COPD screening in general practice using a telephone questionnaire

Undiagnosed and 'overdiagnosed' COPD using postbronchodilator spirometry in primary healthcare settings: a systematic review and meta-analysis

BACKGROUND

Despite chronic obstructive pulmonary disease (COPD) being a major global cause of mortality and hospitalisation, it is often undiagnosed or inaccurately diagnosed in clinical settings.

OBJECTIVE

To systematically synthesise all peer-reviewed papers from primary healthcare settings that have reported data on: (1) undiagnosed COPD, that is, patients with respiratory symptoms and postbronchodilator airflow obstruction consistent with COPD, without a formal clinician's diagnosis of COPD either documented in health records or reported by patients and (2) 'overdiagnosed COPD', that is, clinician's diagnosis without postbronchodilator airflow obstruction.

METHODS

Studies investigating these diagnostic metrics in patients from primary healthcare clinics (according to predefined inclusion/exclusion criteria) were sourced from Medline and Embase and assessed for bias (Johanna Briggs Institute tools for prevalence studies and case series). Meta-analyses of studies of adequate sample size used random effect modelling stratified by risk factor categories.

RESULTS

Of 26 eligible articles, 21 cross-sectional studies investigated 3959 cases of spirometry-defined COPD (with or without symptoms), and 5 peer-reviewed COPD case series investigated 7381 patients. The prevalence of spirometry-confirmed COPD without a diagnosis documented in their health records was 14%-26% in studies of symptomatic smokers (N=3). 1 in 4 patients taking inhaled therapies (25% (95% CI 22% to 28%), N=2) and 1 in 6 smokers irrespective of symptoms (16% (95% CI 14% to 18%), N=6) fulfilled diagnostic spirometry criteria but did not report receiving a COPD-related diagnosis. In an adequately powered series of COPD cases documented in primary healthcare records (N=4), only between 50% and 75% of subjects had any airflow obstruction on postbronchodilator spirometry performed by study researchers, therefore, COPD was clinically 'overdiagnosed' in 25%-50% of subjects.

DISCUSSION

Although data were heterogeneous and of modest quality, undiagnosed COPD was common in primary healthcare, especially for symptomatic smokers and patients treated with inhaled therapies. In contrast, frequent COPD 'overdiagnosis' may represent treatment of asthma/reversible component or another medical diagnosis.

PROSPERO REGISTRATION NUMBER

CRD42022295832.

Effects of Systematic Intervention for Chronic Obstructive Pulmonary Disease on Follow-up and Smoking Cessation Rates and Changes of the Pulmonary Function: A 7-year Longitudinal Study in a Japanese Rural City

Objective The early detection and treatment of chronic obstructive pulmonary disease (COPD) requires comprehensive follow-up over a long period. The aim of this study was to determine the effects of a comprehensive long-term intervention system developed by the COPD Task Force for a rural city in Japan during a 7-year period. Methods This prospective, community-based longitudinal study encompassed 2006-2013 in Matsuura City, Japan. Primary and secondary screenings were performed for the early diagnosis and treatment of COPD. Individuals diagnosed with COPD were managed by the COPD Task Force's comprehensive early intervention system. The outcomes of interest were the rate of continuous follow-up after the diagnosis of COPD, the smoking cessation rate, and changes in the pulmonary function during a 7-year period. Subjects The study included 8,878 residents of 50-89 years of age who resided in Matsuura in 2006. Results In total, 140 participants received definitive diagnoses of COPD in 2006. After 7 years of intervention, 34 patients withdrew; 78 (74%) patients continued with treatment in our intervention system. The rate of smoking cessation was significantly increased in the intervention group (from 30% to 68%; p<0.01) over the 7-year period. The change in forced expiratory volume in 1 second (FEV₁) was -23.2 mL/year. Conclusion Our systematic longitudinal intervention system during a 7-year period led to high rates of follow-up and smoking cessation. Furthermore, our system may be able to prevent the decline of FEV₁ in COPD patients. This intervention system may be effective in rural cities with few respiratory physicians.

