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COPD Diagnosis Study Finds Spirometry Underused, Misdiagnosis Common

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Is Spirometry Properly Used To Diagnose COPD? Results From The BOLD ...

Main findings

Our findings show relevant shortcomings associated with the diagnosis of COPD and the use of spirometry. In the participants of the BOLD study in Salzburg, Austria we observed that: (1) among participants with a reported prior physician's diagnosis of COPD, only 25% reported a lung function test within the last 12 months and only 68% at any time in the past; (2) the likelihood of a correct COPD diagnosis was not different among those reporting or not reporting a prior lung function test; (3) our results suggest that lung function testing is greatly underused to diagnose and monitor COPD and, when used, the quality appears to be of too low to establish a correct diagnosis.

Strengths and limitations of this study

For this analysis we used data from the population-based BOLD study in Salzburg, Austria. Questionnaire data and post-bronchodilator spirometry data were recorded following the highly standardised international BOLD study protocol.6 In Salzburg (one of nine counties of Austria), general practitioners are reimbursed for spirometries by health insurance. In other areas of Austria and in several other European countries, general practitioners are not reimbursed for lung function testing. Our findings may not apply to regions/countries without reimbursement. However, it has to be supposed that the use of spirometry is even less frequent when reimbursement is lacking. Finally, both previous lung function testing and physician diagnosis were based on self-reporting, which can be subject to recall bias. Subjects with a reported previous diagnosis of asthma were excluded from this analysis. However, since reported diagnoses can be subject to recall bias, we cannot be absolutely sure that every case of chronic asthma with persistent airflow limitation has been excluded.

Interpretation of findings in relation to previously published work

Underdiagnosis of COPD has been reported for many countries. For example, the rates of underdiagnosis in Spain and Sweden were reported to be 78% and 89%, respectively.10,11 Ten years after IBERPOC, underdiagnosis in Spain changed from 78% to 73%.12,13 Using data from the BOLD study, we recently reported a rate of underdiagnosis of 88% in Austria.14

On the other hand, our data show that many subjects with a reported diagnosis of COPD do not have persistent airflow limitation when spirometry is performed according to internationally accepted quality control standards. These results indicate that a reported COPD diagnosis is poorly associated with airways obstruction on post-bronchodilator spirometry. On the one hand our data support the notion that many subjects with COPD are undiagnosed. On the other hand, a few others without obstructed airways (in our data 33/68 (48.5%)) are wrongly misdiagnosed and costly and potentially harmful medication may be prescribed to them.15

In current clinical practice COPD is often diagnosed exclusively on the basis of the presence of respiratory symptoms,16 and some general practitioners still believe that spirometry is neither necessary nor helpful to diagnose COPD.17 This is in contrast to current guidelines (GOLD, National Institute for Health and Clinical Excellence, European Respiratory Society/American Thoracic Society) which state that a confident diagnosis of COPD can only be made with spirometry.2,18,19 Although spirometry does not fully capture the impact of COPD on a patient's health, it is still the gold standard for diagnosing the disease and monitoring its progression.2 To date, the BODE index (body mass index, airflow obstruction, dyspnoea, and exercise capacity) and other multicomponent indices used to assess the local and systemic consequences of COPD holistically include spirometry.20,21 Periodic spirometric measurements help to track a patient's decline in lung function, but useful information about lung function decline is unlikely from measurements performed more than once a year.2 In our sample, only 25% of those with a physician's diagnosis of COPD reported a lung function test within the last 12 months. Our data therefore indicate that spirometry is infrequently used for both diagnosing the disease and monitoring its progression.

The infrequent use of spirometry in GP offices and subsequent lack of experience causes uncertainty about both the performance and interpretation of a lung function test,22 as recently emphasised by the UK Primary Care Respiratory Society (PCRS-UK).23 A comparison of lung function test interpretations by family physicians and by pulmonary specialists showed concordant results in only 76% of cases.24 There are several explanations and reasons for the underuse of spirometry, of which time constraints, staffing, and poor training with subsequent lack of confidence in data interpretation are thought to be the most important contributors.25,26 The last of these might explain why spirometry (when performed) was not found to increase the likelihood of a correct respiratory diagnosis. However, well-trained office spirometry can be achieved and training of GP offices has been shown to increase the number of spirometry tests in the three months following training by about 60%, equivalent to an average (median) weekly increase in spirometry from one test every two weeks to one test every week.22

