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COPD: Clinicians Miss Myriad Chances to Spot It Early
Clinicians may be missing the chance to diagnose early-stage chronic obstructive pulmonary disease (COPD) in the vast majority of cases, investigators suggest.
A retrospective review of data on nearly 39,000 patients seen by general practitioners and specialists in the United Kingdom showed that in the 5 years immediately before a diagnosis of COPD, 85% of patients had symptoms, examination findings, or test results that may have heralded early signs of COPD, say Rupert C.M. Jones, MD, from Plymouth University Peninsula School of Medicine and Dentistry in the United Kingdom, and colleagues.
"We suggest that a case-finding approach should be modified to include: all patients older than 40 years with a diagnosis of asthma and who currently smoke; all smokers older than 40 years who have a lower respiratory prescribing event; and follow-up of existing recommendations for smokers aged older than 40 years with any respiratory symptoms, especially if they are male," the investigators write.
Although the study, published online February 13 in Lancet Respiratory Medicine, looked only at patients treated in the United Kingdom, the findings are likely applicable to the United States, according to Professor Chris van Weel, MD, PhD. Dr van Weel, who wrote an accompanying editorial, holds joint appointments at the Australian National University in Canberra and Raboud University Medical Centre in Nijmegen, the Netherlands.
"The under-diagnosis of COPD is a universal problem in most, if not all, countries in the world," Dr. van Weel told Medscape Medical News. "The paper of Jones highlights the diagnostic problem: symptoms are initially insidious and may fluctuate over time. And from my earlier research, it is also clear that patients 'adapt' their daily activities (less physical activities) and therefore may underplay or even become unaware of their symptoms."
He notes that that the problem is not an easy one to solve because the early symptoms of COPD may get lost against the background of comorbidities and differential diagnoses.
"The physician, and in particular the family physician in primary care, has to pay attention to other possible diseases that might cause these symptoms: pneumonia, heart failure, lung cancer. The 'low key symptoms' and the need of applying a broad diagnostic scope together cause what Jones and his colleagues called the 'missed opportunities' to diagnose COPD," Dr. van Weel noted.
In the United States, where there are frequent breaks in the continuity of care, the problem of tracing the missed opportunities identified by Jones et al is likely more acute than in either the United Kingdom or the Netherlands, where primary care practitioners more closely manage and coordinate patient care, he added.
The investigators agree: "For health-care systems outside of the UK that are less focused on primary care—eg, in the USA—implemention of mechanisms to enable clinical information to be shared with family doctors is essential if diagnosis of COPD is to improve," they write.
20 Years Before
The investigators combed through records of 38,859 patients aged 40 years and older, treated in the United Kingdom from 1990 through 2009, who had a coded diagnosis of COPD in their primary care records and for whom there were a minimum of 3 years of continuous practice data for COPD and records of at least 2 prescriptions issued since the diagnosis.
They found that clinicians missed opportunities for diagnosis in 32,900 (85%) of the patients in the 5 years immediately preceding the diagnosis of COPD. They defined a missed opportunity as a consultation for lower respiratory tract problems, lower respiratory tract consultations resulting in a prescription for antibiotics or oral steroids, or chest radiography not leading to a COPD diagnosis.
In addition, both primary care practitioners and specialists missed the diagnostic boat in each of four 5-year spans in the 20 years before a COPD diagnosis. For example, among 379 patients diagnosed in secondary care, 25 (6.6%) had 1 or more hospital admissions in the 5 years before diagnosis compared with 457 of 38,480 (1.2%) diagnosed in primary care ( P < .0001).
Women were more likely to be underdiagnosed than men, receiving fewer chest radiographs in the year before diagnosis and having more hospitalizations within the 2 years immediately preceding a COPD diagnosis, the authors found.