Spirometry, questionnaire and electronic medical record based COPD in a population survey: Comparing prevalence, level of agreement and associations with potential risk factors

BACKGROUND

COPD-diagnosis is confirmed by post-bronchodilator (BD) spirometry. However, epidemiological studies often rely on pre-BD spirometry, self-reports, or medical records. This population-based study aims to determine COPD-prevalence based on four different operational definitions and their level of agreement, and to compare associations between COPD-definitions and risk factors.

METHODS

COPD-prevalence in 1,793 adults from the general Dutch population (aged 18-70 years) was assessed based on self-reported data, Electronic Medical Records (EMR), and post-BD spirometry: using the FEV1/FVC below the lower limit of normal (LLN) and GOLD fixed cut-off (FEV1/FVC <0.70). Using spirometry as a reference, sensitivity was calculated for self-reported and EMR-based COPD. Associations between COPD and known risk factors were assessed with logistic regression. Data were collected as part of the cross-sectional VGO study (Livestock Farming and Neighboring Residents' Health Study).

RESULTS

The highest prevalence was found based on spirometry (GOLD: 10.9%, LLN: 5.9%), followed by self-report (4.6%) and EMR (2.9%). Self-reported or EMR-based COPD identified less than 30% of all COPD-cases based on spirometry. The direction of association between known risk factors and COPD was similar across the four definitions, however, magnitude and significance varied. Especially indicators of allergy were more strongly associated with self-reported COPD compared to the other definitions.

CONCLUSIONS

COPD-prevalence varied depending on the used definition. A substantial number of subjects with spirometry-based COPD cannot be identified with questionnaires or medical records which can cause underestimation of COPD-prevalence. The influence of the different COPD-definitions on associations with known risk factors was limited.

A randomized controlled trial evaluating the effectiveness of a web-based, computer-tailored self-management intervention for people with or at risk for COPD

Introduction

COPD is a leading cause of morbidity and mortality. Self-management interventions are considered important in order to limit the progression of the disease. Computer-tailored interventions could be an effective tool to facilitate self-management.

Methods

This randomized controlled trial tested the effectiveness of a web-based, computer-tailored COPD self-management intervention on physical activity and smoking behavior. Participants were recruited from an online panel and through primary care practices. Those at risk for or diagnosed with COPD, between 40 and 70 years of age, proficient in Dutch, with access to the Internet, and with basic computer skills (n=1,325), were randomly assigned to either the intervention group (n=662) or control group (n=663). The intervention group received the web-based self-management application, while the control group received no intervention. Participants were not blinded to group assignment. After 6 months, the effect of the intervention was assessed for the primary outcomes, smoking cessation and physical activity, by self-reported 7-day point prevalence abstinence and the International Physical Activity Questionnaire – Short Form.

Results

Of the 1,325 participants, 1,071 (80.8%) completed the 6-month follow-up questionnaire. No significant treatment effect was found on either outcome. The application however, was used by only 36% of the participants in the experimental group.

Conclusion

A possible explanation for the nonsignificant effect on the primary outcomes, smoking cessation and physical activity, could be the low exposure to the application as engagement with the program has been shown to be crucial for the effectiveness of computer-tailored interventions. (Netherlands Trial Registry number: NTR3421.)

New scoring system for the differentiation of chronic obstructive pulmonary disease and asthma

BACKGROUND AND OBJECTIVE

It remains difficult to differentiate between chronic obstructive pulmonary disease (COPD) and asthma in clinical practice, especially in a primary care setting. The purpose of this study was to develop a new scoring system for differentiating between COPD and asthma, and to evaluate its effectiveness.

METHODS

First, to identify important variables differentiating COPD from asthma, the data of 197 patients with COPD and 138 patients with asthma were assessed retrospectively. Secondly, a scoring system that was based on these variables was then developed, and its performance was internally validated using a bootstrapping-based method. Thirdly, the scoring system was externally validated using prospectively collected data from patients with COPD (n = 104) or asthma (n = 96).

RESULTS

The final scoring system was composed of the four variables: age of onset of breathlessness (<40 years, 0 points; 40-60 years, 2 points; >60 years, 4 points), continuous breathlessness (no, 0 points; yes, 1 point), diurnal variation of breathlessness (yes, 0 points; no, 1 point) and emphysematous change in chest X-ray (no, 0 points; yes, 1 point). The patients were classified by their total score into three categories: 0-2 points, probable asthma; 3-4 points, difficult-to-differentiate; 5-7 points, probable COPD. The new scoring system performed well in the external validation dataset (area under the curve, 0.86; 95% confidence interval: 0.813-0.911; P < 0.001).

