Spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and COPD

BACKGROUND: Spirometry is recommended for diagnosis and management of obstructive lung disease. While many patients with asthma and COPD are cared for by primary care practices, limited data are available on the use and results associated with spirometry in primary care. OBJECT: To assess the technical adequacy, accuracy of interpretation, and impact of office spirometry. DESIGN: A before-and-after quasiexperimental design. SETTING: Three hundred eighty-two patients from 12 family medicine practices across the United States. PARTICIPANTS: Patients with asthma and COPD, and staff from the 12 practices. MEASUREMENTS: Technical adequacy of spirometry results, concordance between family physician and pulmonary expert interpretations of spirometry test results, and changes in asthma and COPD management following spirometry testing. RESULTS: Of the 368 tests completed over the 6 months, 71% were technically adequate for interpretation. Family physician and pulmonary expert interpretations were concordant in 76% of completed tests. Spirometry was followed by changes in management in 48% of subjects with completed tests, including 107 medication changes (>85% concordant with guideline recommendations) and 102 nonpharmacologic changes. Concordance between family physician and expert interpretations of spirometry results was higher in those patients with asthma compared to those with COPD. DISCUSSION AND CONCLUSIONS: US family physicians can perform and interpret spirometry for asthma and COPD patients at rates comparable to those published in the literature for international primary care studies, and the spirometry results modify care.     

Controversies in the use of spirometry for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers

Office spirometry used to detect COPD in smokers ages 44 and above with respiratory symptoms probably meets the criteria for a population-based screening test and for clinical case finding: If not detected early, COPD causes substantial morbidity or mortality, and smoking cessation is more effective when COPD is recognized before exertional dyspnea develops. Office spirometry is a feasible testing strategy and may be used to encourage smoking cessation efforts that change behavior in at least some patients. Office spirometry is relatively simple and affordable, is safe, and includes an action plan with minimal adverse effects. On the other hand, the false-positive and false-negative rates of office spirometry in the primary care setting may be higher than diagnostic spirometry performed during epidemiologic studies or in diagnostic pulmonary function laboratories, and the incremental benefit of office spirometry on smoking cessation rates is poorly established (when added to referral to an AHCPR-based smoking cessation program).     

Feasibility of spirometry and reversibility testing for the identification of patients with chronic obstructive pulmonary disease on asthma registers in general practice

There is renewed interest in the diagnosis of chronic obstructive pulmonary disease (COPD) within primary care. Primary care physicians have difficulty distinguishing asthma from COPD. We tested the feasibility of using spirometry and if appropriate, reversibility testing, to identify patients with COPD on asthma registers in primary care. We carried out a cross-sectional study in three inner-city group practices in east London. Three hundred and twenty-eight patients aged 50 years and over on practice asthma registers were invited to attend for spirometry and, if appropriate, a trial of oral corticosteroids. The main outcome measures were: feasibility of carrying out spirometry; lung function; severity of COPD; prior diagnosis of COPD; response to a corticosteroid trial; quality of life. One hundred and sixty-eight of 328 (51%) patients attended for spirometry. According to British Thoracic Society criteria, 58 (34%) patients had normal spirometry at the time of assessment; 40 (24%) had active asthma and 57 (34%) had COPD. Thirteen patients (8%) were unable to perform spirometry. Of 57 patients with COPD 30 (53%) had mild, 15 (26%) had moderate and 12 (21%) had severe disease. Twenty-three of 57 (40%) patients with COPD on spirometry had this diagnosis recorded prior to the study. New diagnoses of COPD were more likely in those with mild or moderate disease (P<0.05). Twenty-three of 57 (40%) patients with COPD completed a corticosteroid trial: one showed significant reversibility of lung function. Spirometry was feasible and helped identify patients with COPD on asthma registers in these inner-city practices. Patients aged 50 years and over on asthma registers had a wide spectrum of lung function with considerable diagnostic misclassification. Some patients with normal lung function when tested may have had well controlled asthma. New diagnoses of COPD were mainly in those with mild or moderate disease.     

