Figure 1
The workflow of the dyspnea clinic.
Figure 2
Flowchart of included patients.
Table 1
Baseline characteristics of study population (n = 235) attending the dyspnea clinic.
| Integrated consultation (N = 107) | Non-integrated consultations (N = 128) | P-value | |
|---|---|---|---|
| Age in years | 62 (14.4) | 61 (16.1) | 0.656 |
| Male gender | 48.6% | 46.1% | 0.793 |
| BMI (kg/m2) | 28.1 (5.0) | 27.7 (5.5) | 0.610 |
| Smoke status | |||
| Smoker | 14 (13.1) | 19 (14.8) | 0.851 |
| Former smoker | 55 (51.4) | 63 (49.2) | 0.794 |
| Non-smoker | 38 (35.5 | 46 (35.9) | 1.000 |
| Medical history | |||
| No history | 4 (3.7) | 4 (3.1) | 1.000 |
| Pulmonary | 58 (54.2) | 76 (59.4) | 0.431 |
| Mild cardiovasculara | 29 (27.1) | 15 (11.7) | 0.004 |
| Extensive cardiovascularb | 32 (29.9) | 72 (56.3) | 0.000 |
| Other | 90 (84.1) | 105 (82.0) | 0.729 |
| Medication usage | |||
| No medication | 10 (9.3) | 13 (10.2) | 1.000 |
| Pulmonary | 40 (37.4) | 45 (35.2) | 0.786 |
| Cardiovasculair | 61 (57.0) | 87 (68.0) | 0.103 |
| Other | 85 (79.4) | 97 (75.8) | 0.534 |
[i] Variables are depicted as mean and standard deviation for continuous variables or as number and proportion for categorical variables.
a Contains history of hypertension, asymptomatic vascular disease and/or hypercholesterolemia.
b Contains history of ventricular dysfunction (systolic and diastolic), any arrhythmia, pacemaker implementation, conduction abnormalities, Angina Pectoris (AP), valvular disease, congenital heart disease, Transient Ischaemic Attack (TIA) or Cerebrovasculair accident (CVA), thrombosis, myocardial infarction, pulmonary embolism, Coronary artery bypass grafting (CABG), Percutaneous coronary intervention (PCI) with stents and peripheral vascular disease.
Table 2
Diagnostics used in patients (n = 235) attending the dyspnea clinic.
| Characteristic | Integrated consultation (N = 107) | Non- integrated consultation (N = 128) | P-value | ||
|---|---|---|---|---|---|
| Yes | No | Yes | No | ||
| Standard diagnosticsa, N (%) | |||||
| Basic laboratoryb | 106 (99) | 1 (1) | 127 (99) | 1 (1) | 1.000 |
| Electrocardiogram (ECG) | 106 (99) | 1 (1) | 125 (98) | 3 (2) | 0.628 |
| Echocardiography | 106 (99) | 1 (1) | 113 (88) | 15 (12) | 0.001 |
| Spirometry | 105 (99) | 2 (1) | 127 (99) | 1 (1) | 0.593 |
| Exercise ECG | 69 (65) | 38 (36) | 75 (59) | 53 (41) | 0.420 |
| Mean (SD) number of standard diagnostics per patient | 4.6 (0.6) | 4.4 (0.8) | 0.057 | ||
| Additional diagnostics N (%) | |||||
| Advanced laboratoryc | 29 (27) | 78 (73) | 43 (34) | 85 (66) | 0.321 |
| Chest x-ray | 31 (29) | 76 (71) | 57 (45) | 71 (56) | 0.015 |
| Chest CT scan | 17 (16) | 90 (84) | 27 (21) | 101 (79) | 0.320 |
| Thoracic ultrasound | 3 (3) | 104 (97) | 3 (2) | 125 (98) | 1.000 |
| Ventilation perfusion scan | 7 (7) | 100 (94) | 7 (6) | 121 (95) | 0.787 |
| Histamine provocation test | 10 (9) | 97 (91) | 9 (7) | 119 (93) | 0.632 |
| Fractional exhaled nitric oxide (FeNO) test | 7 (7) | 100 (94) | 8 (6) | 120 (94) | 1.000 |
| Cardiopulmonary exercise test (CPET) | 19 (18) | 88 (82) | 17 (13) | 111 (87) | 0.368 |
| Sputum culture | 1 (1) | 106 (99) | 1 (1) | 127 (99) | 1.000 |
| Bronchoscopy | 1 (1) | 106 (99) | 1 (1) | 127 (99) | 1.000 |
| 24 hour Holter-ECG | 32 (30) | 75 (70) | 28 (22) | 100 (78) | 0.178 |
| Supplementary echocardiography | 5 (5) | 102 (95) | 1 (1) | 127 (99) | 0.095 |
| Coronary CT angiography | 15 (14) | 92 (86) | 12 (9) | 116 (91) | 0.307 |
| Myoview | 8 (8) | 99 (93) | 4 (3) | 124 (97) | 0.148 |
| Dobutamine stress echocardiography | 9 (8) | 98 (92) | 14 (11) | 114 (89) | 0.660 |
| Coronary angiography | 10 (9) | 97 (91) | 23 (18) | 105 (82) | 0.062 |
| Thoracocentesis | 1 (1) | 106 (99) | 2 (2) | 126 (98) | 1.000 |
| Polysomnography | 6 (6) | 101 (94) | 5 (4) | 123 (96) | 0.554 |
| PET scan | 0 (0) | 107 (100) | 2 (2) | 126 (98) | 0.502 |
| Mean (SD) number of additional diagnostics per patient | 2.0 (1.5) | 2.1 (1.5) | 0.644 | ||
| Mean (SD) number of total diagnostics used per patient | 6.6 (1.4) | 6.5 (1.9) | 0.724 | ||
[i] a Standard diagnostics when visiting the dyspnea clinic.
