Simplified COPD screening: validation of the PiKo-6® in primary care

A Two-Staged, Risk-Stratified Strategy Combining FEV1/FEV6 and COPD Diagnostic Questionnaire Acts as an Accurate and Cost-Effective COPD Case-Finding Method

BACKGROUND AND OBJECTIVE

Symptom-based questionnaires and handheld lung function devices are widely used for COPD case finding, but the optimal combination remains unclear. This study aimed to compare the diagnostic accuracy (DA) of various combinations of handheld lung function devices and questionnaires and develop a COPD case-finding strategy.

METHODS

This cross-sectional, prospective, observational study enrolled participants aged ≥ 40 years with respiratory symptoms and ≥ 10 smoking pack-years. Participants completed three questionnaires (COPD diagnostic questionnaire [CDQ], lung function questionnaire; COPD Population Screener) and 2 handheld lung function devices (peak flow meter, microspirometer), followed by spirometry to confirm COPD (post-bronchodilation FEV1/FVC < 0.7). DA is assessed using the area under the ROC curve (AUROC).

RESULTS

Among 224 participants, COPD incidence was 29%. Individually, handheld devices showed significantly higher DA than questionnaires (AUROC 0.678-0.69 for questionnaires vs. 0.807 for peak expiratory flow rate [PEFR] and 0.888 for FEV1/FEV6; all pairwise p < 0.05). FEV1/FEV6-based combinations outperformed PEFR-based combinations (all n = 224; AUROC 0.897-0.903 vs. 0.810-0.818; p < 0.05). The CDQ and FEV1/FEV6 combination reached the highest DA (AUROC 0.903). FEV1/FEV6 < 0.76 was the optimal cutoff value. A two-staged strategy (sensitivity/specificity 0.82/0.84) was proposed: low-risk participants (CDQ ≤ 13) need no further testing; middle-risk (CDQ 14-26) should undergo FEV1/FEV6; and high-risk (CDQ ≥ 27) and middle-risk with FEV1/FEV6 < 0.76 require confirmatory spirometry. This approach would reduce misdiagnoses and save costs and time compared to FEV1/FEV6 alone.

CONCLUSION

FEV1/FEV6 and CDQ combination achieves the highest DA. A two-staged, risk-stratified strategy combining CDQ and FEV1/FEV6 can be accurate and cost-effective to detect at-risk, undiagnosed COPD subjects. External validation is required.

FEV1/FEV6 Cutoff Points to Avoid False Negatives When Using Portable Devices, PICO-6® and COPD-6®, in COPD Detection in Primary Healthcare Services

Background: Chronic obstructive pulmonary disease (COPD) is a frequent but underdiagnosed disease, primarily due to the lack of access to forced spirometry (FS) in primary care. Portable, easy-to-use expiratory flow meters like Piko-6® and COPD-6® that measure FEV1, FEV6, and FEV1/FEV6 ratio provide an alternative. Given that Piko-6® and COPD-6® devices measure FEV6 but not FVC, the aim of the study is to determine the optimal cutoff value for the FEV1/FEV6 ratio of each device to avoid false negatives when these devices are used for COPD screening in primary care (PC). Methods: A total of 664 patients of 35 years of age or older with a cumulative tobacco consumption of 10 or more packs/year were recruited at two university hospitals. FS (gold standard) was performed and FEV1, FVC, and FEV1/FVC measurements were compared with FEV1, FEV6, and FEV1/FEV6 measurements acquired using Piko-6® and COPD-6® devices. The devices were compared using statistical methods including Pearson correlation coefficients, the Youden index (YI), kappa coefficient, Bland-Altman plots, and ROC curves analysis. Results: Correlations between FEV1/FEV6 using Piko-6® and COPD-6® and FEV1/FVC with FS were 0.79 and 0.73, respectively. Piko-6® achieved the best YI in FEV1/FEV6 (0.73), whereas for COPD-6®, it was 0.80. Concordance between Piko-6® and FS was 83.9% (kappa 0.67 ± 0.028) and for COPD-6®, it was 68.7% (kappa 0.42 ± 0.02). Conclusions: This is the first study that compares two hand-held expiratory flow meters with FS. Piko-6® and COPD-6® devices are effective tools for COPD detection, as their measurements provide a good correlation with FS. In order to avoid false negative results, the FEV1/FEV6 cutoff point needs to be increased to 0.73 and 0.80 with Piko-6® and COPD-6®, respectively.

Long-Term Consequences of Spirometry During Military Routine Medical Examinations on Smoking Cessation Compared to Minimal Advice

BACKGROUND

Smoking kills 8 million people a year worldwide. It is the most prevalent cause of death in France by cancer, cardiovascular, or respiratory diseases. Minimal advice consists in asking patients who smoke if they are interested in quitting. It is effective in reducing smoking. The French High Health Authority recommends its systematic use with patients, whatever their reason for seeking treatment. The beneficial effect of spirometry on smoking cessation is controversial. The objective of our study was to measure the consequences of spirometry associated with minimal advice, compared with only minimal advice in soldiers seen during a routine medical examination.

METHODS

Our prospective, longitudinal, open, multicenter, controlled, randomized study was conducted among French military smokers presenting for an occupational medicine visit. Each participant received, depending on their group (intervention or control), either minimal advice associated with an evaluation of lung function by mini-spirometer, or only minimal advice. Follow-up visits were performed at 6 and 12 months. The primary objective was self-reported tobacco use cessation at 6 months.

RESULTS

A total of 267 participants (126 in the intervention group and 141 for the control arm) were included in 10 centers between June 2019 and June 2020. The response rate was 75.6% at 6 months. The cessation rates were 17% and 18% in the intervention and control groups, respectively, with no significant difference between the two groups (P = 0.9). The cessation rate in the general population was 13% at 6 months.

CONCLUSIONS

Spirometry does not seem to influence smoke cessation on a military population at 6 months. The overall cessation rate in our study was well in excess of the 3-6% expected from only providing minimal which is underused in general practice and should be encouraged.

Different Case Finding Approaches to Optimise COPD Diagnosis: Evidence from the RADICALS Trial

Aim

Diagnosis of COPD in primary care is hindered by underuse of spirometry. Case finding using validated symptom and health status questionnaires, and simple handheld devices in high-risk populations may improve diagnosis. This study aimed to determine the best combination of measures to optimise COPD diagnosis in the primary care setting.

Methods

We recruited 335 current or ex-smokers, including those with an established diagnosis of COPD from general practices. Participants' FEV1 and FEV6 were measured using a handheld spirometry device (COPD-6®). Each completed the COPD assessment test (CAT), a modified Medical Research Council (mMRC) dyspnoea scale, St George's Respiratory Questionnaire (SGRQ) and smoking history questionnaire. From these data we calculated the predictive validity for spirometry-confirmed diagnosis of COPD. Area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated for each. Kappa coefficient was used to measure the agreement between the Fixed-Ratio (FR) and Lower Limit of Normal (LLN) spirometric criteria in diagnosing COPD.

Results

FEV1/FEV6 <0.70 alone showed significant association (p<0.0001) with COPD diagnosis and good predictive accuracy (AUROC=0.725). However, no further improvement was found after combining SGRQ, CAT and mMRC with FEV1/FEV6. FEV1/FEV6 <0.70 using the COPD-6® handheld device had moderate sensitivity (65.7%) and high PPV (90.1%), high specificity (79.3%) and NPV (44.8%). There was good agreement between FR and LLN definitions (κ=0.70).

Conclusion

Handheld micro-spirometers can facilitate case finding of COPD in smokers and ex-smokers attending general practice. The fixed ratio criterion currently recommended by COPD-X guidelines offers the simplest method for diagnosing COPD in Australian primary care.

Current Progress of COPD Early Detection: Key Points and Novel Strategies

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide, with approximately 70% to 80% of adults with COPD being undiagnosed. Patients with undiagnosed COPD are at increased risk of poor outcomes and a worsened quality of life, making early detection a crucial strategy to mitigate the impact of COPD and reduce the burden on healthcare systems. In the past decade, increased interest has been focused on the development of effective strategies and instrument for COPD early detection. However, identifying undiagnosed cases of COPD is still challenging. Both screening and case-finding approaches have been adopted to identify undiagnosed COPD, with case-finding being recommended by the 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline and the updated United States Preventive Services Task Force (USPTF) recommendation. Nonetheless, the approaches, criteria, and instruments used for early detection of COPD are varied. However, advances in the taxonomy and risk factors of COPD are continuously being investigated. It is important to continuously assess the current state of knowledge on COPD early detection, given the challenges associated with identifying undiagnosed COPD. This review aims to highlight recent advances in early detection of COPD. To discuss the current challenge and opportunity in COPD early detection, providing an overview of existing literature on COPD case-finding strategies, including the approaches, criteria for subjects, and instruments. The review also summarizes the current progress in COPD case-findings and proposes a COPD case-finding flowchart as an efficient method for identifying at risk COPD patients.

Assessing feasibility of targeted primary care referrals for patients with clinical suspicion of interstitial lung disease using lung ultrasound: a prospective case finding study. The potential benefits of LUS utilization

BACKGROUND

In Primary Health Care (PHC) many interstitial lung disease (ILD) cases may remain at diagnostic delay, due to their challenging presentation and the limited experience of general practitioners (GPs) in recognizing their early symptoms.

OBJECTIVE

We have designed a feasibility study to investigate early ILD case-finding competency between PHC and tertiary care.