CONCLUSIONS

The new scoring system that was developed in this study may be a useful tool for differentiating between COPD and asthma in primary care.

Detection of COPD in a high-risk population: should the diagnostic work-up include bronchodilator reversibility testing?

Background

Underdiagnosis of chronic obstructive pulmonary disease (COPD) is widespread. Early detection of COPD may improve the outcome by timely smoking cessation, a change in lifestyle, and treatment with an inhaled bronchodilator (BD). The objective of this study was to evaluate the diagnostic role of BD reversibility testing in early COPD case finding.

Methods

General practitioners (n=241) consecutively recruited subjects aged ≥35 years with relevant exposure (history of smoking, and/or occupational exposure) and at least one respiratory symptom. Information on age, smoking status, body mass index, dyspnea score (Medical Research Council scale), and spirometry was obtained. Individuals with airway obstruction (forced expiratory volume in one second [FEV₁]/forced vital capacity [FVC] <0.70) underwent a BD test with an inhaled β₂ agonist, which was considered positive if ΔFEV₁ was >0.20 L and >12%. Asthma and COPD were, respectively, defined as an FEV₁ increase >0.50 L and a post-BD FEV₁/FVC <0.70.

Results

In total, 4,049 subjects (51% male) were included (mean age 58 years, body mass index 27, 32 pack-years of smoking). A significant BD response was found in 143 (15%) of the 937 subjects (23%) with airway obstruction at screening spirometry. In 59% of these subjects, the post-BD FEV₁/FVC remained <0.70. In 24% of the subjects with pre-BD airway obstruction, the post-BD FEV₁/FVC ratio was within the reference range. In subjects with confirmed COPD, the mean increase in FEV₁ following BD was 0.11 L±0.10 L. The subjects with COPD and a significant BD response were characterized by a higher prevalence of dyspnea (72% versus 57%, P=0.02) but less cough (55% versus 75%, P=0.001) when compared with COPD subjects without BD reversibility.

Conclusion

Administration of a BD in COPD case finding is important in order to determine the post-BD FEV₁/FVC ratio. Exclusion of subjects with a significant BD response may result in underdiagnosis of COPD, and we question the need for the BD reversibility test in the diagnostic screening algorithm in early COPD case finding.

Early detection of COPD in general practice: patient or practice managed? A randomised controlled trial of two strategies in different socioeconomic environments

Background:

The burden of chronic obstructive pulmonary disease (COPD) is high. Health benefits can be gained in primary care by early detection and preventive measures.

Aims:

To compare the effectiveness of two strategies for population-based early detection of COPD, taking into account different socioeconomic status (SES) settings.

Methods:

Practices were randomised on strategy and stratified on SES setting. The Respiratory Health Screening Questionnaire (RHSQ) was distributed to all participants. In the practice-managed condition, the practice was responsible for the whole procedure, while in the patient-managed condition, patients were responsible for calculating their RHSQ risk score and applying for a spirometry test. The main outcome measure was the rate of COPD diagnoses after screening.

Results:

More new COPD patients were detected in the practice-managed condition (36%) than in the patient-managed condition (18%). In low SES practices, more high-risk patients were found (16%) than in moderate-to-high SES practices (9%). Recalculated for a standard Dutch practice (2,350 patients), the yield would be 8.9 new COPD diagnoses, which is a 20% increase of known cases.

Conclusions:

The practice-managed variant of this screening procedure shows a substantial yield of new COPD diagnoses for both low and moderate-to-high SES practices.

Validation of the COPD Diagnostic Questionnaire in an Australian general practice cohort: a cross-sectional study

BACKGROUND

The gold standard for the diagnosis of chronic obstructive pulmonary disease (COPD) is spirometry, but there are barriers to its use in primary care.

AIMS

To externally validate the COPD Diagnostic Questionnaire (CDQ) as a diagnostic tool in patients at increased risk in Australian general practice and to compare its performance with other CDQ validation studies.

