Doctors miss opportunities to diagnose COPD at an earlier stage in primary and secondary care

A retrospective study of almost 39,000 patients shows that opportunities to diagnose chronic obstructive pulmonary disease (COPD) at an earlier stage are frequently being missed in both primary and secondary care in the UK. The findings, published in The Lancet Respiratory Medicine, reveal missed opportunities to diagnose COPD occurred in up to 85% of people.

“The substantial numbers of patients misdiagnosed and under diagnosed in this study is a cause for concern. It is important that COPD is diagnosed as early as possible so effective treatment can be used to try to reduce lung damage, improve quality of life, and even life expectancy”, explains author Dr Rupert Jones from Plymouth University Peninsula School of Medicine and Dentistry, Plymouth, UK.

“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 recognise the significance of symptoms.”

The UK Department of Health estimates that around 2.2 million people in the UK are undiagnosed and state that earlier diagnosis and treatment could save the National Health Service more than £1 billion over 10 years.

Using data from the General Practice and Optimum Patient Care Research databases, the researchers assessed whether a COPD diagnosis might have been made in an earlier primary or secondary care visit. They identified 38,859 patients aged 40 years or older who had received a COPD diagnosis between 1990 and 2009 and for whom data was available for at least two years before and one year after diagnosis.

Results showed that in the 5 years before diagnosis, 85% of patients had visited their GP or a secondary care clinic at least once with lower respiratory symptoms. These consultations represent missed opportunities to further investigate patients for a possible diagnosis of COPD. Opportunities for diagnosis were missed in 58% of patients in the 6–10 years before diagnosis and 42% in the 11–15 years before diagnosis.

Over the 20 year study, a significant increase in the number of chest x-rays in the 2 years before diagnosis was noted, but only a third of these patients were also given spirometry testing.

They researchers say, “Although we have seen small improvements in earlier diagnosis over the past 20 years, many patients are still being diagnosed with severe or very severe airway obstruction, and the average age of diagnosis has fallen only slightly.”

According to co-author Dr Erika J Sims from Research in Real Life, Cambridge, UK, “These findings confirm that patients with undiagnosed COPD often visit health-care settings many times before eventually receiving a diagnosis. Understanding how to capitalise on these opportunities for earlier diagnosis in the course of routine clinical practice must be a priority for primary care nurses and doctors. 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).”

Writing in a linked Comment, 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-centred 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.”