Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort.
BACKGROUND
Patterns of health-care use and comorbidities present in patients in the period before diagnosis of chronic obstructive pulmonary disease (COPD) are unknown. We investigated these factors to inform future case-finding strategies.


METHODS
We did a retrospective analysis of a clinical cohort in the UK with data from Jan 1, 1990 to Dec 31, 2009 (General Practice Research Database and Optimum Patient Care Research Database). We assessed patients aged 40 years or older who had an electronically coded diagnosis of COPD in their primary care records and had a minimum of 3 years of continuous practice data for COPD (2 years before diagnosis up to a maximum of 20 years, and 1 year after diagnosis) and at least two prescriptions for COPD since diagnosis. We identified missed opportunites to diagnose COPD from routinely collected patient data by reviewing patterns of health-care use and comorbidities present before diagnosis. We assessed patterns of health-care use in terms of lower respiratory consultations (infective and non-infective), lower respiratory consultations with a course of antibiotics or oral steroids, and chest radiography. If these events did not lead to a diagnosis of COPD, they were deemed to be missed opportunities. This study is registered with ClinicalTrials.gov, number NCT01655667.


RESULTS
We assessed data for 38,859 patients. Opportunities for diagnosis were missed in 32,900 (85%) of 38,859 patients in the 5 years immediately preceding diagnosis of COPD; in 12,856 (58%) of 22,286 in the 6-10 years before diagnosis, in 3943 (42%) of 9351 in the 11-15 years before diagnosis; and in 95 (8%) of 1167 in the 16-20 years before diagnosis. Between 1990 and 2009, we noted decreases in the age at diagnosis (0·05 years of age per year, 95% CI 0·03-0·07) and yearly frequency of lower respiratory prescribing consultations (rate ratio 0·982 opportunities per year, 95% CI 0·979-0·985). Prevalence of all comorbidities present at COPD diagnosis increased except for asthma and bronchiectasis, which decreased between 1990 and 2007, from 281 (33·4%) of 842 patients to 451 of 1465 (30·8%) for asthma, and from 53 of 842 (6·3%) to 53 of 1465 (3·6%) for bronchiectasis. In the 2 years before diagnosis, of 6897 patients who had had a chest radiography, only 2296 (33%) also had spirometry.


CONCLUSIONS
Opportunities to diagnose COPD at an earlier stage are being missed, and could be improved by case-finding in patients with lower respiratory tract symptoms and concordant long-term comorbidities.


BACKGROUND
UK Department of Health, Research in Real Life.
Plymouth University Peninsula School of Medicine and Dentistry, Plymouth, UK.
Rupert C M
RC
Jones
Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK; Research in Real Life, Cambridge, UK. Electronic address: david@rirl.org.
David
D
Price
Woodbrook Medical Centre, Loughborough, UK; Centre for Population Health Sciences, Medical School, Edinburgh, UK.
Dermot
D
Ryan
Research in Real Life, Cambridge, UK; Norwich Medical School, University of East Anglia, Norwich, UK.
Erika J
EJ
Sims
Research in Real Life, Cambridge, UK.
Julie
J
von Ziegenweidt
Research in Real Life, Cambridge, UK; NHS Surrey, Leatherhead, UK.
Laurence
L
Mascarenhas
Research in Real Life, Cambridge, UK.
Anne
A
Burden
Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK.
David M G
DM
Halpin
East of England Strategic Health Authority, Cambridge, UK.
Robert
R
Winter
Respiratory Programme, Department of Health, London, UK.
Sue
S
Hill
Respiratory Programme, Department of Health, London, UK.
Matt
M
Kearney
Respiratory Programme, Department of Health, London, UK.
Kevin
K
Holton
Respiratory Programme, Department of Health, London, UK.
Anne
A
Moger
Mundesley Medical Practice, Mundesley, UK.
Daryl
D
Freeman
Research in Real Life, Cambridge, UK.
Alison
A
Chisholm
Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
Eric D
ED
Bateman
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D015897:Comorbidity; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011320:Primary Health Care / Q000706:statistics & numerical data; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis* / Q000453:epidemiology; D013902:Radiography, Thoracic / Q000706:statistics & numerical data; D012140:Respiratory Tract Diseases / Q000188:drug therapy / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D013147:Spirometry / Q000706:statistics & numerical data; D013256:Steroids / Q000627:therapeutic use; D006113:United Kingdom / Q000453:epidemiology
D000900:Anti-Bacterial Agents; D013256:Steroids