Implications for future research, policy and practice

The results of the BOLD study have shown that quality goals for spirometry tests can be met about 90% of the time in population-based samples of adults from several countries.27 Thus, more frequent use of properly performed lung function tests would be likely to increase the rate of correct COPD diagnoses and help to initiate early interventions (e.G. Smoking cessation). This would result in improved patients' health status, slow down the decline in lung function,28 and could avoid exacerbations by prescribing appropriate medication.29,30 Centralisation of spirometry may be an alternative to well-trained office testing. A Community Respiratory Assessment Unit was established in 2004 in West London to provide high-quality spirometry and diagnostic support to primary care physicians. In this case, centralisation of spirometry via a dedicated service has been shown to improve diagnosis and treatment of respiratory disease.31

Conclusions

We observed a significant underutilisation of spirometry among those with a diagnosis of COPD and, when spirometry was used, it was not found to increase the likelihood of a correct COPD diagnosis. These results should not be disregarded in the ongoing debate about screening for COPD, case finding, or selected early detection. However, to reduce underdiagnosis and overdiagnosis of COPD, every effort should be undertaken to establish quality managed spirometry programmes in primary care.

Study: Spirometry Important In COPD Diagnosis - Healio

March 23, 2020

2 min read

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The prevalence of undiagnosed COPD was high among a cohort of individuals participating in low-dose CT lung cancer screening, suggesting that the addition of spirometry to radiological findings would likely improve identification of those with COPD, new data in the Annals of the American Thoracic Society suggest.

For this study, the researchers evaluated 986 participants in the U.K.-based Lung Screen Uptake Trial in which different targeted invitation strategies could improve participation of high-risk, low-income individuals in low-dose CT screening for lung cancer.

"More than half of those attending a 'lung health check' as part of a prescreening assessment were found to have physiological parameters of airflow obstruction consistent with a diagnosis of COPD, while two-thirds did not report a prior diagnosis," Samuel Janes, FRCP, MSc, PhD, head of the department of respiratory medicine at University College London's Lungs for Living Research Centre, said in a press release. "This study highlights that, while the finding of emphysema was fairly common in this population of current or past heavy smokers who were at risk of lung cancer, the physiological changes of airway obstruction found through spirometry was the strongest signal of the presence of respiratory symptoms and thus potentially clinically relevant COPD."

Janes and colleagues polled participants about current or recent respiratory symptoms, including cough or dyspnea within the previous 12 months, and whether they had a history of COPD, pneumonia, asthma and other comorbidities, such as coronary heart disease, hypertension and diabetes. The researchers categorized participants as having undiagnosed COPD if they had not reported a prior diagnosis of COPD, chronic bronchitis or emphysema but met the Global Initiative for Obstructive Lung Disease (GOLD) criteria using pre-bronchodilator spirometry. Thoracic radiologists specializing in the disease read participants' CT scans and characterized COPD as none, mild, moderate or severe based on visual inspection of the images.

In a cohort of participants in low-dose CT lung cancer screening, there was a higher prevalence of undiagnosed COPD.

Results showed that 57% of all participants had COPD as measured using pre-bronchodilator spirometry. Of these, 67% had undiagnosed COPD according to the study definition. Emphysema was also common, found in 73% of patients with known COPD and 68% of those with undiagnosed COPD. Thirty-two percent of those with undiagnosed COPD, however, had no evidence of emphysema on low-dose CT.

The researchers found that more participants with known vs. Undiagnosed COPD used inhalers and had symptoms such as persistent cough (63% vs. 33%; P < .001) and dyspnea (73% vs. 33%; P < .001), although comorbidities were common among all participants.

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Additionally, the adjusted odds of respiratory symptoms were more significant for airflow obstruction than for emphysema, the researchers noted.

"Thirty-two percent of participants with airflow obstruction who did not report a prior diagnosis of COPD had no emphysema on their CT scan, while, conversely, individuals with emphysema did not always have airflow obstruction," Mamta Ruparel, MBBS, BSc, MRCP, PhD, academic clinical lecturer at University College London's Lungs for Living Research Centre, said in the release. "Based on our findings, reliance on CT alone to diagnose COPD risks missing individuals who may actually have this condition while overdiagnosing others. Since individuals at risk for lung cancer are also at risk for COPD, we recommend including spirometry in low-dose CT lung cancer screening programs in order to assist in making accurate diagnoses." – by Melissa Foster

Disclosure: Ruparel reports she received support for the SUMMIT Study from GRAIL Inc., travel funding from Takeda and honorarium from AstraZeneca. Please see the study for all other authors' relevant financial disclosures.

Sources/DisclosuresCollapse Disclosures: Ruparel reports she received support for the SUMMIT Study from GRAIL Inc., travel funding from Takeda and honorarium from AstraZeneca. Please see the study for all other authors' relevant financial disclosures.

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