title: Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial.
abstract: Many individuals with chronic obstructive pulmonary disease (COPD) remain undiagnosed worldwide. Health-care organisations are implementing case-finding programmes without good evidence of which are the most effective and cost-effective approaches. We assessed the effectiveness and cost-effectiveness of two alternative approaches to targeted case finding for COPD compared with routine practice.
  
  
  
  In this cluster-randomised controlled trial, participating general practices in the West Midlands, UK, were randomly assigned (1:1), via a computer-generated block randomisation sequence, to either a targeted case-finding group or a routine care group. Eligible patients were ever-smokers aged 40-79 years without a previously recorded diagnosis of COPD. Patients in the targeted case-finding group were further randomly assigned (1:1) via their household to receive either a screening questionnaire at the general practitioner (GP) consultation (opportunistic) or a screening questionnaire at the GP consultation plus a mailed questionnaire (active). Respondents reporting relevant respiratory symptoms were invited for post-bronchodilator spirometry. Patients, clinicians, and investigators were not masked to allocation, but group allocation was concealed from the researchers who performed the spirometry assessments. Primary outcomes were the percentage of the eligible population diagnosed with COPD within 1 year (defined as post-bronchodilator forced expiratory volume in 1 s [FEV1] to forced vital capacity [FVC] ratio <0·7 in patients with symptoms or a new diagnosis on their GP record) and cost per new COPD diagnosis. Multiple logistic and Poisson regression were used to estimate effect sizes. Costs were obtained from the trial. This trial is registered with ISRCTN, number ISRCTN14930255.
  
  
  
  From Aug 10, 2012, to June 22, 2014, 74 818 eligible patients from 54 diverse general practices were randomly assigned and completed the trial. At 1 year, 1278 (4%) cases of COPD were newly detected in 32 789 eligible patients in the targeted case-finding group compared with 337 (1%) cases in 42 029 patients in the routine care group (adjusted odds ratio [OR] 7·45 [95% CI 4·80-11·55], p<0·0001). The percentage of newly detected COPD cases was higher in the active case-finding group (822 [5%] of 15 378) than in the opportunistic case-finding group (370 [2%] of 15 387; adjusted OR 2·34 [2·06-2·66], p<0·0001; adjusted risk difference 2·9 per 100 patients [95% CI 2·3-3·6], p<0·0001). Active case finding was more cost-effective than opportunistic case finding (£333 vs £376 per case detected, respectively).
  
  
  
  In this well established primary care system, routine practice identified few new cases of COPD. An active targeted approach to case finding including mailed screening questionnaires before spirometry is a cost-effective way to identify undiagnosed patients and has the potential to improve their health.
  
  
  
  National Institute for Health Research.
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK. Electronic address: r.e.jordan@bham.ac.uk.
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Jordan
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK. Electronic address: P.adab@bham.ac.uk.
authors.forename: Peymané
authors.initials: P
authors.lastname: Adab
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Alice
authors.initials: A
authors.lastname: Sitch
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Enocson
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Deirdre
authors.initials: D
authors.lastname: Blissett
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Sue
authors.initials: S
authors.lastname: Jowett
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Jen
authors.initials: J
authors.lastname: Marsh
authors.affiliation: Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Riley
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Martin R
authors.initials: MR
authors.lastname: Miller
authors.affiliation: Lung Investigation Unit, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK.
authors.forename: Brendan G
authors.initials: BG
authors.lastname: Cooper
authors.affiliation: Queen Elizabeth Hospital Research Laboratories, Mindelsohn Way, Birmingham, UK.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Turner
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Kate
authors.initials: K
authors.lastname: Jolly
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Jon G
authors.initials: JG
authors.lastname: Ayres
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Shamil
authors.initials: S
authors.lastname: Haroon
authors.affiliation: Lung Investigation Unit, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK.
authors.forename: Robert
authors.initials: R
authors.lastname: Stockley
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Sheila
authors.initials: S
authors.lastname: Greenfield
authors.affiliation: Business School, University of Birmingham, Birmingham, UK.
authors.forename: Stanley
authors.initials: S
authors.lastname: Siebert
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Amanda J
authors.initials: AJ
authors.lastname: Daley
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: K K
authors.initials: KK
authors.lastname: Cheng
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: David
authors.initials: D
authors.lastname: Fitzmaurice
mesh_terms: D000328:Adult; D000368:Aged; D016000:Cluster Analysis; D003362:Cost-Benefit Analysis; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics / Q000379:methods*; D008875:Middle Aged; D016012:Poisson Distribution; D011320:Primary Health Care / Q000191:economics / Q000379:methods*; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis* / Q000191:economics; D012017:Referral and Consultation; D012044:Regression Analysis; D013147:Spirometry / Q000191:economics / Q000379:methods; D011795:Surveys and Questionnaires; D063189:Symptom Assessment / Q000191:economics / Q000379:methods*; D006113:United Kingdom; D014797:Vital Capacity