Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial

Abstract

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

Hidden morbidity: The results of a collaborative community chronic obstructive pulmonary disease screening initiative

“…However, the true COPD rate within the screened population may be higher due to the likelihood that some cases were missed as a result of the high non‐attendance rate at 1‐stop clinics among current and ex‐smokers. Published reports of primary care based targeted COPD case finding demonstrate a diagnosis rate of between 2% and 20% . There are, however, fundamental differences in methodology, with the screening intervention we describe being short‐term, labour‐intensive and combined with a public awareness campaign.…”

“…It is also important to consider regional variation in smoking and COPD prevalence when considering the effectiveness of different case finding initiatives. Practice‐based targeted case finding in the United Kingdom has been demonstrated to be cost‐effective . No cost‐effectiveness analysis was performed as part of our evaluation.…”

“…A cluster‐randomised trial in the United Kingdom demonstrated that targeted case finding in primary care was cost effective and identified more new cases than routine care . This intervention was defined as case finding because only symptomatic individuals were invited for spirometry.…”

Chronic Obstructive Pulmonary Disease: Perspectives for Primary Health Care

“…Workers exposed to smoke have a higher risk of developing COPD (1.64; 95% CI, 1.25-2.14) than non-exposed individuals 25 , so it is reasonable to argue that a search strategy applied to identify cases, instead of simply diagnosing symptomatic patients, would bring greater benefits to the general population. A strategy designed to detect asymptomatic COPD cases found that in at-risk individuals over 35 years old, this was more effective 26 , especially if a spirometry is combined with a questionnaire 27 28 . A study conducted in Japan that applied a screening strategy to detect cases with follow-up on patients aged 40 and over in the form of regular visits and use of a portable spirometer generated a sensitivity of 40.7%, a specificity of 96.4%, a PPV of 78.6%, and an NPV of 83.5% 29 .…”

Evaluation of symptomatic patients without airflow obstruction: back to the future

“…Although population screening is not recommended in the general population (18), targeted case finding may be an alternative to detect patients who may be at increased risk for COPD (19). In particular, several questionnaires have been evaluated to have a role in identification of the disease (20).…”