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Diagnostics
COPD: Part Two in a Series on COPD Diagnosis and Management
| Author: James Willis |
| Article Date: 4/15/2008 |
Message for the Clinic
COPD imposes an enormous burden on the patient, the healthcare professional and the society in terms of morbidity, mortality, healthcare resource utilization and costs. The disease is both under-diagnosed and misdiagnosed, but evidence suggests that COPD is both preventable and treatable when it is diagnosed early and treated effectively. Non-pharmacological and pharmacological interventions can improve the management of COPD patients at the primary care level.
The burden of COPD
In view of the high prevalence of disease, severe disability and comorbidity with other clinical conditions, COPD poses an enormous socioeconomic burden, both in terms of direct costs to healthcare services and indirect costs to society through loss of productivity.[2,15] Data from the USA suggest that in 1996 the annual direct costs of COPD were US$14.5 billion; the leading cost categories were costs because of hospital stays (US$7.9 billion) and medications (US$5.1 billion). Assessment of the specific costs have indicated that hospitalization of a COPD patient costs up to 2.7 times more than for a non-COPD patient and accounts for approximately 70% of the direct medical costs for COPD. Recently, one prospective follow-up study showed that the direct costs were dependent on the severity of COPD and nearly double that reported for treatment of asthma. Moreover, while hospitalization costs and drug acquisition costs were nearly similar (43.8% and 40.8%), the clinic visits and diagnostic tests represented only 15.4% of the total direct costs.
The use of the Disability-Adjusted Life Years (DALYs), a composite measure estimating the sum of years lost because of premature mortality and years lived with disability, adjusted for the severity of disability, has demonstrated that COPD also poses a substantial social burden. One study has estimated that social burden will double from a value of 2.1% of total DALYs in 1990 to 4.1% of total DALYs in 2020, and thus rise from a ranking of twelfth to fifth for all leading causes of disability.
Goals of COPD Management
It is now recognized that COPD is both preventable and treatable and that the nihilistic attitude among some healthcare workers, resulting as a consequence of the limited success of primary and secondary prevention and the apparently low efficacy of available treatment options, is no longer justified.
While COPD management previously focused on the reduction and control of symptoms, it is now appreciated that improving the health status and quality of life, preventing disease progression, preventing and treating exacerbations and complications, and reducing mortality are equally important. In this regard, the GOLD guidelines have proposed four main components of COPD management: (i) assessing and monitoring disease, (ii) reducing the risk factors, (iii) managing stable COPD and (iv) managing exacerbations. These goals can be achieved by the initiation of comprehensive management initiatives for COPD that include advice and support for smoking cessation, early diagnosis, education and self-management, timely implementation of effective management strategies and multidisciplinary pulmonary rehabilitation programs.
Early Diagnosis of COPD
COPD is often not diagnosed until there are clinical symptoms and the disease is moderately advanced. A National Health and Nutritional Examination Survey (NHANES) in the USA demonstrated that 72% of subjects with mild airflow limitation did not have a current diagnosis of obstructive lung disease, while only half of those with moderate-to-pulmonary function impairment had been diagnosed and treated More recently, the American Lung Association estimated that there were twice as many patients with impaired lung function (indicative of early stage COPD) than patients with diagnosed COPD. One study demonstrated that misdiagnosis of COPD is also common. A survey of subjects with a diagnosis of COPD, chronic bronchitis or emphysema or symptoms of COPD in the USA and Europe, showed that only 23% of patients presenting with COPD symptoms were accurately diagnosed with another 14.5% identified as undiagnosed subjects who fulfilled the symptomatic definition of chronic bronchitis. Moreover, a significant number of patients perceived the severity of their disease incorrectly, based on the modified Medical Research Council (MRC) dyspnoea scale; 35.8% of subjects with the most severe breathlessness scale and 60.3% of subjects with the next most severe scale considered their condition to be mild or moderate.
An early diagnosis of COPD is clearly desirable because of both the clinical and socioeconomic implications of the disease. The GOLD guidelines and the UK National Institute of Clinical Excellence guidelines recommend early diagnosis of COPD in any patient over the age of 35 who has chronic cough (present intermittently or every day throughout the day), chronic sputum production, shortness of breath (dyspnoea), frequent winter 'bronchitis' or wheeze and/or a history of exposure to disease risk factors (particularly tobacco smoke, occupational dusts and chemicals, and smoke from home cooking and heating fuels).
Case Identification
Correct identification of patients with COPD has proved difficult in general practice. Patients are often unwilling to report symptoms, which may play a part in the apparent under diagnosis of COPD. Patients often accept their symptoms as part of ageing or a consequence of smoking, making them less likely to report symptoms. Therefore, it is important that the physician questions the patient extensively to ensure that they are not in a state of denial and have not modified their lifestyle to mask the symptoms of early COPD.