Diagnostic accuracy of primary care asthma/COPD working hypotheses, a real life study

Misdiagnoses are inevitable when working hypotheses of asthma/COPD of General Practitioners (GPs) are not checked by spirometry. To reduce misdiagnoses, Asthma/COPD-support services (AC-services) offer support by performing spirometry assessed together with written medical history by consulting pulmonologists.Research questionsWhich criteria do GPs use to justify their asthma/COPD working hypotheses? How do diagnostic assessments by an AC-service change GPs' working hypotheses? Do GPs' justifications for their working hypotheses influence the extent to which working hypotheses correspond with diagnoses given by an AC-service?MethodWe investigated the working hypotheses of 17 GPs for 284 patients with respiratory problems and their justifications: “clinical symptoms”, “office spirometry”, or “specialist's correspondence”. Working hypotheses were compared with diagnoses given by an AC-service, and the influence of the different justifications categories on diagnostic accuracy of the working hypotheses was described.Results49% of the working hypothesis were only based on clinical information, 21% were also based on office spirometry. For 30% additional specialist information was available. 50% of the working hypotheses were confirmed by the AC-service. The working hypothesis asthma was confirmed more frequently (62%) than the working hypothesis COPD (40%). The justifications for the working hypotheses given by GPs did not influence these results.ConclusionDiagnostic assessments of the AC-service differed significantly from the working hypotheses of GPs, even when these were based on previous specialists' correspondence or on office spirometry. To optimize the diagnoses in primary care, diagnostic support of an AC-service is recommended for all primary care patients with respiratory problems.     

Chronic respiratory symptoms, spirometry and knowledge of COPD among general population

RATIONALE: Infradiagnosis of chronic obstructive pulmonary disease (COPD) may be related to the lack of knowledge about the disease and/or the scarce use of diagnostic procedures. This study analyses the frequency of respiratory symptoms and the knowledge about COPD in the general population, together with the use of spirometry in individuals at risk of COPD. POPULATION AND METHOD: A telephone survey was carried out in 6758 subjects older than 40 years, stratified by age, habitat (urban or rural) and region, screened by random-digit dialling. RESULTS: Up to 24% reported having at least one chronic respiratory symptom and 20.9% had a self-reported respiratory diagnosis. A total of 19.2% were active smokers and 40% had never tried to quit. Only 60% of the individuals with chronic symptoms had consulted a physician and, of them, only 45% had undergone spirometry. Spirometry was mentioned more frequently by subjects attended by pulmonologists than by GPs (67.6 vs. 28.6%; P<0.001). The term COPD was identified only by 8.6% of the participants. CONCLUSIONS: Many individuals with respiratory symptoms do not request medical attention and do not attempt to quit smoking. There is a lack of knowledge about COPD. Physicians should more actively inform about the disease and increase the use of spirometry for early detection.     

Attitudes of physicians toward objective measures of airway function in asthma

BACKGROUND: The National Asthma Education and Prevention Program (NAEPP) recommends pulmonary function testing as part of asthma evaluation. The objectives of this study were to determine the use of spirometry in patients with asthma by primary care physicians and asthma specialists, and to identify barriers to use of spirometry. METHODS: We developed, validated, and administered a mailed survey to primary care physicians and asthma specialists in the general community. We asked about the use of spirometry, access to spirometry, and barriers to spirometry use. RESULTS: Of 975 eligible subjects, 672 (69%) completed the survey. Asthma specialists were more likely to have an office spirometer (78% [216/277] vs. 43% [169/395], P <0.001) than were primary care physicians, and more likely to report measuring pulmonary function in at least 75% of their patients with asthma (83% [223/270] vs. 34% [131/388], P <0.001). In logistic regression analysis, factors most strongly associated with reported spirometry use (in at least 75% of patients) among asthma specialists were owning a spirometer, disagreeing with the statement that the test requires excessive use of office resources, and agreeing that spirometry is a necessary part of the asthma evaluation. Among primary care physicians, owning a spirometer, agreeing that the data are necessary for accurate diagnosis, and believing that they were trained to perform and interpret the test were most strongly associated with reported spirometry use. CONCLUSION: Pulmonary function testing is underutilized by physicians, with rates of utilization lowest among primary care physicians. Providing primary care physicians with better access to spirometry, through provision of a machine and appropriate training in its use and interpretation, may improve compliance with the NAEPP recommendations.     

