A UK-based study published in The Lancet Respiratory Medicine journal finds that opportunities are being missed to diagnose chronic obstructive pulmonary disease in up to 85% of people.
Chronic obstructive pulmonary disease (COPD) is a progressive, destructive disease that can cause irreversible damage to the airways and lungs by the time symptoms are detected. The disease has no clear starting point, but the earlier COPD is diagnosed, the better the chances are of reducing damage to the lungs.
The researchers of the new study note that figures from the UK Department of Health estimate that 835,00 people in the UK are diagnosed with COPD, with a further 2.2 million living with the condition but undiagnosed.
According to the Department of Health, earlier diagnosis of COPD could save the UK National Health Service more than £1 billion over 10 years.
Both patients and doctors can miss the early signs of lung disease that should trigger more extensive testing. Patients - particularly male patients, the study notes - often downplay the significance of symptoms and may not seek medical advice.
Study author Dr. Rupert Jones explains that "the first signs of lung disease should prompt appropriate investigations such as pulmonary function tests (spirometry). However, both general practitioners (GPs) and patients are failing to recognize the significance of symptoms."
85% of COPD patients reported symptoms up to 5 years prior to diagnosis
Dr. Jones and his team conducted a large systematic review, analyzing the medical records of 38,859 patients aged 40 years and older who had been diagnosed with COPD between 1990 and 2009.
The researchers saw that 85% of these patients had visited their doctor or a clinic at least once with respiratory symptoms in the 5 years before diagnosis. Going further back, the data showed that 58% of patients first reported symptoms 6-10 years before diagnosis and 42% in the 11-15 years before diagnosis.
The study authors believe that these reported symptoms represent missed opportunities to proceed with further testing that could have resulted in a COPD diagnosis.
Co-author Dr. Erika J. Sims says:
"These findings confirm that patients with undiagnosed COPD often visit health care settings many times before eventually receiving a diagnosis. Understanding how to capitalize on these opportunities for earlier diagnosis in the course of routine clinical practice must be a priority for primary care nurses and doctors."
Recommendations to improve COPD diagnosis
Giving examples of how COPD diagnosis can be improved in primary care, Dr. Sims says:
"Overall detection can be improved by spirometry testing of patients who have an increased risk of disease, those who smoke (current or past), are aged 40 years or older, with a history of multiple lower respiratory tract complaints, and common COPD comorbidities (eg, diabetes, cardiovascular disease, gastroesophageal reflux disease)."
A 10-year COPD program in Finland saw primary care health workers sharing information with community workers - respiratory nurses, smoking cessation counselors, dietitians - resulting in reduction of hospital admissions and treatment costs, although there was no increase in the number of COPD diagnoses.
In the conclusion to their study, the authors suggest that it might be easier to identify people at risk of COPD by systematically auditing patient records rather than only checking medical history when a patient goes to their doctor with symptoms.
Because the frequency of missed diagnoses in the patient data increased in the 5 years immediately before diagnosis, the researchers think that implementing a 5-year review window of individual clinical episodes could help correctly identify cases of COPD.
The researchers argue that combining this approach with a model similar to the Finnish program could both improve the number of diagnoses and cut the associated treatment costs of COPD.
Commenting on the study, Chris van Weel, a professor of primary health care research at the Australian National University in Canberra, Australia, says:
"The early diagnosis and management of COPD needs better primary care and general practice, rather than greater respiratory expertise. Patient-centered continuity of care is needed, with an eye to the prevailing epidemiology, to assess signs and symptoms over time. Access to spirometry is crucial, but inevitably, this assessment will often be marred with clinical uncertainty. Better to acknowledge this uncertainty upfront; for both doctor and patients."