METHODS

A cross-sectional prospective case-finding study was launched at two private health care centers of Heraklion, Crete, Greece, during nine months (2021-2022). After clinical assessment by GP, PHC attenders, who agreed to participate in the study, were referred to the Respiratory Medicine Department, University Hospital of Heraklion, Crete, underwent Lung Ultrasound (LUS) and those with an overall suspicion for ILDs underwent high resolution computed tomography (HRCT) scan. Descriptive statistics and chi-square tests were used. Multiple Poisson regression analysis was performed to explain positive LUS and HRCT decision with selected variables.

RESULTS

One hundred and nine patients out of 183 were finally included (54.1% females; mean age 61, SD: 8.3 years). Thirty-five (32.1%) were current smokers. Overall, two out of ten cases were assessed to need HRCT due to a moderate or high suspicion (19.3%; 95%CI 12.7, 27.4). However, in those who had dyspnea in relation to counterparts, a significantly higher percentage of patients with LUS findings (57.9% vs. 34.0%, p=0.013) was found, as in those who had crackles (100.0% vs. 44.2%, p= 0.005). Detected possible ILD provisional labelling cases were 6, and most importantly, 5 of those cases were considered highly suspicious for further evaluation based on LUS findings.

CONCLUSIONS

This is a feasibility study exploring potentials by combining data of medical history, basic auscultation skills, as crackles detection, and inexpensive and radiation-free imaging technique, such as LUS. Cases of ILD labeling may be hidden within PHC, sometimes, much before any clinical manifestation.

Rapid FEV1/FVC Decline Is Related With Incidence of Obstructive Lung Disease and Mortality in General Population

BACKGROUND

Forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) naturally decreases with age; however, an excessive decline may be related with increased morbidity and mortality. This study aimed to evaluate the FEV₁/FVC decline rate in the Korean general population and to identify whether rapid FEV₁/FVC decline is a risk factor for obstructive lung disease (OLD) and all-cause and respiratory mortality.

METHODS

We evaluated individuals aged 40-69 years who underwent baseline and biannual follow-up spirometric assessments for up to 18 years, excluding those with airflow limitations at baseline. Based on the quartiles of the annual FEV₁/FVC decline rate, the most negative FEV₁/FVC change (1^st quartile of annual FEV₁/FVC decline rate) was classified as rapid FEV₁/FVC decline. We investigated the risk of progression to OLD and all-cause and respiratory mortality in individuals with rapid FEV₁/FVC decline.

RESULTS

The annual FEV₁/FVC decline rate in the eligible 7,768 patients was 0.32 percentage point/year. The incidence rate of OLD was significantly higher in patients with rapid FEV₁/FVC decline than in those with non-rapid FEV₁/FVC decline (adjusted incidence rate, 2.119; 95% confidence interval [CI], 1.932-2.324). Rapid FEV₁/FVC decline was an independent risk factor for all-cause mortality (adjusted hazard [HR], 1.374; 95% CI, 1.105-1.709) and respiratory mortality (adjusted HR, 1.353; 95% CI, 1.089-1.680).

CONCLUSION

The annual FEV₁/FVC decline rate was 0.32%p in the general population in Korea. The incidence rate of OLD and the hazards of all-cause and respiratory mortality were increased in rapid FEV₁/FVC decliners.

Accuracy and economic evaluation of screening tests for undiagnosed COPD among hypertensive individuals in Brazil

In Brazil, prevalence of diagnosed COPD among adults aged 40 years and over is 16% although over 70% of cases remain undiagnosed. Hypertension is common and well-recorded in primary care, and frequently co-exists with COPD because of common causes such as tobacco smoking, therefore we conducted a cross-sectional screening test accuracy study in nine Basic Health Units in Brazil, among hypertensive patients aged ≥40 years to identify the optimum screening test/combinations to detect undiagnosed COPD. We compared six index tests (four screening questionnaires, microspirometer and peak flow) against the reference test defined as those below the lower limit of normal (LLN-GLI) on quality diagnostic spirometry, with confirmed COPD at clinical review. Of 1162 participants, 6.8% (n = 79) had clinically confirmed COPD. Peak flow had a higher specificity but lower sensitivity than microspirometry (sensitivity 44.3% [95% CI 33.1, 55.9], specificity 95.5% [95% CI 94.1, 96.6]). SBQ performed well compared to the other questionnaires (sensitivity 75.9% [95% CI 65.0, 84.9], specificity 59.2% [95% CI 56.2, 62.1]). A strategy requiring both SBQ and peak flow to be positive yielded sensitivity of 39.2% (95% CI 28.4, 50.9) and specificity of 97.0% (95% CI 95.7, 97.9). The use of simple screening tests was feasible within the Brazilian primary care setting. The combination of SBQ and peak flow appeared most efficient, when considering performance of the test, cost and ease of use (costing £1690 (5554 R$) with 26.7 cases detected per 1,000 patients). However, the choice of screening tests depends on the clinical setting and availability of resources.ISRCTN registration number: 11377960.

Sex Differences in the International Primary Care Airways Group Questionnaire for Screening of Chronic Obstructive Pulmonary Disease: A Retrospective, Cross-Sectional Study

Background and Objective

Methods

Results

Conclusion

Accuracy of portable spirometers in the diagnosis of chronic obstructive pulmonary disease A meta-analysis

Portable spirometers has been approved for diagnosing chronic obstructive pulmonary disease (COPD). However, their diagnostic accuracy has not been reviewed. Therefore, the purpose of this study was to systematically evaluate the diagnostic value of portable spirometers in detecting COPD. A comprehensive literature search for relevant studies was conducted in PubMed, Embase, CNKI, Wan Fang, and Web of Science databases. Pooled sensitivity, specificity, summary receiver operating characteristic (SROC), area under the curve (AUC), and other related indices were calculated using the bivariate mixed-effect model. Subgroup analysis was performed to explore the source of heterogeneity. Thirty one studies were included in the meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic ratio (DOR), SROC, and AUC of the SROC of portable spirometers were 0.85 (0.81–0.88), 0.85 (0.81–0.88), 5.6 (4.4–7.3), 0.18 (0.15–0.22), 31 (21–46) and 0.91 (0.89–0.94), respectively. Among the three commonly used types of portable spirometers, the accuracy of PIKO-6 was higher (0.95) than that of COPD-6 (0.91) and PEF (0.82). Subgroup analysis indicated that the accuracy of a multi-indices portable spirometer was higher than that of a single-index one (P < 0.05). In addition, portable spirometry performed by professional technicians in tertiary hospitals was more accurate than for those conducted by trained technicians in primary care facilities and communities (P < 0.05). Moreover, the accuracy of studies conducted in developing country was superior to developed country (P < 0.05). Portable spirometers have high accuracy in the diagnosis of COPD. Multi-index COPD-6 and PIKO-6 displayed higher accuracy than others. Standardized training of instrument operators should be considered to achieve reliable results.

Accuracy of the COPD diagnostic questionnaire as a screening tool in primary care

BACKGROUND

The COPD Diagnostic Questionnaire (CDQ) was developed to identify people who would benefit from spirometry testing to confirm Chronic Obstructive Pulmonary Disease (COPD). The aim of this study was to determine the usefulness of a cut-off score of 16.5 on the CDQ in identifying those at increased risk of obstruction, in a mixed population of people 'at risk' of COPD and those with an 'existing' COPD diagnosis.

METHODS

People 'at risk' of COPD (aged > 40 years, current/ex-smoker) and those with 'existing' COPD were identified from four general practices and invited to participate. Participants completed the CDQ and those with a CDQ score ≥ 16.5 were categorised as having intermediate to increased likelihood of airflow obstruction. Pre and post-bronchodilator spirometry determined the presence of airway obstruction (FEV1/FVC ratio < 0.7). Sensitivity, specificity and accuracy of the CDQ was determined compared to spirometry as the gold standard.

RESULTS

One hundred forty-one participants attended an initial assessment ('at risk' = 111 (79%), 'existing' COPD = 30 (21%)). A cut-off score of 16.5 corresponded to a sensitivity of 81%, specificity of 36% and accuracy of 50%, in the entire mixed population. The area under the ROC curve was 0.59 ± 0.50 indicating low diagnostic accuracy of the CDQ. Similar results were found in the 'existing' COPD group alone.

CONCLUSION

Whilst a cut-off score of 16.5 on the CDQ may result in a large number of false positives, clinicians may still wish to use the CDQ to refine who receives spirometry due to its high sensitivity.

TRIAL REGISTRATION

ANZCTR, ACTRN12619001127190. Registered 12 August 2019 - Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx.

The Effectiveness and Harms of Screening for Chronic Obstructive Pulmonary Disease: An Updated Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to perform meta-analyses to update a previous systematic review (SR) conducted by the US Preventive Services Task Force (USPSTF) to evaluate the benefits and harms of screening for chronic obstructive pulmonary disease (COPD) in asymptomatic adults.

METHODS

MEDLINE, EMBASE, Cochrane Library, and regional databases were searched from their inception to January 2020. Studies for diagnostic accuracy, preventive services effect, treatment efficacy, and treatment harms were included.