Confidence and understanding among general practitioners and practice nurses in the UK about diagnosis and management of COPD

In order to assess the confidence of healthcare professionals in diagnosing and managing COPD telephone interviews were conducted with 60 practice nurses and 46 general practitioners (GPs) in 2001 and 61 nurses and 39 GPs in 2005. The nurses all ran respiratory clinics. 80% of GPs were confident about diagnosing COPD and this had increased from 52% in 2001. Fifty five percent of nurses were confident and there was no change from 2001. In 2005, 79% of GPs and 70% of nurses were confident about differentiating asthma and COPD. Smoking history, breathlessness, age of onset, lack of response to asthma therapy and cough were reported as features differentiating COPD from asthma. Most respondents stated that spirometry is essential to diagnose COPD and in 2005 nearly all practices had access to a spirometry service. GPs were more confident about interpreting spirometry results in 2005 than nurses and their confidence had increased significantly from 2001. In 2005, nearly all respondents had heard of pulmonary rehabilitation, and significantly more had a programme in their area in 2005 than 2001 (69% vs. 49% p=0.05). Fifty four percent of GPs were confident about which patients to refer for long term oxygen therapy in 2005 but nurses were less confident. There had not been any significant change between 2001 and 2005. In 2005 only 35% of respondents had access to a pulse oximeter. When presented with case scenarios, GPs self-reported confidence was not reflected in their diagnoses or investigation and management strategies and they seem to favour cardiac over respiratory diagnoses.     

Geographic variation of spirometry use in newly diagnosed COPD

BACKGROUND: Studies indicate that not all physicians in clinical practice use spirometry routinely in the diagnosis of COPD. Understanding the patterns of spirometry use across geographic regions in patients with newly diagnosed COPD may help to identify the factors associated with the use of spirometry and to improve the quality of COPD care. The objective of this study was to characterize the regional variation in spirometry use for patients with newly diagnosed COPD using the Healthcare Effectiveness Data and Information Set (HEDIS) 2006 spirometry performance measure. METHODS: We identified patients within the Veteran Health Administration who were >42 years of age who had received a new diagnosis of COPD between July 2003 and June 2004. The date of the COPD diagnosis was the index date. Spirometry use from 760 days prior to the index date to 180 days after the index date was identified. The Veterans Integrated Service Networks (VISNs) was used as the geographic unit for comparison. RESULTS: Of the 93,724 patients included in the study, 36.7% underwent spirometry during the study period. Using the largest VISN as the referent, there was more than a threefold difference in the adjusted odds ratios (AORs) for spirometry use between the regions with the lowest use (AOR, 0.52; 95% confidence interval [CI], 0.48 to 0.57) and the highest use (AOR, 1.61; 95% CI, 1.46 to 1.78). CONCLUSIONS: Overall, the use of spirometry in patients with newly diagnosed COPD was low using the new HEDIS spirometry measure with a significant regional variation comprising a more than threefold difference between the regions with the lowest and highest rates of spirometry use.     

Asthma and COPD among aboriginals in Alberta,Canada

BACKGROUND: Aboriginals in Canada bear a disproportionately higher burden of some chronic illnesses than nonaboriginals. Although there is a greater prevalence of smoking, poor housing, and overcrowding in aboriginal than nonaboriginal communities, the rates of office and emergency visits for asthma and COPD among aboriginals are not well known. STUDY OBJECTIVE: To determine whether aboriginals require higher rates of asthma and COPD emergency and office visits than nonaboriginals. SETTING: Population-based cohort of people residing in Alberta, Canada (population 2.8 million) between April 1, 1996, and March 31, 1997. DESIGN: Retrospective cohort study. RESULTS: We observed that aboriginals were 2.1 times (95% confidence interval [CI], 2.0 to 2.2) and 1.6 times (95% CI, 1.6 to 1.6) more likely to have an emergency and office visit for asthma or COPD, respectively, when compared to age-matched and sex-matched nonaboriginals. However, they were 55% (95% CI, 52 to 58%) less likely to see a specialist and 66% (95% CI, 63 to 70%) less likely to undergo spirometry than nonaboriginals. CONCLUSIONS: These findings indicate that aboriginals bear a disproportionately higher burden of asthma and COPD than nonaboriginals. However, lower use of spirometry and specialist services suggests that there might be access barriers to quality health care for aboriginals in Canada.     