Taking a detailed medical history (including the presence of allergic airways disease and other comorbid disease e.g. heart disease and rheumatic disease, family history of COPD, pattern of symptom development, history of exacerbations and hospitalization as a result of respiratory disorder, and impact of disease on the patient's lifestyle) is also particularly useful for a new patient who may have COPD because it may aid in the development of specific management strategies at the outset.
Spirometry
The need for spirometry to establish a diagnosis of COPD is acknowledged by leading international guidelines, including those specifically designed for primary care. It is the best screening tool for COPD and is sensitive enough to detect COPD in its early stages, long before disabling effects are apparent. It should, therefore, be used to confirm the presence of the disease in any patient thought to be at risk of COPD.
Spirometry is a simple technique that can be performed in primary care to assess lung function in terms of maximal volume of air forcibly exhaled from the point of maximal inspiration [forced vital capacity (FVC)] and the volume of air exhaled during the first second of this maneuver [forced expiratory volume in 1 s (FEV1)]. It is suggested that a post bronchodilator FEV1 < 80% of predicted together with an FEV1/FVC ratio of < 70% is indicative of airflow limitation that is not fully reversible. The level of the patient's symptoms and the use of specific spirometric cut-points are also used to define the severity of disease, although the latter have not been validated clinically and are used only for purposes of simplicity.
Despite the recommendation for use of FEV as a global marker for confirmation of diagnosis of COPD, spirometry may not be commonly performed in primary care practice for reasons including limited access, lack of training, cost and time constraints. However, inexpensive tools are available for training healthcare professionals to perform spirometry. Moreover, in a recent study, spirometry was found to be a cost effective diagnostic tool for case finding in a resource-limited setting. The introduction of spirometry in this study resulted in a fourfold increase in COPD case finding and a reduction of incorrectly diagnosed patients in general practice.
Reducing the Risks of COPD
To aid the prevention of COPD, the primary care team should work with all their patients to help them stop smoking, regardless of their spirometry results. In addition, raising awareness of COPD, including its symptoms and progression, is essential for the early identification of the disease and to encourage patients to discuss their symptoms with their healthcare professional. Primary care professionals are at the forefront of COPD diagnosis and management and are, therefore, ideally placed to provide education and support to their patients. Part III to continue in the next issue of Physicians Office Resource.
COPD imposes an enormous burden on the patient, the healthcare professional and the society in terms of morbidity, mortality, healthcare resource utilization and costs. The disease is both under-diagnosed and misdiagnosed, but evidence suggests that COPD is both preventable and treatable when it is diagnosed early and treated effectively. Non-pharmacological and pharmacological interventions can improve the management of COPD patients at the primary care level.
The burden of COPD
In view of the high prevalence of disease, severe disability and comorbidity with other clinical conditions, COPD poses an enormous socioeconomic burden, both in terms of direct costs to healthcare services and indirect costs to society through loss of productivity.[2,15] Data from the USA suggest that in 1996 the annual direct costs of COPD were US$14.5 billion; the leading cost categories were costs because of hospital stays (US$7.9 billion) and medications (US$5.1 billion). Assessment of the specific costs have indicated that hospitalization of a COPD patient costs up to 2.7 times more than for a non-COPD patient and accounts for approximately 70% of the direct medical costs for COPD. Recently, one prospective follow-up study showed that the direct costs were dependent on the severity of COPD and nearly double that reported for treatment of asthma. Moreover, while hospitalization costs and drug acquisition costs were nearly similar (43.8% and 40.8%), the clinic visits and diagnostic tests represented only 15.4% of the total direct costs.
The use of the Disability-Adjusted Life Years (DALYs), a composite measure estimating the sum of years lost because of premature mortality and years lived with disability, adjusted for the severity of disability, has demonstrated that COPD also poses a substantial social burden. One study has estimated that social burden will double from a value of 2.1% of total DALYs in 1990 to 4.1% of total DALYs in 2020, and thus rise from a ranking of twelfth to fifth for all leading causes of disability.
Goals of COPD Management
It is now recognized that COPD is both preventable and treatable and that the nihilistic attitude among some healthcare workers, resulting as a consequence of the limited success of primary and secondary prevention and the apparently low efficacy of available treatment options, is no longer justified.
While COPD management previously focused on the reduction and control of symptoms, it is now appreciated that improving the health status and quality of life, preventing disease progression, preventing and treating exacerbations and complications, and reducing mortality are equally important. In this regard, the GOLD guidelines have proposed four main components of COPD management: (i) assessing and monitoring disease, (ii) reducing the risk factors, (iii) managing stable COPD and (iv) managing exacerbations. These goals can be achieved by the initiation of comprehensive management initiatives for COPD that include advice and support for smoking cessation, early diagnosis, education and self-management, timely implementation of effective management strategies and multidisciplinary pulmonary rehabilitation programs.