b Basic laboratory includes hemoglobin-value (Hb) and renal function.
c Advanced laboratory includes all other laboratory diagnostics. When the referring general practitioner performed laboratory only Hb and renal function was included for basic laboratory diagnostics, other laboratory diagnostics were not included for advanced diagnostics.
Figure 3
Diagnostic time during care trajectory. Time is depicted in median days with IQR.
Table 3
Medical conclusions made in the integrated and non-integrated consultation groups.
| Characteristic, N(%) | Integrated consultation (N = 107) | Non-integrated consultation (N = 128) | P-value |
|---|---|---|---|
| Symptomatic cardiovascular disease | 30 (28.0) | 60 (46.9) | 0.005 |
| Angina Pectoris | 10 (9.3) | 13 (10.2) | 1.000 |
| Chronotropic insufficiencya | 8 (7.5) | 21 (16.4) | 0.046 |
| Other arrhythmia’s | 7 (6.5) | 8 (6.3) | 1.000 |
| Valvular disease | 6 (5.6) | 10 (7.8) | 0.607 |
| Ventricular dysfunction; systolic; symptomatic | 2 (1.9) | 9 (7.0) | 0.071 |
| Ventricular dysfunction; diastolic; symptomatic | 1 (0.9) | 6 (4.7) | 0.130 |
| Secondary pulmonary hypertension | 2 (1.9) | 3 (2.3) | 1.000 |
| Symptomatic dyspnea due to anemia | 2 (1.9) | 5 (3.9) | 0.459 |
| Atrial fibrillation | 2 (1.9) | 4 (3.1) | 0.691 |
| Pulmonary embolism | 0 (0.0) | 4 (3.1) | 0.128 |
| Congenital heart disease | 0 (0.0) | 2 (1.6) | 0.502 |
| Conduction abnormalities | 0 (0.0) | 0 (0.0) | – |
| Asymptomatic cardiovascular disease | 21 (19.6) | 15 (11.7) | 0.104 |
| Hypertension | 15 (14.0) | 4 (3.1) | 0.003 |
| Asymptomatic vascular disease | 5 (4.7) | 11 (8.6) | 0.302 |
| Ventricular dysfunction; systolic; asymptomatic | 2 (1.9) | 0 (0.0) | 0.206 |
| Ventricular dysfunction; diastolic; asymptomatic | 1 (0.9) | 1 (0.8) | 1.000 |
| Pulmonary disease | 47 (43.9) | 67 (52.3) | 0.238 |
| COPD | 22 (20.6) | 31 (24.2) | 0.534 |
| Asthma | 9 (8.4) | 21 (16.4) | 0.079 |
| Combination of asthma and COPD | 3 (2.8) | 3 (2.3) | 1.000 |
| Exacerbation of known asthma or COPD | 3 (2.8) | 4 (3.1) | 1.000 |
| Aspecific bronchial hyper reactivity | 5 (4.7) | 3 (2.3) | 0.474 |
| OSAS | 3 (2.8) | 5 (3.9) | 0.731 |
| Post pulmonary embolism syndrome | 0 (0.0) | 3 (2.3) | 0.253 |
| Interstitial lung disease | 3 (2.8) | 0 (0.0) | 0.093 |
| Thoracic deformities | 1 (0.9) | 0 (0.0) | 0.455 |
| Sarcoidosis | 0 (0.0) | 0 (0.0) | – |
| Non-pathologic diagnosis | 51 (48) | 56 (44) | 0.600 |
| Deconditioningb | 18 (16.8) | 29 (22.7) | 0.326 |
| Dysregulated breathing mechanisms | 15 (14.0) | 17 (13.3) | 1.000 |
| Obesity | 13 (12.1) | 24 (18.8) | 0.209 |
| No explanation | 20 (18.7) | 7 (5.5) | 0.002 |
| Spontaneous improvement before analysis | 1 (10.9) | 1 (0.8) | 1.000 |
| Malignancies | 3 (2.8) | 2 (1.6) | 0.662 |
| Lung cancer | 1 (0.9) | 1 (0.8) | 1.000 |
| Metastatic disease | 2 (1.9) | 2 (1.6) | 1.000 |
| Other explanations | 10 (9.3) | 4 (3.1) | 0.055 |
| Mean (SD) number of conclusions per patient | 1.5 (0.7) | 1.6 (0.7) | 0.21 |
[i] Values are in n (%) unless stated otherwise.
Patients can have more than one conclusion.
COPD, chronic obstructive pulmonary disease.
OSAS, obstructive sleep apnea syndrome.
a Inability of the heart to increase its rate to compensate for increased activity or demand.
b Result of decreased physical activity, bed rest, disease, aging or other causes.