Diagnosis and early detection of COPD using spirometry

The standard respiratory function test for case detection of chronic obstructive pulmonary disease (COPD) is spirometry. The criterion for diagnosis defined in guidelines is based on the FEV₁/FVC ratio forced expiratory ratio (FER) and its severity is based on forced expiratory volume in one second (FEV₁) from measurements obtained during maximal forced expiratory manoeuvres. Spirometry is a safe and practical procedure, and when conducted by a trained operator using a spirometer that provides quality feedback, the majority of patients can be coached to provide acceptable and repeatable results. This allows potentially wide application of testing to improve recognition and diagnosis of COPD, such as for case finding in primary care. However, COPD remains substantially under diagnosed in primary care and a major reason for this is underuse of spirometry. The presence of symptoms is not a reliable indicator of disease and diagnosis is often delayed until more severe airflow obstruction is present. Early diagnosis is worthwhile, as it allows risk factors for COPD such as smoking to be addressed promptly and treatment optimised. Paradoxically, investigation of the patho-physiology in COPD has shown that extensive small airway disease exists before it is detectable with conventional spirometric indices, and methods to detect airway disease earlier using the flow-volume curve are discussed.     

Use of spirometry and patterns of prescribing in COPD in primary care

OBJECTIVE: To investigate the use and interpretation of spirometry in primary care (PC) in the diagnosis of chronic obstructive pulmonary disease (COPD) and to identify the treatment schedules administered. METHODS: An observational study was performed in a randomized sample of 251 PC physicians including 2130 patients with COPD. Data on the performance of spirometry and the results and the treatment administered were collected as were sociodemographic and clinical data. RESULTS: Spirometric results were obtained in 1243 (58.4%). Most (1118/1243; 89.9%) corresponded to FEV1 (%) values with a mean of 57% (SD=21.5%). It is of note that only 31.8% of spirometric results provided post-bonchodilator results, and 42.9% and 43.1% of the spirometries presented not plausible FVC or FEV1 values, respectively. Treatment varied greatly, with more than 3 drugs being prescribed in 30.6% of the cases. Long-acting beta-2 agonists and inhaled corticosteroids were prescribed in more than 50% of the patients. Tiotropium was administered in 32.4%. According to the GOLD guidelines, 22.8% of the patients in GOLD II, 50% in III and 66.7% in IV were receiving incorrect treatment. CONCLUSIONS: Only 58.4% of the cases included had undergone spirometry. Important deficiencies were observed in the interpretation of the results of spirometry. These difficulties may influence the low implementation of treatment guidelines in COPD in PC.     

Patterns of care for COPD by Japanese physicians

OBJECTIVE: COPD treatment guidelines are available worldwide, yet it is not known how widely they are followed. This study evaluated the clinical care of COPD patients in Japan as compared to guideline recommendations. METHODS: A sample of general and specialist physicians was selected from private outpatient clinics and public hospitals in Japan. Physicians were provided two clinical vignettes (COPD and asthma) and asked to make a diagnosis. They were next asked to define diagnostic tests and treatment recommendations specifically for a COPD patient. Responses were compared to recommendations from current COPD guidelines. RESULTS: For the COPD unknown vignette, 6.2% of physicians diagnosed COPD while 54% diagnosed chronic bronchitis or emphysema. For COPD diagnosis, 81.9% of physicians recommended a CXR, 49.1% spirometry, and 17.7% a computed tomography scan. The most frequently recommended medication for a newly diagnosed COPD patient was theophylline (37.2%) followed by expectorants (32.1%) and inhaled anticholinergics (25.9%). Inhaled beta-agonists were recommended by fewer than 20% of all physicians. CONCLUSION: Care for COPD patients by selected Japanese physicians diverges from published practice guidelines. COPD is an infrequently used diagnostic label; diagnostic evaluation is characterized by a high use of computed tomography scans, particularly by specialists; and bronchodilator use was low.     

