BackgroundGiven that physical activity (PA) has a positive impact on COPD symptoms and prognosis, this study examined the factors that both encourage and limit participation in PA for individuals with COPD in a primary care setting from the perspective of social cognitive theory.MethodsA purposive sample of 26 individuals with a range of COPD severity (age range: 50–89 years; males =15) were recruited from primary care to participate in one of four focus groups. Thematic analysis was undertaken to identify key concepts related to their self-efficacy beliefs.ResultsSeveral barriers and enablers closely related to self-efficacy beliefs and symptom severity were identified. The main barriers were health related (fatigue, mobility problems, breathing issues caused by the weather), psychological (embarrassment, fear, frustration/disappointment), attitudinal (feeling in control of their condition, PA perception, older age perception), and motivational. The main enabling factors were related to motivation (autonomous or controlled), attitudes, self-regulation, and performance accomplishments.Clinical implicationsWhen designing interventions for individuals with COPD, it is important to understand the patient-specific social cognitive influences on PA participation. This information can then inform individually tailored management planning.

Word count: 4222 3 RESEARCH IN CONTEXT Evidence before this studyIt is widely accepted that COPD is substantially under-diagnosed worldwide. Mass population screening with spirometry is not recommended although early identification of undiagnosed patients with clinical disease is generally supported because COPD has significant patient, healthcare and societal burden which could potentially be lessened through timely diagnosis. A comprehensive systematic review of the effectiveness of case-finding studies, published in 2015, revealed 39 published studies but few included a comparator arm. Only one RCT has compared a case-finding approach with routine care to identify clinically significant COPD, identifying that opportunistic administration of a screening questionnaire at practice visits was twice as effective as routine care, but non-comparative studies suggest that high yields could be achieved from active case finding with mailed questionnaires to high risk patients. No previous trial has compared the clinical and costeffectiveness of alternative approaches to case-finding in a real-life primary care setting. Added value of this studyTargetCOPD is the first randomised controlled trial to evaluate the effectiveness and costeffectiveness of active case-finding for COPD compared with opportunistic case finding and to compare these approaches with routine care. Among 54 general practices, we found that when targeting ever smokers aged 40-79 years, active case finding was more than twice as effective as opportunistic case finding, and that together, these targeted approaches were over seven times as effective as current routine care. Active case finding was also more cost-effective than opportunistic case finding. Implications of all the available evidenceIn a real-life setting, active case-finding comprising an initial mailed questionnaire followed by spirometry should be recommended for identifying undiagnosed COPD in primary care. An important proportion of these previously undiagnosed patients have significant breathlessness and earlier identification and management with effective treatments including inhalers and pulmonary rehabilitation has the potential to improve their health. This trial provides the evidence for guidelines which was previously lacking. 4 SUMMARY Background

Why was the cohort set up?Chronic obstructive pulmonary disease (COPD) affects 5-10% of people worldwide (1), is rising in prevalence (2) and is the third most common cause of death (3). The annual burden of COPD regarding healthcare (mainly exacerbations resulting in emergency admissions) and societal (predominantly lost productivity) costs was estimated to be around $49.9billion in the USA (2010 prices (4)) and €48.4billion in the EU (2011 prices (5)). A substantial proportion of those with COPD are of working age, but there is some evidence that they have poorer employment history (6), higher rate of sickness absence (7) and poorer work performance (presenteeism) (8) compared to the general population.There remains much uncertainty about the natural history of COPD (9, 10) and which interventions are effective in altering the course of early disease. Furthermore, up to 85% of cases (11-13) are undiagnosed; representing many with potentially unmet need. Partly in response to reports (14)(15)(16) highlighting the burden of COPD, extent of underdiagnosis and uncertainty about prognosis of early disease, expert reviews have highlighted a need for further longitudinal data (9, 10). However, established cohorts usually represent secondary care patients with more advanced disease, with short duration of follow up and, generally small samples (17)(18)(19). While large population cohorts have sometimes addressed questions relevant to COPD (20-28), limitations in outcome measures and quality of lung function testing provide insufficient data to inform the COPD arena. Importantly, there are no primary care COPD cohorts with case-found patients and few with patients representing the full range of disease severity, particularly those with mild to moderate disease, and diverse socioeconomic mix.In recent years, several studies have also focused on patients reporting respiratory symptoms but who have normal lung function (former GOLD severity stage 0 (29)). The evidence on progression to COPD is limited and contradictory (23, 30, 31) and methods for assessing symptoms are inconsistent (23, 32). Thus there is also a paucity of evidence on the clinical relevance and natural history for this patient group.Better understanding of natural history and prognostic factors is needed to facilitate consultations, and to inform management decisions and health service planning. Existing COPD prognostic indices (PI) mainly focus on predicting mortality risk (17,(33)(34)(35)(36), though others were developed to predict additional outcomes such as exacerbations (37, 38), COPD-related hospitalisation (39), respiratory hospital attendance/admission (40), exacerbation or hospitalisation (41, 42). Only three indices (38,41,42) were derived in primary care populations despite this being where most COPD patients are managed, and most included patients with more severe established disease. No indices were developed in populations that included case-found patients. The methods and basis for selecting prognostic variables are rarely described, and...