RESULTS

Eighteen studies were included, and twelve of these were newly added in this update. In meta-analyses, the pooled sensitivity and specificity for COPD diagnosis using spirometry were 73.4% and 89.0%, respectively. The relative effect of smoking cessation intervention with screening spirometry, presented as abstinence rate, was not statistically significant (risk ratio [RR], 1.21; 95% confidence interval [CI], 0.87-1.67) when all selected studies were pooled, but screening on smoking cessation was effective (RR, 1.58; 95% CI, 1.14-2.19) when limited to studies with smoking cessation programs that provided smoking cessation medicines or intensive counseling at public health centers or medical institutions.

CONCLUSION

In this study, no direct evidence for the impact on health outcomes of screening asymptomatic adults for COPD was identified similar to the previous SR. Further research is necessary to confirm the benefits of COPD screening.

Validity of a portable spirometer in the communities of China

Background

The lack of simple and affordable spirometry has led to the missed and delayed diagnoses of chronic respiratory diseases in communities. The PUS201P is a portable spirometry developed to solve this problem.

Objective

We aimed to verify the consistency of the PUS201P spirometer with conventional Jaeger spirometer.

Methods

In this cross-sectional study, we randomly recruited 202 subjects aged > 40 years. Testing with the portable spirometry and conventional spirometry were performed on all participants. We compared forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), FEV₁/FVC measured by the PUS201P device with the conventional spirometer. Pearson correlation coefficient and Interclass Correlation Coefficient (ICC) were assessed to confirm the consistency of the measures from two instruments. Bland–Altman graph was created to assess the agreement of the measures from two devices.

Results

202 participants were included in this study. The ICC on FEV₁, FVC, FEV₁/FVC measured by the portable spirometer and the conventional spirometer were 0.95 (95% confidence interval [CI]: 0.94–0.96), 0.92 (95% CI: 0.90–0.94], 0.93 (95% CI: 0.91–0.95), respectively. The Bland–Altman plots showed that the mean difference between the measures from two spirometers are always located in the 95% limits of agreement.

Conclusions

Our results support that the measures from the portable spirometer and the conventional spirometer have a good agreement and reproducibility. And the portable spirometer is a reliable tool to screen and diagnose chronic airway diseases in the primary care settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01872-9.

Self-Reported Smoking Status 10-Months After a Single Session Intervention Including an Education Conference About Smoking Harms and Announcement of Spirometric Lung-Age

Background

Studies investigating the effects of announcing spirometric lung-age (SLA) on the smokers' self-reported smoking status reported conflicting results.

Main objective

To evaluate the effects of a single session intervention including an education conference about smoking harms and announcement of SLA on the participants' self-reported smoking status.

Methodology

An interventional study was conducted in a cable factory. The intervention included four steps: PowerPoint presentation about raising smoking hazards awareness; general questionnaire; measurement of the anthropometric and spirometric data, and announcement of SLA; and evaluation of the smokers' self-reported smoking status 10 months later (quitted smoking, decreased consumption; stable consumption, increased consumption).

Results

Thirty-six smokers completed the four steps. Ten months after the intervention, 11.1% of smokers quitted smoking, 52.7% decreased their consumption by 7  ±  4 cigarettes/day, 30.5% kept a stable consumption, and 5.5% increased their consumption by 9  ±  6 cigarettes/day.

Conclusion

Providing an education conference combined with announcing SLA motivated 64% of smokers to quit smoking or to reduce their cigarette consumption.

Accuracy and cost-effectiveness of different screening strategies for identifying undiagnosed COPD among primary care patients (≥40 years) in China: a cross-sectional screening test accuracy study: findings from the Breathe Well group

OBJECTIVES

To examine the accuracy and cost-effectiveness of various chronic obstructive pulmonary disease (COPD) screening tests and combinations within a Chinese primary care population.

DESIGN

Screening test accuracy study.

SETTING

Urban and rural community health centres in four municipalities of China: Beijing (north), Chengdu (southwest), Guangzhou (south) and Shenyang (northeast).

PARTICIPANTS

Community residents aged 40 years and above who attended community health centres for any reason were invited to participate. 2445 participants (mean age 59.8 (SD 9.6) years, 39.1% (n=956) male) completed the study (February-December 2019), 68.9% (n=1684) were never-smokers and 3.6% (n=88) had an existing COPD diagnosis. 13.7% (n=333) of participants had spirometry-confirmed airflow obstruction.

INTERVENTIONS

Participants completed six index tests (screening questionnaires (COPD Diagnostic Questionnaire, COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE), Chinese Symptom-Based Questionnaire (C-SBQ), COPD-SQ), microspirometry (COPD-6), peak flow (model of peak flow meters used in the study (USPE)) and the reference test (ndd Easy On-PC).

PRIMARY AND SECONDARY OUTCOMES

Cases were defined as those with forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) below the lower limit of normal (LLN-GLI) on the reference test. Performance of individual screening tests and their combinations was evaluated, with cost-effectiveness analyses providing cost per additional true case detected.

RESULTS

Airflow measurement devices (sensitivities 64.9% (95% CI 59.5% to 70.0%) and 67.3% (95% CI 61.9% to 72.3%), specificities 89.7% (95% CI 88.4% to 91.0%) and 82.6% (95% CI 80.9% to 84.2%) for microspirometry and peak flow, respectively) generally performed better than questionnaires, the most accurate of which was C-SBQ (sensitivity 63.1% (95% CI 57.6% to 68.3%) specificity 74.2% (95% CI 72.3% to 76.1%)). The combination of C-SBQ and microspirometry used in parallel maximised sensitivity (81.4%) (95% CI 76.8% to 85.4%) and had specificity of 68.0% (95% CI 66.0% to 70.0%), with an incremental cost-effectiveness ratio of £64.20 (CNY385) per additional case detected compared with peak flow.

CONCLUSIONS

Simple screening tests to identify undiagnosed COPD within the primary care setting in China is possible, and a combination of C-SBQ and microspirometry is the most sensitive and cost-effective. Further work is required to explore optimal cut-points and effectiveness of programme implementation.

TRIAL REGISTRATION NUMBER

ISRCTN13357135.

Validity of the Handheld Expiratory Flowmeter for COPD Screening in the Primary Care Setting of China

Purpose

The use of simple and affordable screening tools for chronic obstructive pulmonary disease (COPD) is limited. We aimed to assess the validity of a handheld expiratory flowmeter (Vitalograph Ltd., COPD-6^®, Ireland) for COPD screening in Chinese primary care settings.

Methods

In our cross-sectional study, subjects were randomly selected in eight primary care settings. Tests with the handheld expiratory flowmeter and the conventional spirometry were sequentially performed on all participants. The correlation between the handheld expiratory flowmeter and the conventional spirometry was determined. Validity was determined by the area under the receiver operator characteristic curve (AUC) of the forced expiratory volume in one second (FEV₁)_/forced expiratory volume in six seconds (FEV₆) that used to detect airway obstruction. The sensitivity, specificity, predictive values, and likelihood ratio were calculated according to different FEV₁/FEV₆ cut-off points.

Results

A total of 229 subjects (15.4%) were diagnosed with airflow limitation by conventional spirometry. FEV₁, FEV₆, and FEV₁/FEV₆ measured by the handheld expiratory flowmeter were correlated with FEV₁, FVC, and FEV₁/FVC measured by the conventional spirometry (r=0.889, 0.835 and 0.647, p<0.001), respectively. AUC of the FEV₁/FEV₆ to determine airflow obstruction was 0.857 (95% CI: 0.826 to 0.888). No significant difference of AUC was observed between the symptomatic group and the asymptomatic group (AUC=0.869 vs 0.843, P=0.425). A similar phenomenon was found in the AUC of smokers and never-smokers (AUC=0.862 vs 0.840; P=0.515). The cut-off point for FEV₁/FEV₆ was 0.77 and the corresponding sensitivity and specificity were 71.2% and 89.8%, respectively.

Conclusion

The handheld expiratory flowmeter might be used as a screening device for COPD in Chinese primary care settings.

Performance of alternative COPD case-finding tools: a systematic review and meta-analysis

RATIONALE

Guidelines recommend pre-/post-bronchodilator spirometry for diagnosing COPD, but resource constraints limit the availability of spirometry in primary care in low- and middle-income countries. Although spirometry is the diagnostic gold standard, we shall assess alternative tools for settings without spirometry.

METHODS

A systematic literature review and meta-analysis was conducted, utilising Cochrane, CINAHL, Google Scholar, PubMed and Web of Science (search cut-off was May 01, 2020). Published studies comparing the accuracy of diagnostic tools for COPD with post-bronchodilator spirometry were considered. Studies without sensitivity/specificity data, without a separate validation sample and outside of primary care were excluded. Sensitivity, specificity and area under the curve (AUC) were assessed.

RESULTS

Of 7578 studies, 24 were included (14 635 participants). Hand devices yielded a larger AUC than questionnaires. The meta-analysis included 17 studies and the overall AUC of micro-spirometers (0.84, 95% CI 0.80-0.89) was larger when compared to the COPD population screener (COPD-PS) questionnaire (0.77, 95% CI 0.63-0.85) and the COPD diagnostic questionnaire (CDQ) (0.72, 95% CI 0.64-0.78). However, only the difference between micro-spirometers and the CDQ was significant.

CONCLUSIONS

The CDQ and the COPD-PS questionnaire were approximately equally accurate tools. Questionnaires ensured testing of symptomatic patients, but micro-spirometers were more accurate. A combination could increase accuracy but was not evaluated in the meta-analysis.