Difficulties in the Interpretation of Lung Function Tests in the Diagnosis of Asthma and Chronic Obstructive Pulmonary Disease

Objective. To ascertain differences in the interpretation of spirometry and peak flow measurement between primary care (several practioners and nurses) and specialists in patients with a pre-existing diagnosis of asthma and chronic obstructive pulmonary disease (COPD). Design. A randomized, prospective cohort study of 98 patients with a pre-existing diagnosis of asthma or COPD. Two chest specialists independently interpreted the peak flow and spirometric data and they were also blinded to the primary care results. Results. There was total agreement in interpretation of the data between general practitioners and specialists in only 20 (20.4%). Levels of diagnostic agreement were highest between the two chest specialists (55%) and lowest between the general practice records and the diagnosis assigned by general practitioners (16%). Disagreement between general practitioners and the two chest specialists was consistent (38%) indicating systematic differences in interpretation. Conclusions. This study raises concerns about differences in the interpretation of spirometry and peak expiratory flow rates in general and hospital practice and the guidelines on which these interpretations are based.     

Teaching time for metered-dose inhalers in the emergency setting

OBJECTIVES: In some acute-care settings, practitioners are reluctant to institute bronchodilator therapy with metered-dose inhalers (MDIs) as standard management. Such therapy requires that personnel ensure optimal use of these devices. We prospectively evaluated the time required to teach patients correct inhaler use for the emergency treatment of asthma and COPD, and patient factors associated with duration of teaching. DESIGN: MDI arm within a single-center randomized clinical trial comparing bronchodilator administration by MDI with a delivery enhancement device (MDI/DED) vs delivery by wet nebulizer. SETTING: All subjects were treated for asthma or COPD exacerbations at the respiratory acute-care day hospital of the Montreal Chest Institute, immediately after presentation to our emergency department. Inhaler-use education was provided according to a predetermined protocol. MEASUREMENTS: Subjects' baseline characteristics were obtained from medical charts, spirometry, and questionnaires; satisfaction was evaluated by questionnaire. All inhaler-use education was observed and timed. RESULTS: Sixty-one patients with asthma (median age, 46 years) and 32 patients with COPD (median age, 68.5 years) were randomized to treatment by MDI/DED. Mean FEV1 (percent predicted) was 63.5% for patients with asthma and 39.5% for patients with COPD. Five patients could not complete MDI teaching and therefore received subsequent treatment by wet nebulization. For the 88 other patients, the median teaching time was 6.5 min. Shorter teaching-time requirements were independently associated with higher initial arterial oxygen saturation, home DED use after previous MDI instruction, and a single initial bronchodilator treatment by wet nebulization. Most subjects expressed satisfaction with MDI/DED teaching and treatment. CONCLUSIONS: Successful MDI/DED teaching followed by self-medication is feasible in the emergency setting, based on a simple protocol. A single bronchodilator dose administered by wet nebulization may facilitate subsequent MDI teaching.     

