Case finding for chronic obstructive pulmonary disease in people attending long-term condition clinics in primary care

Abstract

Despite increased interest and awareness of chronic obstructive pulmonary disease (COPD), nearly half of the people with COPD remain undiagnosed. Inviting people at risk for screening is unlikely to be effective as many will not attend. Co-morbidities are common in people with COPD but COPD is also a comorbidity of other long-term conditions and people with these conditions are under regular review in primary care clinics. This study aimed to develop a pilot programme to case find people with COPD among patients attending other long-term clinics in primary care. Twenty-three general practices were recruited to participate in South West England. All current or ex-smokers aged ≥35 attending a long-term condition clinic who were not known to have COPD were asked to complete a questionnaire designed to help identify people with COPD and to perform microspirometry. Practices were asked to collect data on up to 100 patients. One thousand three hundred and thirty-three patients were assessed. Four hundred and ten people (31%) were current smokers. Six hundred and thirteen (46%) had high questionnaire scores and 287 (22%) of these also had a forced expiratory volume in 1 second (FEV) below the lower limit of normal (LLN). The mean FEV in these patients was 59.0% of predicted (range 22-79.0%). Two hundred and twenty-four had an FEV between 50% and 80% of predicted, 50 had an FEV between 30% and 50% of predicted. One hundred and sixteen (40%) of the people with an FEV below the LLN were still smoking and 55 accepted referral to cessation services. A total of 56% of the other smokers assessed but not thought to have COPD also accepted referral. Assessing symptoms and performing microspirometry in people attending long-term condition clinics in primary care is feasible and has a high yield of identifying people likely to have previously undiagnosed COPD.

Call to action: improving primary care for women with COPD

“… 28 – 30 The use of validated questionnaires can be useful to facilitate case finding and monitoring. 30 , 31 A diagnosis of COPD should be considered in any woman with prior or current risk factor exposure, such as respiratory infection (Table 1 ), presenting with symptoms such as breathlessness, chronic cough, regular sputum production or wheeze, and/or with a positive result on a COPD risk evaluation questionnaire. 30 Physicians should be alert to the early identification and diagnosis of COPD in women due to the increased use of tobacco among women in high-income countries, and because of a higher risk of exposure to indoor air pollutants (e.g.…”

“… 3 Using validated screening questionnaires could help identify COPD in such patients. 3 , 30 , 31 In addition, the coughing associated with COPD is associated with a social stigma (particularly in current, or ex-smokers) that may result in feelings of embarrassment, guilt and shame among women, making them reluctant to seek care. 38 Poverty is more common in women than men, particularly older women, and may impact on access to healthcare and obtaining a timely diagnosis.…”

Reluctance of patients with chronic obstructive pulmonary disease in its early stages and their families to participate in a partnership-based self-management trial: A search for explanation

“…Under such circumstances, the potential participants would be seeking healthcare for an active health problem. The situation would be related to respiratory issues or connected to likely co-morbidities of COPD 36 for which a disease diagnosis with spirometry needs to be made. In cases where the person has a confirmed COPD diagnosis, the clinician would refer the patient to a research team that would simultaneously on-site, face-to-face, or in a telephone conversation present the study in more detail.…”

The ‘missing millions’

“…Therefore, a case finding programme for undiagnosed COPD among subjects with long-term conditions appears to be a realistic prospect. The article in this issue by Halpin et al 13 took the approach of basing their selection criteria from attendees at long-term conditions clinics in primary care as the case-finding setting. Initial steps screened ever smokers for symptoms using a validated questionnaire, followed by the use of microspirometry in those with high questionnaire scores.…”