Diagnostic accuracy of screening tools for chronic obstructive pulmonary disease in primary health care: Rapid evidence synthesis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) contributed significantly to burden of diseases in India, with missed, incorrect, and delayed diagnosis in primary care. We conducted a rapid evidence synthesis, to summarize the evidence on accuracy of the screening tests for COPD in primary health care on request form State Health Resource Centre, Chhattisgarh.

METHODS

Considering the rapid nature of decision making, our approach was to first search for existing systematic reviews. We identified one existing systematic review on the topic with the search conducted until 2014. We updated the review by searching in two major databases screened, title/abstracts, and full texts of studies as per eligibility criteria and extracted relevant data. A narrative synthesis was conducted.

RESULTS

We retrieved 7,007 and included five new studies, to add to 10 studies of the existing systematic review. Overall, 13 studies assessed diagnostic accuracy of screening questionnaires [e.g., COPD Diagnostic Questionnaire (CDQ)], five assessed handheld flow meters (COPD6 and PICO-6), and four assessed the combination of both the tests. The CDQ questionnaire using a score threshold ≥16.5 or >17 demonstrated comparatively a higher sensitivity both in pooled result for ever-smokers [87.5% (95% CI 83.1--90.9%)] and among the adults >35 years [73.8--93% (95% CI 69--98%)] when compared to a different score threshold of CDQ and other questionnaires. Handheld flow meters reported a pooled high sensitivity of 79.9% (95% CI 74.2--84.7%) in ever-smokers and 87.9% in adults with age >35 years.

CONCLUSIONS

The need for better diagnosis of COPD in primary healthcare can be addressed by using of COPD Diagnostic Questionnaire alone or in combination with hand-held flow meters. There is scope for more implementation research on the domain.

Novel App-Based Portable Spirometer for the Early Detection of COPD

Chronic obstructive pulmonary disease (COPD) is preventable and treatable. However, many patients remain undiagnosed and untreated due to the underutilization or unavailability of spirometers. Accordingly, we used Spirobank Smart, an app-based spirometer, for facilitating the early detection of COPD in outpatient clinics. This prospective study recruited individuals who were at risk of COPD (i.e., with age of ≥40 years, ≥10 pack-years of smoking, and at least one respiratory symptoms) but had no previous COPD diagnosis. Eligible participants were examined with Spirobank Smart and then underwent confirmatory spirometry (performed using a diagnostic spirometer), regardless of their Spirobank Smart test results. COPD was defined and confirmed using the postbronchodilator forced expiratory volume in 1 s/forced vital capacity values of <0.70 as measured by confirmatory spirometry. A total of 767 participants were enrolled and examined using Spirobank Smart; 370 participants (94.3% men, mean age of 60.9 years and mean 42.6 pack-years of smoking) underwent confirmatory spirometry. Confirmatory spirometry identified COPD in 103 participants (27.8%). At the optimal cutoff point of 0.74 that was determined using Spirobank Smart for COPD diagnosis, the area under the receiver operating characteristic was 0.903 (95% confidence interval (CI) = 0.860-0.947). Multivariate logistic regression revealed that participants who have an FEV1/FVC ratio of <74% that was determined using Spirobank Smart (odds ratio (OR) = 58.58, 95% CI = 27.29-125.75) and old age (OR = 3.23, 95% CI = 1.04-10.07 for 60 ≤ age < 65; OR = 5.82, 95% CI = 2.22-15.27 for age ≥ 65) had a higher risk of COPD. The Spirobank Smart is a simple and adequate tool for early COPD detection in outpatient clinics. Early diagnosis and appropriate therapy based on GOLD guidelines can positively influence respiratory symptoms and quality of life.

FEV1/FEV6 is effective as a surrogate for FEV1/FVC in the diagnosis of chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

Chronic Obstructive Pulmonary Disease (COPD) causes substantial morbidity and mortality across the globe. Diagnosis of COPD requires post-bronchodilator FEV1/FVC <0.70 as per GOLD Guidelines. FVC maneuver requires a minimum of 6 seconds of forceful expiration with no flow for 1 second for an accepted effort, which lacks any fixed cut-off point. This leads to discomfort, especially in advanced COPD and old aged population. We conducted this study to find the utility of FEV1/FEV6 as a surrogate for FEV1/FVC, the correlation between the two ratios, and the fixed cut-off value of FEV1/FEV6 for COPD diagnosis.

METHODS

This was a prospective, cross-sectional study approved by the institutional ethics committee conducted from January 2017 to November 2018. Consented patients above 18 years suspected of COPD underwent Spirometry as per ATS guidelines. FEV1, FEV6, FEV1/FEV6 and FEV1/FVC ratios were recorded from the best acceptable maneuver.

RESULTS

Out of 560 screened patients, 122 diagnosed as COPD. The correlation coefficient between the post-bronchodilator FEV1/FVC ratio and FEV1/FEV6 ratio was 0.972 (p < 0.01). The relationship between the post-bronchodilator FEV1/FVC ratio and FEV1/FEV6 ratio (linear regression analysis) was found out as: FEV1/FVC = -1.845 + 1.009(FEV1/FEV6). Using this formula, the post-bronchodilator FEV1/FEV6 value of 71.845 was obtained corresponding to the post-bronchodilator FEV1/FVC value of 70.00.

CONCLUSION

We found a positive correlation coefficient (r = 0.972, p < 0.001) between the FEV1/FEV6 and FEV1/FVC ratios and the cut off value of 71.845 (p < 0.01) for the post-bronchodilator FEV1/FEV6 ratio for the diagnosis of COPD. Thus FEV1/FEV6 should be used as a surrogate for FEV1/FVC for the diagnosis of COPD.

Study to evaluate the effectiveness and cost-effectiveness of different screening strategies for identifying undiagnosed COPD among residents (≥40 years) in four cities in China: protocol for a multicentre cross-sectional study on behalf of the Breathe Well group

INTRODUCTION

The latest chronic obstructive pulmonary disease (COPD) epidemiology survey in China estimated that there were 99 million potential COPD patients in the country, the majority of whom are undiagnosed. Screening for COPD in primary care settings is of vital importance for China, but it is not known which strategy would be the most suitable for adoption in primary care. Studies have been conducted to test the accuracy of questionnaires, expiratory peak flow meters and microspirometers to screen for COPD, but no study has directly evaluated and compared the effectiveness and cost-effectiveness of these methods in the Chinese setting.

METHODS AND ANALYSIS

We present the protocol for a multicentre cross-sectional study, to be conducted in eight community hospitals from four cities among Chinese adults aged 40 years or older to investigate the effectiveness and cost-effectiveness of different case-finding methods for COPD, and determine the test performance of individual and combinations of screening tests and strategies in comparison with quality diagnostic spirometry. Index tests are screening questionnaires (COPD Diagnostic Questionnaire (CDQ), COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk Questionnaire (CAPTURE), symptom-based questionnaire, COPD Screening Questionnaire (COPD-SQ)), microspirometer and peak flow. Each participant will complete all of these tests in one assessment. The primary analysis will compare the performance of a screening questionnaire with a handheld device. Secondary analyses will include the comparative performance of each index test, as well as a comparison of strategies where we use a screening questionnaire and a handheld device. Approximately 2000 participants will be recruited over 9 to 12 months.

ETHICS AND DISSEMINATION

The study has been approved by Peking University Hospital and University of Birmingham. All study participants will provide written informed consent. Study results will be published in appropriate journal and presented at national and international conferences, as well as relevant social media and various community/stakeholder engagement activities.

TRIAL REGISTRATION NUMBER

ISRCTN13357135.

Predictive value of spirometry in early detection of lung disease in adults: a cohort study

BACKGROUND

Spirometry is essential to identify cases with obstructive lung diseases (OLDs) in primary care. However, knowledge about the long-term prognostic outcome among younger individuals is sparse.

AIM

To describe the predictive value of spirometry among individuals in the age groups 30-49 years and 45-64 years.

DESIGN & SETTING

A population-based cohort study supplied with data from Danish national registries.

METHOD

Spirometry was performed in 905 adults aged 30-49 years in 1991 and in 1277 adults aged 45-64 years in 2006. The participants were categorised into three groups: forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) <70, 70-75, and >75. They were followed throughout 2017 using Danish national registries. Lung disease was defined as fulfilling at least one of the following: two prescriptions for respiratory medicine were redeemed within a year; one lung-related contact to the hospital; or lung-related death.

RESULTS

In the 1991 cohort, 21% developed lung diseases and in the 2006 cohort 17% developed lung diseases throughout 2017. The probability of developing lung disease if FEV1/FVC 70-75 was 35% (95% confidence interval [CI] = 25% to 44%) in the 1991 cohort and 23% (95% CI = 17% to 28%) in the 2006 cohort. The positive predicted value (PPV) was higher for both cohorts when focusing on smoking history and self-reported respiratory symptoms.

CONCLUSION

The initial spirometry has a high predictive value to identify cases of future lung diseases. In addition, the group with FEV1/FVC 70-75 had a high risk of developing lung diseases later in life, suggesting this group would be a meaningful target of special interest.