Aging and disability affect misdiagnosis of COPD in elderly asthmatics: the SARA study

STUDY OBJECTIVES: This study investigated to what extent a diagnosis of COPD is erroneously made or the disease remains unrecognized in elderly asthmatic patients, and identified factors leading to misdiagnosis and underdiagnosis of asthma in such patients. DESIGN: A multicenter study involving 24 Italian pulmonary or geriatric institutions. PATIENTS: One hundred twenty-eight asthmatic patients (98 women, 76.6%) aged 73 +/- 6.4 years (mean +/- SD) were selected from the cohort of the Salute Respiratoria nell'Anziano (respiratory health in the elderly) study. METHODS: All patients underwent a clinical evaluation that included clinical history and spirometry with a bronchodilator test. A diagnosis of asthma was based on criteria proposed by international guidelines adapted to the elderly population. A multidimensional geriatric assessment was performed to estimate physical and cognitive impairments and mood state. Finally, the diagnosis of respiratory disease previously made by a doctor, if any, was recorded. RESULTS: Of asthmatic patients, COPD had been improperly diagnosed in 19.5%, whereas 27.3% of asthmatic patients did not report any previous diagnosis of asthma. The main correlates of misdiagnosis were older age and disability. Conversely, underdiagnosis was associated with better functional conditions, expressed by spirometry, even when wheezing or a significant response to the bronchodilator test occurred. CONCLUSIONS: Asthma in the elderly is frequently confused with COPD. Misdiagnosis can be related to older age and to greater degree of disability. Asthma in patients with mild functional impairment may be underdiagnosed in spite of overt respiratory symptoms suggestive of asthma.     

Difficulties in the Interpretation of Lung Function Tests in the Diagnosis of Asthma and Chronic Obstructive Pulmonary Disease

Objective. To ascertain differences in the interpretation of spirometry and peak flow measurement between primary care (several practioners and nurses) and specialists in patients with a pre-existing diagnosis of asthma and chronic obstructive pulmonary disease (COPD). Design. A randomized, prospective cohort study of 98 patients with a pre-existing diagnosis of asthma or COPD. Two chest specialists independently interpreted the peak flow and spirometric data and they were also blinded to the primary care results. Results. There was total agreement in interpretation of the data between general practitioners and specialists in only 20 (20.4%). Levels of diagnostic agreement were highest between the two chest specialists (55%) and lowest between the general practice records and the diagnosis assigned by general practitioners (16%). Disagreement between general practitioners and the two chest specialists was consistent (38%) indicating systematic differences in interpretation. Conclusions. This study raises concerns about differences in the interpretation of spirometry and peak expiratory flow rates in general and hospital practice and the guidelines on which these interpretations are based.     

Office spirometry for lung health assessment in adults: A consensus statement from the National Lung Health Education Program

COPD is easily detected in its preclinical phase using spirometry, and successful smoking cessation (a cost-effective intervention) prevents further disease progression. This consensus statement recommends the widespread use of office spirometry by primary-care providers for patients >/= 45 years old who smoke cigarettes. Discussion of the spirometry results with current smokers should be accompanied by strong advice to quit smoking and referral to local smoking cessation resources. Spirometry also is recommended for patients with respiratory symptoms such as chronic cough, episodic wheezing, and exertional dyspnea in order to detect airways obstruction due to asthma or COPD. Although diagnostic-quality spirometry may be used to detect COPD, we recommend the development, validation, and implementation of a new type of spirometry-office spirometry-for this purpose in the primary-care setting. In order to encourage the widespread use of office spirometers, their specifications differ somewhat from those for diagnostic spirometers, allowing lower instrument cost, smaller size, less effort to perform the test, improved ease of calibration checks, and an improved quality-assurance program.     

Poor sensitivity of symptoms in early detection of COPD

The prevalence of chronic obstructive pulmonary disease (COPD) has been increasing. However, COPD is often underdiagnosed. The objective of this study was to determine how many outpatients had persistent airflow limitation and could be diagnosed as COPD by post-bronchodilator spirometry. We also evaluated whether the newly diagnosed patients had any symptoms. All outpatients with liver or general diseases over 40 years old who regularly visited to our hospital were tested for pulmonary function by spirometry. Patients with airflow limitation by the first screening spirometry had further examinations including post-bronchodilator spirometry and chest radiograph by pulmonary specialists. A total of 288 patients accepted a first spirometry. The most common chronic diseases of these patients were chronic hepatitis (33.7%), fatty liver (26.4%), liver cirrhosis (8.3%), diabetes (3.5%) and hypertension (3.1%). Approximately half of the patients had a smoking history. 44 of 288 patients (15.3%) showed airflow limitation by pre-bronchodilator spirometry. Of these, 8 patients did not show airflow limitation by a repeat pre-bronchodilator spirometry nor did 5 patients by post-bronchodilator spirometry. The rest were diagnosed as COPD (80.6%), asthma (16.1%) and bronchiectasis (3.2%). The prevalence of COPD was 8.7%. Approximately half of the patients (13/25, 52.0%) diagnosed as COPD had never complained of any respiratory symptoms. Because symptoms such as dyspnea on exertion, cough and sputum are less sensitive for the diagnosis of COPD, the propagation of spirometry in a general practice/setting should be recommended for establishing the diagnosis rate of COPD rather than relying on the presence of respiratory symptoms.     