Early Diagnosis of COPD
COPD is often not diagnosed until there are clinical symptoms and the disease is moderately advanced. A National Health and Nutritional Examination Survey (NHANES) in the USA demonstrated that 72% of subjects with mild airflow limitation did not have a current diagnosis of obstructive lung disease, while only half of those with moderate-to-pulmonary function impairment had been diagnosed and treated More recently, the American Lung Association estimated that there were twice as many patients with impaired lung function (indicative of early stage COPD) than patients with diagnosed COPD. One study demonstrated that misdiagnosis of COPD is also common. A survey of subjects with a diagnosis of COPD, chronic bronchitis or emphysema or symptoms of COPD in the USA and Europe, showed that only 23% of patients presenting with COPD symptoms were accurately diagnosed with another 14.5% identified as undiagnosed subjects who fulfilled the symptomatic definition of chronic bronchitis. Moreover, a significant number of patients perceived the severity of their disease incorrectly, based on the modified Medical Research Council (MRC) dyspnoea scale; 35.8% of subjects with the most severe breathlessness scale and 60.3% of subjects with the next most severe scale considered their condition to be mild or moderate.
An early diagnosis of COPD is clearly desirable because of both the clinical and socioeconomic implications of the disease. The GOLD guidelines and the UK National Institute of Clinical Excellence guidelines recommend early diagnosis of COPD in any patient over the age of 35 who has chronic cough (present intermittently or every day throughout the day), chronic sputum production, shortness of breath (dyspnoea), frequent winter 'bronchitis' or wheeze and/or a history of exposure to disease risk factors (particularly tobacco smoke, occupational dusts and chemicals, and smoke from home cooking and heating fuels).
Case Identification
Correct identification of patients with COPD has proved difficult in general practice. Patients are often unwilling to report symptoms, which may play a part in the apparent under diagnosis of COPD. Patients often accept their symptoms as part of ageing or a consequence of smoking, making them less likely to report symptoms. Therefore, it is important that the physician questions the patient extensively to ensure that they are not in a state of denial and have not modified their lifestyle to mask the symptoms of early COPD.
Taking a detailed medical history (including the presence of allergic airways disease and other comorbid disease e.g. heart disease and rheumatic disease, family history of COPD, pattern of symptom development, history of exacerbations and hospitalization as a result of respiratory disorder, and impact of disease on the patient's lifestyle) is also particularly useful for a new patient who may have COPD because it may aid in the development of specific management strategies at the outset.
Spirometry
The need for spirometry to establish a diagnosis of COPD is acknowledged by leading international guidelines, including those specifically designed for primary care. It is the best screening tool for COPD and is sensitive enough to detect COPD in its early stages, long before disabling effects are apparent. It should, therefore, be used to confirm the presence of the disease in any patient thought to be at risk of COPD.
Spirometry is a simple technique that can be performed in primary care to assess lung function in terms of maximal volume of air forcibly exhaled from the point of maximal inspiration [forced vital capacity (FVC)] and the volume of air exhaled during the first second of this maneuver [forced expiratory volume in 1 s (FEV1)]. It is suggested that a post bronchodilator FEV1 < 80% of predicted together with an FEV1/FVC ratio of < 70% is indicative of airflow limitation that is not fully reversible. The level of the patient's symptoms and the use of specific spirometric cut-points are also used to define the severity of disease, although the latter have not been validated clinically and are used only for purposes of simplicity.
Despite the recommendation for use of FEV as a global marker for confirmation of diagnosis of COPD, spirometry may not be commonly performed in primary care practice for reasons including limited access, lack of training, cost and time constraints. However, inexpensive tools are available for training healthcare professionals to perform spirometry. Moreover, in a recent study, spirometry was found to be a cost effective diagnostic tool for case finding in a resource-limited setting. The introduction of spirometry in this study resulted in a fourfold increase in COPD case finding and a reduction of incorrectly diagnosed patients in general practice.
Reducing the Risks of COPD
To aid the prevention of COPD, the primary care team should work with all their patients to help them stop smoking, regardless of their spirometry results. In addition, raising awareness of COPD, including its symptoms and progression, is essential for the early identification of the disease and to encourage patients to discuss their symptoms with their healthcare professional. Primary care professionals are at the forefront of COPD diagnosis and management and are, therefore, ideally placed to provide education and support to their patients. Part III to continue in the next issue of Physicians Office Resource.