Lung function in adults and future burden of obstructive lung diseases in a long-term follow-up

Spirometry is recommended in symptomatic smokers to identify obstructive lung diseases. However, it is unknown whether there are certain characteristics that can be used to identify the individual risk of developing obstructive lung diseases. The aim of this study was to examine the association between lung function in adults and burden of lung diseases throughout 27 years of follow-up. We performed a cohort study among individuals aged 30-49 years at baseline (1991). Spirometry measurements were divided into three groups: (1) FEV1/FVC < 70, (2) FEV1/FVC: 70-75, (3) FEV1/FVC > 75 (reference). Using negative binominal regression, the burden of lung diseases was measured by contacts to general practice, hospitalisations, redeemed respiratory medicine and socioeconomic parameters between 1991 and 2017. A total of 905 citizens were included; mean age of 40.3 years, 47.5% were males and 51.2% were smokers at baseline. The group with an FEV1/FVC: 70-75 received more respiratory medicine (IRR = 3.37 (95% CI: 2.69-4.23)), had lower income (IRR = 0.96 (95% CI: 0.93-0.98)), and had more contacts to general practice (IRR = 1.14 (95% CI: 1.07-1.21)) and hospitals for lung diseases (IRR = 2.39 (95% CI: 1.96-5.85)) compared to the reference group. We found an association between lung function and the future burden of lung diseases throughout 27 years of follow-up. In particular, adults with an FEV1/FVC: 70-75 need extra attention in the case finding.

Goals of COPD treatment: Focus on symptoms and exacerbations

Chronic obstructive pulmonary disease (COPD) is currently a leading cause of death worldwide, and its burden is expected to rise in the coming years. Common COPD symptoms include dyspnea, cough and/or sputum production. Some patients may experience acute worsening of symptoms (known as an exacerbation), and therefore require additional therapy. Exacerbations are mainly triggered by respiratory infections and environmental factors. Healthcare professionals face many challenges in COPD management, including the heterogeneity of the disease and under-reporting of symptoms. The authors review these challenges and provide recommendations for the best methods to assess COPD. The goals of COPD treatment include recognising the impact that both symptoms and exacerbations have on patients' lives when considering optimal patient-focused management. The review discusses the need for COPD management strategies to include both pharmacologic and non-pharmacologic approaches and provides recommendations for monitoring treatment outcomes and adjusting management strategies accordingly. Novel treatment strategies including precision medicine and point-of-care testing are also discussed.

Association Between Everyday Technology Use, Activities of Daily Living and Health-Related Quality of Life in Chronic Obstructive Pulmonary Disease

Purpose

A decline in the ability to perform activities of daily living (ADL) and ability to use everyday technology can pose threats to independent living, healthcare management and quality of life (QOL) of patients suffering from chronic obstructive pulmonary disease (COPD). Evidence of the relationship between these variables remains limited. The dual aim of this study was, first, to investigate if health-related QOL (HRQOL) was associated with quality in ADL performance and everyday technology use; second, to examine whether lung function, years with COPD diagnosis, living status or educational level affected physical and mental domains of HRQOL.

Methods

This cross-sectional study included (N=80) participants aged 46-87 years recruited at healthcare centres in the Northern Region of Denmark using a convenience sampling procedure. Data were gathered through standardized assessments and analysed using multiple regression analysis.

Results

The regression model explained 50.6% (R2=0.506) of the variation in HRQOL-physical. The following four variables were statistically significantly associated with HRQOL - physical: years since COPD diagnosis (p=0.023), ability to use everyday technology (p=0.006), amount of relevant everyday technologies (p=0.015) and ADL motor ability (p<0.01). The regression model explained 22.80% (R2=0.228) of HRQOL - mental. Only the variable ability to use everyday technology was statistically significantly associated with HRQOL - mental (p=0.009).

Conclusion

Quality of ADL performance and everyday technology use seem to be associated with HRQOL in people living with COPD. The only demographic variable associated with HRQOL was years with COPD. This indicates that healthcare professionals should enhance their attention also to ADL-performance and everyday technology use when striving to increase the HRQOL of persons living with COPD.

Accuracy of Vitalograph lung monitor as a screening test for COPD in primary care

Microspirometry may be useful as the second stage of a screening pathway among patients reporting respiratory symptoms. We assessed sensitivity and specificity of the Vitalograph® lung monitor compared with post-bronchodilator confirmatory spirometry (ndd Easy on-PC) among primary care chronic obstructive pulmonary disease (COPD) patients within the Birmingham COPD cohort. We report a case-control analysis within 71 general practices in the UK. Eligible patients were aged ≥40 years who were either on a clinical COPD register or reported chronic respiratory symptoms on a questionnaire. Participants performed pre- and post-bronchodilator microspirometry, prior to confirmatory spirometry. Out of the 544 participants, COPD was confirmed in 337 according to post-bronchodilator confirmatory spirometry. Pre-bronchodilator, using the LLN as a cut-point, the lung monitor had a sensitivity of 50.5% (95% CI 45.0%, 55.9%) and a specificity of 99.0% (95% CI 96.6%, 99.9%) in our sample. Using a fixed ratio of FEV1/FEV6 < 0.7 to define obstruction in the lung monitor, sensitivity increased (58.8%; 95% CI 53.0, 63.8) while specificity was virtually identical (98.6%; 95% CI 95.8, 99.7). Within our sample, the optimal cut-point for the lung monitor was FEV1/FEV6 < 0.78, with sensitivity of 82.8% (95% CI 78.3%, 86.7%) and specificity of 85.0% (95% CI 79.4%, 89.6%). Test performance of the lung monitor was unaffected by bronchodilation. The lung monitor could be used in primary care without a bronchodilator using a simple ratio of FEV1/FEV6 as part of a screening pathway for COPD among patients reporting respiratory symptoms.

Spirometric indices of early airflow impairment in individuals at risk of developing COPD: Spirometry beyond FEV1/FVC

Spirometry is the current gold standard for diagnosing and monitoring the progression of Chronic Obstructive Pulmonary Disease (COPD). However, many current and former smokers who do not meet established spirometric criteria for the diagnosis of this disease have symptoms and clinical courses similar to those with diagnosed COPD. Large longitudinal observational studies following individuals at risk of developing COPD offer us additional insight into spirometric patterns of disease development and progression. Analysis of forced expiratory maneuver changes over time may allow us to better understand early changes predictive of progressive disease. This review discusses the theoretical ability of spirometry to capture fine pathophysiologic changes in early airway disease, highlights the shortcomings of current diagnostic criteria, and reviews existing evidence for spirometric measures which may be used to better detect early airflow impairment.

External validation of the PUMA COPD diagnostic questionnaire in a general practice sample and the PLATINO study population

Background

A seven-item prescreening questionnaire (gender, age, pack-years smoking, dyspnea, sputum, cough, previous spirometry data) was developed for COPD detection in the primary care setting (PUMA Study) of four Latin America countries.

Objectives

To validate the PUMA prescreening COPD questionnaire externally in two different populations (primary care and general).

Methods

The PUMA prescreening COPD questionnaire score was applied to subjects from the Hospital Maciel, Montevideo (primary care), case-finding program and the PLATINO population (general) using PUMA study inclusion criteria. Post-bronchodilator FEV₁/FVC <0.70 and lower limit of normal (LLN) criteria were used to define COPD. Area under the received operator curve (ROC_AUC), sensitivity, specificity, predictive positive and negative values (PNV), number needed to treat (NNT), and best cut-points of the score were calculated.

Results

974 individuals from Hospital Maciel and 2512 from the PLATINO population were eligible, using post-bronchodilator FEV₁/FVC <0.70, 45.1% and 18.7% had COPD, respectively, and using LLN 38.4% and 15.4% had COPD, respectively. From Hospital Maciel (post-bronchodilator FEV₁/FVC <0.70), the best cut-point of ≥6 had moderate discriminatory power (ROC_AUC 0.70), sensitivity 69.9%, specificity 62.1%, PNV 70.9%, and NNT of 3. The discriminatory power was 0.73 (ROC_AUC) in the PLATINO population with three potential cut-points (Youden’s index): ≥3 (sensitivity 85.4%, specificity 46.9%), ≥4 (sensitivity 66.7%, specificity 66.5%), and ≥5 (sensitivity 51.5%, specificity 81.6%); the PNV at each cut-point was 93.3%, 89.9%, and 88.0%, respectively. The NNT was 5 for scores ≥3 and ≥4, and 4 for ≥5. The mean accuracy using the LLN for Hospital Maciel and PLATINO was 0.67 and 0.70, respectively.

Conclusion

External validation of the PUMA prescreening questionnaire in two Latin American populations (general and primary care) suggests moderate accuracy, similar to the original study in which the questionnaire was developed.

[Feasibility and benefits of training to screen for chronic obstructive pulmonary disease]

INTRODUCTION

Though still under-diagnosed, chronic obstructive pulmonary disease (COPD) currently affects nearly 3.5 million people in France. The present study presents the results of continuing medical education sessions on COPD screening by electronic mini-spirometry.

METHODS

From April 2013 to December 2015, the sessions involved 73 health professionals. The study analysed three questionnaires administered before, after, and long after sessions led by experts within a professional associative network.

RESULTS

The sessions proved efficient in increasing the participants' theoretical knowledge. It increased the percentage of correct answers regarding the nature of COPD (90 % vs. 81%), the functions, features, and outputs of mini-spirometers, and the treatment recommendations. The sessions led to non-negligible changes in everyday medical practice regarding the acquisition of a mini-spirometer (+13 devices), the presentation of COPD to the patients (+33 practitioners), the dialogue on tobacco use (+32 practitioners), vaccination (+33 practitioners), and compliance with the treatment recommendations (+43 practitioners).

