms remain largely untreated. We used a case-finding method to identify adults in the community with respiratory symptoms without diagnosed lung disease. Participants who were found to have undiagnosed COPD or asthma on spirometry were enrolled in a multicenter, randomized, controlled trial to determine whether early diagnosis and treatment reduces health care utilization for respiratory illness and improves health outcomes. Participants were assigned to receive the intervention (evaluation by a pulmonologist and an asthma-COPD educator who were instructed to initiate guideline-based care) or usual care by their primary care practitioner. The primary outcome was the annualized rate of participant-initiated health care utilization for respiratory illness. Secondary outcomes included changes from baseline to 1 year in disease-specific quality of life, as assessed with the St. George Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better health status); symptom burden, as assessed with the COPD Assessment Test (CAT; scores range from 0 to 40, with lower scores indicating better health status); and forced expiratory volume in 1 second (FEV Of 38,353 persons interviewed, 595 were found to have undiagnosed COPD or asthma and 508 underwent randomization: 253 were assigned to the intervention group and 255 to the usual-care group. The annualized rate of a primary-outcome event was lower in the intervention group than in the usual-care group (0.53 vs. 1.12 events per person-year; incidence rate ratio, 0.48; 95% confidence interval [CI], 0.36 to 0.63; P<0.001). At 12 months, the SGRQ score was lower than the baseline score by 10.2 points in the intervention group and by 6.8 points in the usual-care group (difference, -3.5 points; 95% CI, -6.0 to -0.9), and the CAT score was lower than the baseline score by 3.8 points and 2.6 points, respectively (difference, -1.3 points; 95% CI, -2.4 to -0.1). The FEV In this trial in which a strategy was used to identify adults in the community with undiagnosed asthma or COPD, those who received pulmonologist-directed treatment had less subsequent health care utilization for respiratory illness than those who received usual care. (Funded by Canadian Institutes of Health Research; UCAP ClinicalTrials.gov number, NCT03148210.).

Sections du résumé

BACKGROUND BACKGROUND
Many persons with chronic obstructive pulmonary disease (COPD) or asthma have not received a diagnosis, so their respiratory symptoms remain largely untreated.
METHODS METHODS
We used a case-finding method to identify adults in the community with respiratory symptoms without diagnosed lung disease. Participants who were found to have undiagnosed COPD or asthma on spirometry were enrolled in a multicenter, randomized, controlled trial to determine whether early diagnosis and treatment reduces health care utilization for respiratory illness and improves health outcomes. Participants were assigned to receive the intervention (evaluation by a pulmonologist and an asthma-COPD educator who were instructed to initiate guideline-based care) or usual care by their primary care practitioner. The primary outcome was the annualized rate of participant-initiated health care utilization for respiratory illness. Secondary outcomes included changes from baseline to 1 year in disease-specific quality of life, as assessed with the St. George Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better health status); symptom burden, as assessed with the COPD Assessment Test (CAT; scores range from 0 to 40, with lower scores indicating better health status); and forced expiratory volume in 1 second (FEV
RESULTS RESULTS
Of 38,353 persons interviewed, 595 were found to have undiagnosed COPD or asthma and 508 underwent randomization: 253 were assigned to the intervention group and 255 to the usual-care group. The annualized rate of a primary-outcome event was lower in the intervention group than in the usual-care group (0.53 vs. 1.12 events per person-year; incidence rate ratio, 0.48; 95% confidence interval [CI], 0.36 to 0.63; P<0.001). At 12 months, the SGRQ score was lower than the baseline score by 10.2 points in the intervention group and by 6.8 points in the usual-care group (difference, -3.5 points; 95% CI, -6.0 to -0.9), and the CAT score was lower than the baseline score by 3.8 points and 2.6 points, respectively (difference, -1.3 points; 95% CI, -2.4 to -0.1). The FEV
CONCLUSIONS CONCLUSIONS
In this trial in which a strategy was used to identify adults in the community with undiagnosed asthma or COPD, those who received pulmonologist-directed treatment had less subsequent health care utilization for respiratory illness than those who received usual care. (Funded by Canadian Institutes of Health Research; UCAP ClinicalTrials.gov number, NCT03148210.).

Identifiants

DOI: 10.1056/NEJMoa2401389 PMID: 38767248
pubmed: 38767248
doi: 10.1056/NEJMoa2401389
doi:

Banques de données

ClinicalTrials.gov
['NCT03148210']

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Subventions

Organisme : Institute of Circulatory and Respiratory Health
ID : FDN grant #154322

Informations de copyright

Copyright © 2024 Massachusetts Medical Society.

Auteurs

Shawn D Aaron (SD)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.
ORCID: 0000-0002-4762-3542

Katherine L Vandemheen (KL)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

G Alex Whitmore (GA)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Celine Bergeron (C)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Louis-Philippe Boulet (LP)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Andréanne Côté (A)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

R Andrew McIvor (RA)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Erika Penz (E)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Stephen K Field (SK)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Catherine Lemière (C)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Irvin Mayers (I)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Mohit Bhutani (M)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Tanweer Azher (T)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

M Diane Lougheed (MD)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Samir Gupta (S)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Nicole Ezer (N)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Christopher J Licskai (CJ)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Paul Hernandez (P)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Martha Ainslie (M)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Gonzalo G Alvarez (GG)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Sunita Mulpuru (S)

From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (S.D.A., K.L.V., G.G.A., S.M.), the Desautels Faculty of Management (G.A.W.) and the Department of Medicine (N.E.), McGill University, and the Department of Medicine, Université de Montreal (C.L.), Montreal, the Department of Medicine, University of British Columbia, Vancouver (C.B.), Centre de Recherche, Hôpital Laval, Université Laval, Quebec, QC (L.-P.B., A.C.), Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON (R.A.M.), the Department of Medicine, University of Saskatchewan, Saskatoon (E.P.), Cumming School of Medicine, University of Calgary, Calgary, AB (S.K.F.), the Department of Medicine, University of Alberta, Edmonton (I.M., M.B.), the Department of Medicine, Memorial University, St. John's, NL (T.A.), the Department of Medicine, Queen's University, Kingston, ON (M.D.L.), the Department of Medicine and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto (S.G.), the Department of Medicine, University of Western Ontario, London (C.J.L.), the Department of Medicine, Dalhousie University, Halifax, NS (P.H.), and the Department of Medicine, University of Manitoba, Winnipeg (M.A.) - all in Canada.

Classifications MeSH