Clinicians may be missing the chance to diagnose early-stage chronic obstructive pulmonary disease (COPD) in the vast majority of cases, investigators suggest.
A review of data on nearly 39,000 patients seen by general practitioners and specialists in the United Kingdom showed that in the five years immediately before a diagnosis of COPD, 85 percent of patients had symptoms, examination findings, or test results that may have heralded early signs of COPD, say Rupert C.M. Jones, MD, from Plymouth University Peninsula School of Medicine and Dentistry in the United Kingdom, and colleagues.
“We suggest that a case-finding approach should be modified to include: all patients older than 40 years with a diagnosis of asthma and who currently smoke; all smokers older than 40 years who have a lower respiratory prescribing event; and follow-up of existing recommendations for smokers aged older than 40 years with any respiratory symptoms, especially if they are male,” the investigators write.
Although the study, published online Feb. 13 in Lancet Respiratory Medicine, looked only at patients treated in the United Kingdom, the findings are likely applicable to the United States, according to Professor Chris van Weel, MD, PhD. Dr van Weel, who wrote an accompanying editorial, holds joint appointments at the Australian National University in Canberra and Raboud University Medical Centre in Nijmegen, the Netherlands.
“The under-diagnosis of COPD is a universal problem in most, if not all, countries in the world,” Dr. van Weel told Medscape Medical News. “The paper of Jones highlights the diagnostic problem: symptoms are initially insidious and may fluctuate over time. And from my earlier research, it is also clear that patients ‘adapt’ their daily activities (less physical activities) and therefore may underplay or even become unaware of their symptoms.”
He notes that that the problem is not an easy one to solve because the early symptoms of COPD may get lost against the background of comorbidities and differential diagnoses.
“The physician, and in particular the family physician in primary care, has to pay attention to other possible diseases that might cause these symptoms: pneumonia, heart failure, lung cancer. The ‘low key symptoms’ and the need of applying a broad diagnostic scope together cause what Jones and his colleagues called the ‘missed opportunities’ to diagnose COPD,” Dr. van Weel said.
In the United States, where there are frequent breaks in the continuity of care, the problem of tracing the missed opportunities identified by Jones and fellow researchers is likely more acute than in either the United Kingdom or the Netherlands, where primary care practitioners more closely manage and coordinate patient care, he added.
The investigators agree: “For health-care systems outside of the UK that are less focused on primary care … implementation of mechanisms to enable clinical information to be shared with family doctors is essential if diagnosis of COPD is to improve,” they write.
Women were more likely to be underdiagnosed than men, receiving fewer chest radiographs in the year before diagnosis and having more hospitalizations within the two years immediately preceding a COPD diagnosis, the authors found.
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