CONCLUSION

These results encourage both holding and following up such sessions. The specialized professional environment ensures knowledge updates and offers subsequent assistance. Further improving these sessions will increase their benefits in terms of diagnosis, treatment, and health economy.

Handheld flow meter improves COPD detectability regardless of using a conventional questionnaire: A split-sample validation study

BACKGROUND AND OBJECTIVE

Improved detectability of chronic obstructive pulmonary disease (COPD) using a handheld flow meter (HFM) with symptom-based questionnaires has not been sufficiently evaluated. This study aimed to identify the benefit of using an HFM in COPD screening.

METHODS

A total of 2008 participants, who were ≥ 40 years of age, from Isumi City, Japan, were recruited. We developed two novel point systems for detecting COPD, one incorporated score of HFM alone (sHFM) and the other incorporated the score of International Primary Care Airway Group questionnaire (IPAG) and HFM (sIPAG + HFM). Validation using random sample allocation (split-sample validation) was carried out to assess the predictive performance of these models.

RESULTS

Participants were assigned to a data set for model creation (n = 1007) or a data set for model assessment (n = 1001) to perform split-sample validation. Decision curve analysis showed that the net benefits of sHFM and sIPAG + HFM were higher than that of the IPAG score (sIPAG) and specificity of the former two were also significantly higher than that of sIPAG. However, the curves of sHFM and sIPAG + HFM were crossing and practically the same with no significant difference in sensitivity and specificity.

CONCLUSION

This study confirms that HFM is significantly advantageous in detecting COPD despite the use of a conventional questionnaire.

Interdisciplinary COPD intervention in primary care: a cluster randomised controlled trial

We evaluated the effectiveness of an interdisciplinary, primary care-based model of care for chronic obstructive pulmonary disease (COPD).A cluster randomised controlled trial was conducted in 43 general practices in Australia. Adults with a history of smoking and/or COPD, aged ≥40 years with two or more clinic visits in the previous year were enrolled following spirometric confirmation of COPD. The model of care comprised smoking cessation support, home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase). Main outcomes included changes in St George's Respiratory Questionnaire (SGRQ) score, COPD Assessment Test (CAT), dyspnoea, smoking abstinence and lung function at 6 and 12 months.We identified 272 participants with COPD (157 intervention, 115 usual care); 49 (31%) out of 157 completed both HMR and HomeBase. Intention-to-treat analysis showed no statistically significant difference in change in SGRQ at 6 months (adjusted between-group difference 2.45 favouring intervention, 95% CI -0.89-5.79). Per protocol analyses showed clinically and statistically significant improvements in SGRQ in those receiving the full intervention compared to usual care (difference 5.22, 95% CI 0.19-10.25). No statistically significant differences were observed in change in CAT, dyspnoea, smoking abstinence or lung function.No significant evidence was found for the effectiveness of this interdisciplinary model of care for COPD in primary care over usual care. Low uptake was a limitation.

Usefulness of The Piko-6 Portable Device for Early COPD Detection in Primary Care

INTRODUCTION

COPD is a highly prevalent but underdiagnosed disease, due to the limited availability of forced spirometry (FS) in primary care (PC). Microspirometers are inexpensive, easy-to-use devices that can measure FEV₆ and FEV₁/FEV₆, and may help reduce underdiagnosis. The aim of this study was to validate the Piko-6 COPD screening device by demonstrating a good correlation with standard FS.

METHODS

FS and Piko-6 determinations were made in 155 patients suspected of having COPD. The correlations, ROC curves, and Youden's index of both methods were compared, taking FS as the gold standard.

RESULTS

FEV₁, FVC and FEV₆ correlation coefficients and FEV₁/FVC and FEV₁/FEV₆ ratios were 0.87 (CI 0.836-0.909), 0.729 (CI 064-0.795) and 0.947 (95% CI 0.928-0.961), respectively. The ROC curve for FEV₁ determined by Piko-6 achieved an area under the curve of 0.86 (95% CI: 0.78-0.92). Youden's index with a cut-off point of 0.70 for FEV1/FEV6 was 0.97.

CONCLUSIONS

Piko-6 may be useful for COPD screening in PC. Measurements obtained with this device correlate well with those determined by FS, particularly the FEV₁/FEV₆ ratio. This, combined with its low cost and ease of use, may contribute to reducing COPD underdiagnosis, although its exact role in the diagnostic process remains to be determined.

Point of care microspirometry to facilitate the COPD diagnostic process in primary care: a clustered randomised trial

We studied if pre-bronchodilator FEV1/FEV6 determinations with microspirometers by GPs improve the diagnostic process for COPD in a 6-8 month clustered randomised controlled trial in Dutch general practices ( http://www.trialregister.nl : NTR4041). GPs allocated to microspirometry (MI) used COPD-6® microspirometers in patients ≥50 years old with a smoking history and respiratory complaints that could indicate undiagnosed COPD and ask to refer patients for full spirometry if MI was positive (FEV1/FEV6 <0.73). Introduction of the COPD-6® was postponed in the usual care (UC) group. GPs of both study arms were asked to list all patients that fulfilled study criteria and at the end of the study we screened the electronic medical record system for number of patients that fulfilled study criteria and visited their GP within the study period. Main end point was a documented diagnostic conclusion of COPD within 3 months after the patient's visit. We used multilevel logistic regression with correction for relevant covariates. Next, we described the process of care. 21 practices (88 GPs) participated and 416 possible undiagnosed COPD patient visited these practices in the study period. 78 (of 192 visiting) subjects were listed by MI GPs and diagnostic conclusions were documented in 77%, compared to 61 listed (of 224 visiting) subjects and 44% with documented diagnostic conclusions by UC GPs (Odds Ratio: OR: 4.3, 95%CI: 1.6-11.5). Microspirometry improved the diagnostic process for possible underlying COPD in patients who consulted their GP with respiratory symptoms, but the majority of possible undiagnosed COPD patients remained unrecognised by GPs.

Community pharmacy-based case finding for COPD in urban and rural settings is feasible and effective

BACKGROUND AND OBJECTIVE

Case finding of patients at risk of COPD by community pharmacists could identify a substantial number of people with undiagnosed COPD, but little is known about the feasibility and effectiveness of pharmacy-based COPD case finding using microspirometry. The objective of this study was to assess the feasibility and effectiveness of COPD case-finding service provided by community pharmacists, utilizing a combination of risk assessment questionnaire and microspirometry.

METHODS

A 6-month service was conducted in 21 community pharmacies in Australia. Pharmacists trained in COPD case finding, including lung function test (LFT), invited their patients aged ≥35 years with a history of smoking and/or respiratory symptoms to participate. High-risk patients were identified via a COPD risk assessment questionnaire (Initial Screening Questionnaire [ISQ]) and underwent LFT. Pharmacists referred patients with a forced expiratory volume in 1 second (FEV1)/forced expiratory volume in 6 seconds (FEV6) ratio <0.75 to their general practitioner (GP) for further assessment and diagnosis.

RESULTS

In all, 91 of 167 (54%) patients had an ISQ score >3 indicating high COPD risk. Of the 157 patients who were able to complete LFT, 61 (39%) had an FEV1/FEV6 ratio of <0.75 and were referred to their GP. Patients with high ISQ symptoms scores (>3) were at a significantly higher risk of an FEV1/FEV6 ratio of <0.75, compared to patients with fewer COPD symptoms. A total of 15 (10%) patients were diagnosed with COPD by their GP. Another eight (5%) patients were diagnosed with other medical conditions and 87% of these were initiated on treatment. Although only half of all screened patients lived in regional areas, 93% of those diagnosed with COPD were from regional areas.

CONCLUSION

A brief community pharmacy-based COPD case-finding service utilizing the ISQ, LFT and GP referral is feasible and may lead to identification and diagnosis of a substantial number of people with COPD. This might be an important strategy for reducing the burden of COPD, particularly for those living in rural locations.

Interdisciplinary model of care (RADICALS) for early detection and management of chronic obstructive pulmonary disease (COPD) in Australian primary care: study protocol for a cluster randomised controlled trial

INTRODUCTION

Up to half of all smokers develop clinically significant chronic obstructive pulmonary disease (COPD). Gaps exist in the implementation and uptake of evidence-based guidelines for managing COPD in primary care. We describe the methodology of a cluster randomised controlled trial (cRCT) evaluating the efficacy and cost-effectiveness of an interdisciplinary model of care aimed at reducing the burden of smoking and COPD in Australian primary care settings.

METHODS AND ANALYSIS

A cRCT is being undertaken to evaluate an interdisciplinary model of care (RADICALS - Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers). General practice clinics across Melbourne, Australia, are identified and randomised to the intervention group (RADICALS) or usual care. Patients who are current or ex-smokers, of at least 10 pack years, including those with an existing diagnosis of COPD, are being recruited to identify 280 participants with a spirometry-confirmed diagnosis of COPD. Handheld lung function devices are being used to facilitate case-finding. RADICALS includes individualised smoking cessation support, home-based pulmonary rehabilitation and home medicines review. Patients at control group sites receive usual care and Quitline referral, as appropriate. Follow-ups occur at 6 and 12 months from baseline to assess changes in quality of life, abstinence rates, health resource utilisation, symptom severity and lung function. The primary outcome is change in St George's Respiratory Questionnaire score of patients with COPD at 6 months from baseline.

ETHICS AND DISSEMINATION

This project has been approved by the Monash University Human Research Ethics Committee and La Trobe University Human Ethics Committee (CF14/1018 - 2014000433). Results of the study will be disseminated in peer-reviewed journals and research conferences. If the intervention is successful, the RADICALS programme could potentially be integrated into general practices across Australia and sustained over time.