BackgroundPulmonary rehabilitation (PR) is a cost-effective, internationally recommended intervention for patients with chronic obstructive pulmonary disease (COPD). Referral is predominately led by primary healthcare practitioners (PHCPs), but referral and patient uptake is poor.AimTo understand barriers and enablers for PHCPs when considering patient referral to PR, to explore the influence of patient characteristics, and to understand how referral rates may be increased.Design and settingPHCPs who care for and refer patients with COPD to PR were purposively selected from general practices across Cambridgeshire and Peterborough, and the West Midlands.MethodA qualitative study. Semi-structured interviews were undertaken to theme saturation, exploring PR referral. Images depicting patients with varying COPD severity were used to stimulate memory and associative recall. Interviews were recorded, transcribed verbatim, and analysed using rapid qualitative analysis.ResultsA total of 19 PHCPs were interviewed. Barriers to PR referral included limited awareness of the clinical benefits, little knowledge of local PR providers, consultation time constraints, and presumed low patient motivation. While practice nurses had the greatest knowledge, they still described difficulty in promoting PR. PHCPs frequently described assessing patient suitability based on presumed accessibility, social, and disease-specific characteristics rather than the clinical benefits of PR. Referrals were facilitated by financial incentives for the practice and positive feedback from patients and providers.ConclusionThere were more barriers to PR referral than enablers. Providers must engage better with PHCPs, patients with COPD, and carers, and actively promote PR. Increasing PHCPs’ awareness of the benefits of PR, financial incentives, and alternative referral pathways should be considered.

Introduction‘One-off’ systematic case-finding for COPD using a respiratory screening questionnaire is more effective and cost-effective than routine care at identifying new cases. However, it is not known whether early diagnosis and treatment is beneficial in the longer term. We estimated the long-term cost-effectiveness of a regular case-finding programme in primary care.MethodsA Markov decision analytic model was developed to compare the cost-effectiveness of a 3-yearly systematic case-finding programme targeted to ever smokers aged ≥50 years with the current routine diagnostic process in UK primary care. Patient-level data on case-finding pathways was obtained from a large randomised controlled trial. Information on the natural history of COPD and treatment effects was obtained from a linked COPD cohort, UK primary care database and published literature. The discounted lifetime cost per quality-adjusted life-year (QALY) gained was calculated from a health service perspective.ResultsThe incremental cost-effectiveness ratio of systematic case-finding versus current care was £16 596 per additional QALY gained, with a 78% probability of cost-effectiveness at a £20 000 per QALY willingness-to-pay threshold. The base case result was robust to multiple one-way sensitivity analyses. The main drivers were response rate to the initial screening questionnaire and attendance rate for the confirmatory spirometry test.DiscussionRegular systematic case-finding for COPD using a screening questionnaire in primary care is likely to be cost-effective in the long-term despite uncertainties in treatment effectiveness. Further knowledge of the natural history of case-found patients and the effectiveness of their management will improve confidence to implement such an approach.