METHODS

Patients were recruited from 36 general practices in Sydney, Australia. Former or current smokers aged 40-85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse. The CDQ was collected and pre- and postbronchodilator spirometry was performed. Cases for whom complete CDQ data were present and the spirometry met quality standards were analysed.

RESULTS

Of 1,631 patients who attended case-finding recruitment, 1,054 (65%) could be analysed. Spirometry showed 13% had COPD. The ability of the CDQ to discriminate between patients with and without COPD was fair, represented by the area under the receiver operating characteristic curve of 0.713. With a CDQ cut-off point value of 16.5 the sensitivity was 80% and specificity 47% and, at a cut-off point value of 19.5, the sensitivity was 63% and specificity 70%.

CONCLUSIONS

The CDQ did not discriminate between patients with and without COPD accurately enough to use as a diagnostic tool in patients at increased risk of COPD in Australian general practice. Further research is needed on the value of the CDQ as a tool for selecting patients for spirometry.

Early detection of COPD in general practice: implementation, workload and socioeconomic status. A mixed methods observational study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is underdiagnosed in general practice. Our aim was to implement a population-based approach for the early detection of COPD and to assess its impact on primary care workload and costs, and the influence of socioeconomic status (SES).

METHODS

An observational study with mixed methods was performed in 10 Dutch general practices of either low or moderate to high SES. The Respiratory Health Screening Questionnaire was posted during a three-month period to all persons aged 45, 55, and 65 years (one age group per month). The practices calculated the risk, and patients at high risk of COPD were invited for spirometry at the practice. The general practitioner used the spirometric results and a consultation to establish a clinical diagnosis. Qualitative and quantitative data on workload, cost, and barriers were evaluated.

RESULTS

Ten practices returned 293 (35.3%) COPD risk tests for the three age groups. Participants from low SES practices responded better than those from moderate to high SES practices (40.8% vs. 30.5%). In practices with low SES 17.9% of the tests indicated high risk compared with 16.1% in practices with moderate to high SES. Nine patients (23%) were newly diagnosed with COPD. The healthcare providers' extra workload averaged 18.5 hours during the three months for one standard practice. The average cost of this survey programme (three age groups in three months) was €520 for low SES practices and €398 for moderate to high SES practices. All healthcare providers affirmed that the extra workload in this survey model is acceptable and feasible when finances are compensated.

CONCLUSIONS

Early detection of COPD is feasible in daily life primary care. In moderate to high SES practices the costs of detecting COPD were less than in low SES practices.

A randomised controlled trial testing a web-based, computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease: a study protocol

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality. Effective self-management support interventions are needed to improve the health and functional status of people with COPD or at risk for COPD. Computer-tailored technology could be an effective way to provide this support.

METHODS/DESIGN

This paper presents the protocol of a randomised controlled trial testing the effectiveness of a web-based, computer-tailored self-management intervention to change health behaviours of people with or at risk for COPD. An intervention group will be compared to a usual care control group, in which the intervention group will receive a web-based, computer-tailored self-management intervention. Participants will be recruited from an online panel and through general practices. Outcomes will be measured at baseline and at 6 months. The primary outcomes will be smoking behaviour, measuring the 7-day point prevalence abstinence and physical activity, measured in minutes. Secondary outcomes will include dyspnoea score, quality of life, stages of change, intention to change behaviour and alternative smoking behaviour measures, including current smoking behaviour, 24-hour point prevalence abstinence, prolonged abstinence, continued abstinence and number of quit attempts.

DISCUSSION

To the best of our knowledge, this will be the first randomised controlled trial to test the effectiveness of a web-based, computer-tailored self-management intervention for people with or at risk for COPD. The results will be important to explore the possible benefits of computer-tailored interventions for the self-management of people with or at risk for COPD and potentially other chronic health conditions.

DUTCH TRIAL REGISTER

NTR3421.