TRIAL REGISTRATION NUMBER

ACTRN12614001155684; Pre-results.

Multicenter study of the COPD-6 screening device: feasible for early detection of chronic obstructive pulmonary disease in primary care?

Background and aim

Early detection of COPD may reduce the future burden of the disease. We aimed to investigate whether prescreening with a COPD-6 screening device (measuring FEV₁ and FEV₆) facilitates early detection of COPD in primary care.

Methods

In primary care, individuals at high risk of COPD (ie, age ≥35 years, relevant exposure, and at least one respiratory symptom) and no previous diagnosis of obstructive lung disease were examined with a COPD-6 screening device. In prioritized order, the criteria for proceeding to confirmatory spirometry were FEV₁/FEV₆ <0.7, FEV₁ <80%pred, or clinical suspicion of COPD regardless of test result (medical doctor’s [MD] decision). Based on spirometry, including bronchodilator (BD) reversibility test, individuals were classified as COPD (post-BD FEV₁/FVC <0.70), asthma (ΔFEV₁ ≥0.50 L), or no obstructive lung disease.

Results

A total of 2,990 subjects (54% men, mean age 59 years, and mean 28 pack-years) were enrolled, of whom 949 (32%) proceeded from COPD-6 screening to confirmative spirometry based on the following criteria: 510 (54%) FEV₁/FEV₆ <0.70, 382 (40%) FEV₁ <80%pred, and 57 (6%) MD decision. Following confirmative spirometry, the 949 individuals were diagnosed as having COPD (51%), asthma (3%), and no obstructive lung disease (45%). COPD was diagnosed in 487 (16%) of the enrolled subjects in whom confirmative spirometry was performed in 69% based on FEV₁/FEV₆ <0.7 and in 29% based on FEV₁ ≤80%pred.

Conclusion

Prescreening with the COPD-6 device showed acceptable specificity for the selection of subjects for diagnostic spirometry and is likely to be a useful alternative to current practice in primary care.

Peak flow meter with a questionnaire and mini-spirometer to help detect asthma and COPD in real-life clinical practice: a cross-sectional study

Peak flow meter with questionnaire and mini-spirometer are considered as alternative tools to spirometry for screening of asthma and chronic obstructive pulmonary disease. However, the accuracy of these tools together, in clinical settings for disease diagnosis, has not been studied. Two hundred consecutive patients with respiratory complaints answered a short symptom questionnaire and performed peak expiratory flow measurements, standard spirometry with Koko spirometer and mini-spirometry (COPD-6). Spirometry was repeated after bronchodilation. Physician made a final diagnosis of asthma, chronic obstructive pulmonary disease and others. One eighty nine patients (78 females) with age 51 ± 17 years with asthma (115), chronic obstructive pulmonary disease (33) and others (41) completed the study. "Breathlessness > 6months" and "cough > 6months" were important symptoms to detect obstructive airways disease. "Asymptomatic period > 2 weeks" had the best sensitivity (Sn) and specificity (Sp) to differentiate asthma and chronic obstructive pulmonary disease. A peak expiratory flow of < 80% predicted was the best cut-off to detect airflow limitation (Sn 90%, Sp 50%). Respiratory symptoms with PEF < 80% predicted, had Sn 84 and Sp 93% to detect OAD. COPD-6 device under-estimated FEV1 by 13 mL (95% CI: -212, 185). At a cut-off of 0.75, the FEV1/FEV6 had the best accuracy (Sn 80%, Sp 86%) to detect airflow limitation. Peak flow meter with few symptom questions can be effectively used in clinical practice for objective detection of asthma and chronic obstructive pulmonary disease, in the absence of good quality spirometry. Mini-spirometers are useful in detection of obstructive airways diseases but FEV1 measured is inaccurate.

CHRONIC LUNG DISEASES

DIFFERENTIATING CONDITIONS IN POORLY-EQUIPPED SETTINGS: A simple questionnaire and peak flow meter measurements can help doctors differentiate between asthma and chronic lung disease. In clinical settings where access to specialist equipment and knowledge is limited, it can be challenging for doctors to tell the difference between asthma and chronic obstructive pulmonary disease (COPD). To determine a viable alternative method for differentiating between these diseases, Rahul Kodgule and colleagues at the Chest Research Foundation in Pune, India, trialed a simplified version of two existing symptom questionnaires, combined with peak flow meter measurements. They assessed 189 patients using this method, and found it aided diagnosis with high sensitivity and specificity. Breathlessness, cough and wheeze were the minimal symptoms required for COPD diagnosis, while the length of asymptomatic periods was most helpful in distinguishing asthma from COPD.

Active case finding strategy for chronic obstructive pulmonary disease with handheld spirometry

The early detection and diagnosis of chronic obstructive pulmonary disease (COPD) is critical to providing appropriate and timely treatment. We explored a new active case-finding strategy for COPD using handheld spirometry.We recruited subjects over 40 years of age with a smoking history of more than 10 pack-years who visited a primary clinic complaining of respiratory symptoms. A total of 190 of subjects were enrolled. Medical information was obtained from historical records and physical examination by general practitioners. All subjects had their pulmonary function evaluated using handheld spirometry with a COPD-6 device. Because forced expiratory volume in 6 seconds (FEV6) has been suggested as an alternative to FVC, we measured forced expiratory volume in 1 second (FEV1)/FEV6 for diagnosis of airflow limitation. All subjects were then referred to tertiary referral hospitals to complete a "Could it be COPD?" questionnaire, handheld spiromtery, and conventional spirometry. The results of each instrument were compared to evaluate the efficacy of both handheld spirometry and the questionnaire.COPD was newly diagnosed in 45 (23.7%) patients. According to our receiver-operating characteristic (ROC) curve analysis, sensitivity and specificity were maximal when the FEV1/FEV6 ratio was less than 77%. The area under the ROC curve was 0.759. The sensitivity, specificity, positive predictive value, and negative predictive value were 72.7%, 77.1%, 50%, and 90%, respectively. The area under the ROC curve of respiratory symptoms listed on the questionnaire ranged from 0.5 to 0.65, which indicates that there is almost no difference compared with the results of handheld spirometry.The present study demonstrated the efficacy of handheld spirometry as an active case-finding tool for COPD in a primary clinical setting. This study suggested that physicians should recommend handheld spirometry for people over the age of 40, who have a smoking history of more than 10 pack-years, regardless of respiratory symptoms. Furthermore, people who have abnormal results, determined using the FEV1/FEV6 ≤0.77 cut-off, should be referred for further conventional spirometry to confirm the diagnosis of COPD. However, further studies within the general population are necessary to establish efficacy in the public.

Which is the Best Screening Strategy for COPD among Smokers in Primary Care?

We developed a questionnaire to detect cases of chronic obstructive pulmonary disease (COPD) and compared its reliability with other strategies. In order to develop the new questionnaire (COPD screening questionnaire from Terrassa [EGARPOC]) we used data from an epidemiological study on the prevalence of COPD in smokers and calculated the odds ratio for each variable showing significance for the diagnosis of COPD on regression analysis. For comparison among questionnaires and the portable spirometer COPD-6, a cross-sectional multicenter study was performed. The study included 407 smokers or ex-smokers over the age of 40 years with no known diagnosis of COPD, who completed the different questionnaires (EGARPOC, Respiratory Health Screening Questionnaire, COPD-population screener and 2 questions) and underwent spirometry with the COPD-6. We determined the sensitivity, specificity, positive and negative predictive values (S, Sp, PPV and NPV, respectively) and the area under the receiver operating characteristic ROC curve (AUC ROC) of all the questionnaires and the different COPD-6 cut-offs. The prevalence of COPD was 26.3%. The EGARPOC questionnaire showed an S of 81.8%, an Sp of 70.6%, and an NPV of 91.8%; 73.3% of individuals were correctly classified, and the AUC ROC was 0.841. On comparing the questionnaires by the Chi-square test, the 2-question questionnaire showed the worst discrimination; while with an optimal cut-off of forced expiratory volume in one 1 second (FEV₁)/FEV₆ of 0.78, the COPD-6 was significantly better than the questionnaires in the detection of COPD. Using a cut-off of FEV₁/FEV₆ of 0.78 the COPD-6 was found to be the best screening tool for COPD in primary care compared to the questionnaires tested, which did not show differences among them.

Diagnostic accuracy of a pocket screening spirometer in diagnosing chronic obstructive pulmonary disease in general practice: a cross sectional validation study using tertiary care as a reference

BACKGROUND

COPD-6™ is a lung function testing device for a rapid pre-spirometry testing to screen-out at-risk individuals not having COPD and indicating those at risk. The aim of this study was to validate COPD-6™ lung function testing (index test) in general practice in discriminating patients with COPD out of the population at risk - smokers/ex-smokers with no previous diagnosis of COPD, using measurements at tertiary care as reference standard.

METHODS

Consecutive 227 subjects (115 women, 185 smokers/42 ex-smokers, ≥20 pack-years) with no previous diagnosis of COPD, aged 52.5 (SD 6.8) years from 26 general practitioners (GPs) were recruited, lung function tested with COPD-6™, referred to the tertiary institution for repeated COPD-6™ testing followed by spirometry with a bronchodilator (salbutamol), examination, and pulmonologist consultation for the diagnosis and severity of COPD.

