Missed diagnosis and overtreatment of COPD among smoking primary care population in Central Greece: old problems persist

Abstract

BackgroundThe diagnosis of COPD is not always consistent with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy in daily clinical practice, especially in primary care. This study aimed to estimate the overall COPD prevalence and severity, to identify differences between newly and previously diagnosed patients, and to evaluate the potential COPD overtreatment in a smoking population attending a primary care spirometry surveillance program.MethodsA study was conducted in 10 primary health care centers of Central Greece during a 7-month period. Eligible participants were aged ≥40 years and were either current smokers or exsmokers.ResultsA total of 186 subjects were included (68% males, mean age 62.3±12.6 years, mean life-time tobacco exposure 50 pack-years). COPD prevalence was 17.8%, identified to be higher in elderly males. Forty-two percent of the COPD group were newly diagnosed patients, who were of younger age, current smokers, presented with less dyspnea and better health status, and mainly appeared with mild-to-moderate disease. Interestingly, 61.4% of non-COPD and 85.7% of newly diagnosed COPD individuals had been using inhaled medication under primary care provider’s prescription without ever undergoing spirometry or further evaluation by a pulmonologist; thus, the phenomena of COPD overdiagnosis and missed diagnosis came into the spotlight. Moreover, only 26.3% of known COPD patients were properly medicated according to GOLD guidelines, while half of them were inappropriately treated with triple inhaled therapy.ConclusionWe reported a significant prevalence of COPD in smoking population attending this spirometry program. A remarkable proportion of COPD patients were undiagnosed and made case finding worthwhile. Underutilization of spirometry in the diagnosis and management of COPD as well as general practitioners’ nonadherence to the GOLD treatment guidelines was confirmed by our data. These findings highlight the need for a major overhaul and culture change in primary care settings of Central Greece.

Adherence of North-African Pulmonologists to the 2017-Global Initiative for Chronic Obstructive Lung Disease (GOLD) Pharmacological Treatment Guidelines (PTGs) of Stable Chronic Obstructive Pulmonary Disease (COPD)

“…In this study, ICS was prescribed in 75.7% of the patients ( Table 2). The problem of overprescription of ICS was highlighted in the literature [5,13,44,45]. For example, ICS (alone or with other medicines) was prescribed in 89, 85, 68.4, and 50% of Turkish [44], Greek [45], Greek [5], and Italian [13] COPD patients, respectively.…”

“…The problem of overprescription of ICS was highlighted in the literature [5,13,44,45]. For example, ICS (alone or with other medicines) was prescribed in 89, 85, 68.4, and 50% of Turkish [44], Greek [45], Greek [5], and Italian [13] COPD patients, respectively. Ten reasons BioMed Research International 7 BioMed Research International can be advanced to explain this ICS over prescription: (i) ICS is a treatment always available in hospitals; (ii) pulmonologists aim to cover all the stages/groups of COPD; (iii) lack of awareness with regard to the 2017-GOLD PTGs, even among pulmonologists [46]; (iv) repetition of the drugs previously prescribed by another physician without a cautious assessment [13]; (v) presence of wheezing [47]; (vi) high CAT score [47]; (vii) a belief that ICS are more effective [13]; (viii) higher preference for combination devices, including ICS-LABA rather than ICS and LABA in separate devices [13]; and (ix) information received from pharmaceutical companies [13].…”

Trends in prevalence and incidence of chronic respiratory diseases from 1990 to 2017

“…The relationships between the incidences and the SDI/ HDI were assessed. Notably, the prevalence of missed diagnoses of CRDs varied across all five SDI regions and countries with different HDIs, [22][23][24][25] thus affecting the estimated incidences of reported CRDs. In addition, the national epidemiologic survey on CRDs in many countries with large populations were not conducted in recent years, which may lead to an underestimation of the disease burden.…”

Use of the terms “overdiagnosis” and “misdiagnosis” in the COPD literature: a rapid review

“…15 studies reported overdiagnosis or misdiagnosis if the physician's diagnosis was discordant with the spirometry result, which showed either a normal or restrictive pattern [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. A physician diagnosis with normal spirometry could have been a case in which the physician did not use spirometry to establish a diagnosis of COPD (and a normal spirometry was later found in the study) [10,[14][15][16][17][21][22][23], or a case in which the physician "ignored" a normal spirometry result [12,20,24]. Most of these studies cited underutilisation of spirometry as the primary cause of overdiagnosis and misdiagnosis in this context.…”

“…Eight studies considered these cases to be misdiagnosed [14,15,[18][19][20][21][22]24]. In two studies the terms "overdiagnosis" and misdiagnosis were used interchangeably to describe this concept [16,23].…”