Design, rationale, and baseline demographics of SEARCH I: a prospective cluster-randomized study

Questionnaires are available to identify patients at risk for several chronic diseases, including COPD, but are infrequently utilized in primary care. COPD is often underdiagnosed, while at the same time the US Preventive Services Task Force recommends against spirometric screening for COPD in asymptomatic adults. Use of a symptom-based questionnaire and subsequent handheld spirometric device depending on the answers to the questionnaire is a promising approach to identify patients at risk for COPD. Screening, Evaluating and Assessing Rate CHanges of diagnosing respiratory conditions in primary care 1 (SEARCH I) was a prospective cluster-randomized study in 168 US primary care practices evaluating the effect of the COPD-Population Screener (COPD-PS™) questionnaire. The effect of this questionnaire alone or sequentially with the handheld copd-6^TM device was evaluated on new diagnoses of COPD and on respiratory diagnostic practice patterns (including referrals for pulmonary function testing, referrals to pulmonologists, new diagnoses of COPD, and new respiratory medication prescriptions). Participating practices entered a total of 9704 consecutive consenting subjects aged ≥ 40 years attending primary care clinics. Study arm results were compared for new COPD diagnosis rates between usual care and (1) COPD-PS plus copd-6 and (2) COPD-PS alone. A cluster-randomization design allowed comparison of the intervention effects at the practice level instead of individuals being the subjects of the intervention. Regional principal investigators controlled the flow of study information to sub-investigators at participating practices to reduce observation bias (Hawthorne effect). The results of SEARCH I, to be published subsequently, will provide insight into the real world utility of the COPD-PS as well as two-stage COPD case finding with COPD-PS and copd-6.

Dual role of Toll-like receptors in asthma and chronic obstructive pulmonary disease

During the last decade, significant research has been focused on Toll-like receptors (TLRs) in the pathogenesis of airway diseases. TLRs are pattern recognition receptors that play pivotal roles in the detection of and response to pathogens. Because of the involvement of TLRs in innate and adaptive immunity, these receptors are currently being exploited as possible targets for drug development. Asthma and chronic obstructive pulmonary disease (COPD) are chronic inflammatory airway diseases in which innate and adaptive immunity play an important role. To date, asthma is the most common chronic disease in children aged 5 years and older. COPD is prevalent amongst the elderly and is currently the fifth-leading cause of death worldwide with still-growing prevalence. Both of these inflammatory diseases result in shortness of breath, which is treated, often ineffectively, with bronchodilators and glucocorticosteroids. Symptomatic treatment approaches are similar for both diseases; however, the underlying immunological mechanisms differ greatly. There is a clear need for improved treatment specific for asthma and for COPD. This review provides an update on the role of TLRs in asthma and in COPD and discusses the merits and difficulties of targeting these proteins as novel treatment strategies for airway diseases. TLR agonist, TLR adjuvant, and TLR antagonist therapies could all be argued to be effective in airway disease management. Because of a possible dual role of TLRs in airway diseases with shared symptoms and risk factors but different immunological mechanisms, caution should be taken while designing pulmonary TLR-based therapies.

The prevalence of chronic obstructive pulmonary disease in Maastricht, the Netherlands

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an increasing public health problem worldwide. Although epidemiologic data on COPD are important to raise awareness of the burden of disease, there are no actual spirometry-based data on the prevalence of COPD in the Netherlands.

METHODS

Using the Burden of Obstructive Lung Disease (BOLD) protocol and study design, a population-based sample of adults, aged ≥ 40 years, in the area of Maastricht, the Netherlands was surveyed. Post-bronchodilator spirometry and questionnaires with information on smoking history and reported respiratory disease were collected. COPD was defined as post-bronchodilator FEV(1)/FVC ratio < 0,7 (GOLD) or < the lower limit of normal (LLN) (95th percentile) of the population distribution for FEV(1)/FVC. Data were statistically weighted for the total number of people in the Maastricht population.

RESULTS

Overall prevalence of COPD was 24%, and was higher for men (28.5%) than for women (195%). (unweighted p = 0.002) The prevalence of GOLD stage 2 or higher COPD was 10%. The prevalence of LLN-defined COPD was 19% and 10% for stage 2 or higher. Overall prevalence of current smoking was 23%. The prevalence of COPD increased with age and amount of pack-years, although 14% of never smokers fulfilled spirometric criteria for COPD. The prevalence of doctor-diagnosed COPD was only 8.8%.

CONCLUSION

Almost one quarter of the Maastricht population aged ≥ 40 years had COPD. Considering the ageing population and still an important smoking prevalence, this burden is bound to increase and imposes great demands to public health care and society in the Netherlands.