RESULTS

COPD was diagnosed in 43 subjects (18.9 %), with an AUC of 0.827 (95 % CI 0.769-0.875, P < 0.001) for the diagnosis of COPD when lung function was measured using COPD-6™ in GP's office with a specificity of 100 % (95 % CI, 97.95-100 %) but a very low sensitivity of 32.56 % (95 % CI, 20.49-47.48 %). Significant agreement for forced expiratory volume in 1 s measured at GP's office and at lung function lab was found (mean difference 0.01 L, p = 0.667) but not for other measured parameters (p < 0.001 for all).

CONCLUSIONS

Our study results point out that active case finding in a population at risk for COPD should be instituted (almost 20 % of undiagnosed COPD). Based on our results lung function testing with COPD-6™ can substitute spirometry testing in cases where it is not readily available to the patient/physician taken into account that the traditional FEV1/FEV6 cutoff value of <0.7 is not the only criterion for diagnosis and/or further referral.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01550679 Registered 28 September 2014, retrospectively registered.

Strategies for Management of the Early Chronic Obstructive Lung Disease

Lung function reportedly declines with age and that this decline is accelerated during disease progression. However, a recent study showed that the decline might peak in the mild and moderate stage. The prognosis of chronic obstructive pulmonary disease (COPD) can be improved if the disease is diagnosed in its early stages, prior to the peak of decline in lung function. This article reviews recent studies on early COPD and the possibility of applying the U.S. Preventive Services Task Force recommendation 2008 and 2015 for early detection of COPD in Korea.

Development of a simple screening tool for opportunistic COPD case finding in primary care in Latin America: The PUMA study

BACKGROUND AND OBJECTIVE

Opportunistic chronic obstructive pulmonary disease (COPD) case finding approaches for high-risk individuals with or without symptoms is a feasible option for disease identification. PUMA is an opportunistic case finding study conducted in primary care setting of Argentina, Colombia, Venezuela and Uruguay. The objectives were to measure COPD prevalence in an at-risk population visiting primary care for any reason, to assess the yield of this opportunistic approach and the accuracy of a score developed to detect COPD.

METHODS

Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 s (FEV1 )/forced vital capacity (FVC) < 0.70 and the lower limit of normal of FEV1 /FVC.

RESULTS

A total of 1743 subjects completed the interview; 1540 performed acceptable spirometry. COPD prevalence was 20.1% (n = 309; ranging from 11.0% in Venezuela to 29.6% in Argentina) when defined using post-BD FEV1 /FVC < 0.70, and 14.7% (n = 226; ranging from 8.3% in Venezuela to 21.8% in Colombia) using the lower limit of normal. Logistic regression analysis for both definitions showed that the risk of COPD was significantly higher for persons >50 years, heavy smokers (>30 pack-years), with dyspnoea, and having prior spirometry. A simple score and a weighted score constructed using the following predictive factors: gender, age, pack-years smoking, dyspnoea, sputum, cough and spirometry, had a mean accuracy for detecting COPD (post-BD FEV1 /FVC < 0.70) of 76% and 79% for the simple and weighted scores, respectively.

CONCLUSION

This simple seven-item score is an accurate screening tool to select subjects for spirometry in primary care.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

Long‐lasting neutropenia associated with acute myeloid leukemia (AML) and its treatment gives rise to a high risk of pneumonia. The use of broad‐spectrum antibiotic prophylaxis during outpatient management has not completely protected patients against admission due to infections and neutropenic fever, emphasizing the need to approach infection protection with complementary efforts. In a randomized controlled design, we examined the applicability of patient‐performed daily spirometry [forced expiratory volume in one second (FEV1)] as an early warning tool and explored the effectiveness of positive expiratory pressure (PEP) in preventing pneumonia among 80 AML patients. Twenty‐five incidences of pneumonia were detected among 23 patients (6 interventions, 17 controls), giving a prevalence of 28.75% during 5420 days of observation. We found a significant difference in incidence between intervention versus control group (2.17 per 1000 days vs. 6.52 per 1000 days, P = 0.021, respectively). A cross point at 80‐76% of the personal FEV1 reference value showed high sensitivity and specificity on pneumonia development. Our data demonstrate the feasibility of educating AML patients in their continuous daily measurement of FEV1 and use of PEP. Daily measures of FEV1 may be an important early warning tool for assessment of pulmonary deterioration during critical phases of neutropenia. We suggest that strategic patient education in the use of spirometry and PEP should be part of standard of care for AML patients undergoing induction chemotherapy. Am. J. Hematol. 91:271–276, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.

Insight into Best Variables for COPD Case Identification: A Random Forests Analysis

RATIONALE

This study is part of a larger, multi-method project to develop a questionnaire for identifying undiagnosed cases of chronic obstructive pulmonary disease (COPD) in primary care settings, with specific interest in the detection of patients with moderate to severe airway obstruction or risk of exacerbation.

OBJECTIVES

To examine 3 existing datasets for insight into key features of COPD that could be useful in the identification of undiagnosed COPD.

METHODS

Random forests analyses were applied to the following databases: COPD Foundation Peak Flow Study Cohort (N=5761), Burden of Obstructive Lung Disease (BOLD) Kentucky site (N=508), and COPDGene® (N=10,214). Four scenarios were examined to find the best, smallest sets of variables that distinguished cases and controls:(1) moderate to severe COPD (forced expiratory volume in 1 second [FEV1] <50% predicted) versus no COPD; (2) undiagnosed versus diagnosed COPD; (3) COPD with and without exacerbation history; and (4) clinically significant COPD (FEV1<60% predicted or history of acute exacerbation) versus all others.

RESULTS

From 4 to 8 variables were able to differentiate cases from controls, with sensitivity ≥73 (range: 73-90) and specificity >68 (range: 68-93). Across scenarios, the best models included age, smoking status or history, symptoms (cough, wheeze, phlegm), general or breathing-related activity limitation, episodes of acute bronchitis, and/or missed work days and non-work activities due to breathing or health.

CONCLUSIONS

Results provide insight into variables that should be considered during the development of candidate items for a new questionnaire to identify undiagnosed cases of clinically significant COPD.

Screening for Chronic Obstructive Pulmonary Disease: Validity and Reliability of a Portable Device in Non-Specialized Healthcare Settings

Introduction and Objectives

The underdiagnosis of chronic obstructive pulmonary disease (COPD) could be improved through screening using portable devices simpler than conventional spirometers in specific healthcare settings to reach a higher percentage of the at-risk population. This study was designed to assess the validity and reliability of the COPD-6 portable device to screen for COPD in non-specialized healthcare settings.

Methods

Prospective cohort study to validate a diagnostic test. Three cohorts were recruited: primary care (PC), emergency services (ES) and community pharmacies (CPh). Study population: individuals with risk factors for COPD (>40 years, smoking >10 pack-years, with respiratory symptoms). The values measured using the COPD-6 were FEV1, FEV6 and the FEV1/FEV6 ratio. Subsequently, participants underwent conventional spirometry at hospital, using a post-bronchodilator FEV1/FVC value <0.7 as the gold standard criterion for the COPD diagnosis.

Results

437 participants were included, 362 were valid for the analysis. COPD was diagnosed in 114 patients (31.5%). The area under the ROC curve for the COPD-6 for COPD screening was 0.8.The best cut-off point for the FEV1/FEV6 ratio was 0.8 (sensitivity, 92.1%) using spirometry with the bronchodilator test as the gold standard. There were practically no differences in the COPD-6 performancein the different settings and also regarding age, gender and smoking status.

Conclusions

The COPD-6 device is a valid tool for COPD screening in non-specialized healthcare settings. In this context, the best cut-off point for the FEV1/FEV6 ratio is 0.8.

Diagnostic accuracy of screening tests for COPD: a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is widely underdiagnosed. A number of studies have evaluated the accuracy of screening tests for COPD, but their findings have not been formally summarised. We therefore sought to determine and compare the diagnostic accuracy of such screening tests in primary care.

METHODS

Systematic review and meta-analysis of the diagnostic accuracy of screening tests for COPD confirmed by spirometry in primary care. We searched MEDLINE, EMBASE and other bibliographic databases from 1997 to 2013 for diagnostic accuracy studies that evaluated 1 or more index tests in primary care among individuals aged ≥35 years with no prior diagnosis of COPD. Bivariate meta-analysis of sensitivity and specificity was performed where appropriate. Methodological quality was assessed independently by 2 reviewers using the QUADAS-2 tool.

RESULTS

10 studies were included. 8 assessed screening questionnaires (the COPD Diagnostic Questionnaire (CDQ) was the most evaluated, n=4), 4 assessed handheld flow meters (eg, COPD-6) and 1 assessed their combination. Among ever smokers, the CDQ (score threshold ≥19.5; n=4) had a pooled sensitivity of 64.5% (95% CI 59.9% to 68.8%) and specificity of 65.2% (52.9% to 75.8%), and handheld flow meters (n=3) had a sensitivity of 79.9% (95% CI 74.2% to 84.7%) and specificity of 84.4% (68.9% to 93.0%). Inadequate blinding between index tests and spirometry was the main risk of bias.

CONCLUSIONS

Handheld flow meters demonstrated higher test accuracy than the CDQ for COPD screening in primary care. The choice of alternative screening tests within whole screening programmes should now be fully evaluated.

PROSPERO REGISTRATION NUMBER

CRD42012002074.