The Online Cough Clinic's Spectacular Success: Check Out Your Chronic Cough On The Internet, With Expert Advice At Your Fingertips!

Main Category: Ear, Nose and Throat
Also Included In: Respiratory / Asthma;  Flu / Cold / SARS
Article Date: 06 Oct 2008 - 1:00 PDT

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Chronic cough is one of the conditions doctors hate, since it is poorly understood and hard to treat. A British team has set out to improve diagnosis and treatment by providing patients with expert consultation… on the Net!
The results of this groundbreaking project, presented in Berlin to the Annual Congress of the European Respiratory Society (ERS), open the way to a new, interactive medical approach to one of the commonest health problems.

An approach which brings benefits for both patients and doctors.

Chronic cough is officially defined as a persistent cough lasting eight weeks or more. Doctors see many patients with this problem, but find it very difficult to diagnose, especially when there is no obvious underlying respiratory disease.

The condition impacts severely on patients' lives. Not only is it a daily nuisance, but it also contributes heavily to social isolation. Patients no longer dare to go to the theatre or cinema, still less to church, or any venue where their uncontrollable coughing would cause embarrassment. It can be damaging in professional life, too, since repeated, chronic coughing is not exactly welcome at meetings..

Guidelines have been published by the ERS on chronic cough, as on many other serious conditions, in order to help doctors with diagnosis and treatment, and downloadable documents have been placed on its website. But Alyn Morice and his colleagues at Castle Hill Hospital in Cottingham (UK) wanted to do more, and make the Guidelines easier to apply. That led to the development of their groundbreaking interactive website for patients, which they named the Online Cough Clinic.

Easier doctor-patient dialogue

The online clinic gathers information from the patient using a standard three-page questionnaire, where symptoms and medical history are reviewed in a systematic and detailed manner. "It's much more detailed than the average appointment", Morice told the Congress in Berlin, "where there is never enough time to ask the patient all the relevant questions !"

Overall, sixteen questions, related to various symptoms, provide the data for the diagnosis. The patient's answers are sent to a server which uses a weighted algorithm developed by experts to assess the most plausible diagnosis among the three commonest causes, namely gastro-oesophageal reflux, asthma and rhinitis.

The patient is then sent an email informing him of the likely reason for his cough and details of the appropriate treatment under the ERS Guidelines. It comes in the form of an individualised letter that the patient is invited to show to his general practitioner (GP) as a basis for discussion. This procedure allows the doctor to save a considerable amount of time, without in any way undermining his expertise.

"This is an aid for both patient and doctor, perhaps pointing to a previously unconsidered diagnosis" said Morice. "Our objective is personalise the expert opinion found in the ERS guidelines in order to enhance the consultation."

More than 8 000 participants already

Between January 2006 and October 2007, 8,546 patients used the Online Cough Clinic. Slightly over half (57%) were women. By way of a precaution, only patients aged over 18, who have had a normal chest X-ray within the past year and have no traces of blood in their sputum, are allowed to take the questionnaire. Clinic users were aged 45.5 on average.

As the British team told the Congress, one in three of the online patients had been suffering from chronic cough for over a year, and 13% for over five years. Overall, 41% of participants were ex-smokers, 11% had been diagnosed with respiratory disease in recent years, 21.6% were being treated with inhalers (which, paradoxically, often lead to chronic coughing!) and 7% were under treatment for hypertension using inhibitors of Angiotensin-Converting Enzyme (ACE inhibitors), which are known to cause coughing as a side-effect.

Gastro-oesophageal reflux the chief culprit

The commonest etiology identified by the algorithm, in 46% of cases, was gastro-oesophageal reflux. A further 38% of cases were diagnosed as asthma and 15% as rhinitis. "The prevalence of reflux is higher than seen in some epidemiological studies", comments Morice. "Perhaps they identified the tip of the iceberg, and the rest is emerging now."

In addition to the directly usable clinical results, the researchers were keen to hear about users' experience of their new tool. So they sent a follow-up questionnaire to users two months after the original consultation.
The results are very impressive: 94% of participants found the website easy to use, and 73% found the advice helpful. Importantly, 60% of patients felt it had helped them to communicate with their GP. And 62% followed the recommended treatment.
The team plans to develop another follow-up questionnaire to obtain data on the effectiveness of the treatments proposed.

"This interactive application of the Guidelines makes them much more practical and useful", the authors explained in Berlin. "And this method could be applied to a large range of conditions. Online clinics should make a major contribution to health care in years to come."

Morice's team is already planning to adapt the Online Cough Clinic for other countries, likewise on the basis of the ERS Guidelines. And these clinics, based on a single model, would represent a powerful epidemiological monitoring tool. Watch this space…

European Respiratory Society

European Respiratory Society Annual Congress