COPD in a Nationally Representative Sample: Sociodemographic Factors and Co-morbidity,Diagnosis Method,and Healthcare Utilization

Introduction: In 2011, the Centers for Disease Control and Prevention for the first time ever collected nationally representative prevalence data on chronic obstructive pulmonary disease (COPD), spirometry diagnosis, and healthcare utilization factors related to COPD. This research reports on that data and describes characteristics of adults with COPD who reported diagnosis by spirometry compared to those who did not report diagnosis by spirometry. Variables examined included basic elements of healthcare utilization such as emergency room visits, hospitalization or personal physician utilization. Methods: This is a cross-sectional study using novel data from the 2011 Behavioral Risk Factor Surveillance System COPD Module. Weighted multivariable logistic regression examined factors associated with (n = 13,484) and without spirometry (n = 3,131). Results: Spirometry to diagnose COPD was reported by 78% of adults and increased with age. In multivariable modeling, spirometry was more likely in: Black, non-Hispanic compared to white non-Hispanic; current and former compared to never smokers; adults with co-morbidity including asthma, depression, and cardiovascular disease; adults with a doctor; and those who had been to emergency room/hospital for COPD. Those less likely to receive a spirometry were: Hispanic and reported exercise in the past 30 days. Conclusions: This study identified that adults diagnosed with COPD without a spirometry tended to be Hispanic, younger, healthier, and had less utilization of medical resources. This study is a first step in understanding the potential impact of COPD diagnosis made without spirometry.     

Gender bias in the diagnosis of COPD

BACKGROUND: COPD is thought to be more prevalent among men than women, a finding usually attributed to higher smoking rates and more frequent occupational exposures of significance for men. However, smoking prevalence has increased among women and there is evidence that women may be more susceptible to the adverse pulmonary function effects of smoking than men. There may also be underdiagnosis and misdiagnosis of COPD in both sexes because objective measures of lung function are underused. OBJECTIVES: We undertook the present study to determine if there is gender bias in the diagnosis of COPD, such that women are less likely than men to receive a diagnosis of COPD. We also attempted to determine if underuse of lung function measurements was a factor in any bias detected. METHODS: We surveyed a random sample of 192 primary-care physicians (96 American and 96 Canadian; 154 men and 38 women) using a hypothetical case presentation and a structured interview. The case of cough and dyspnea in a smoker was presented in six versions differing only in the age and sex of the patient. After presentation of the history and physical findings, physicians were asked to state the most probable diagnosis and to choose the diagnostic studies needed. Physicians were then presented with spirometric findings of moderate or severe obstruction without significant bronchodilator response, and the questions repeated. Finally, the negative outcome of an oral steroid trial was described. RESULTS: Initially, COPD was given as the most probable diagnosis significantly more often for men than women (58% vs 42%; p < 0.05). The likelihood of a COPD diagnosis increased significantly and initial differences between sexes decreased as objective information was provided. After spirometry, COPD diagnosis rates for men and women were 74% vs 66% (p = not significant); after the steroid trial 85% vs 79% (p = not significant). Only 22% of physicians would have requested spirometry after the initial presentation. CONCLUSIONS: In North America, primary-care physicians underdiagnosed COPD, particularly in women. Spirometry reduces the risk of underdiagnosis and gender bias but is underused.