Chest
Volume 148, Issue 4, October 2015, Pages 971-985
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Original Research
COPD
Determinants of Underdiagnosis of COPD in National and International Surveys

https://doi.org/10.1378/chest.14-2535Get rights and content

BACKGROUND

COPD ranks within the top three causes of mortality in the global burden of disease, yet it remains largely underdiagnosed. We assessed the underdiagnosis of COPD and its determinants in national and international surveys of general populations.

METHODS

We analyzed representative samples of adults aged ≥ 40 years randomly selected from well-defined administrative areas worldwide (44 sites from 27 countries). Postbronchodilator FEV1/FVC < lower limit of normal (LLN) was used to define chronic airflow limitation consistent with COPD. Undiagnosed COPD was considered when participants had postbronchodilator FEV1/FVC < LLN but were not given a diagnosis of COPD.

RESULTS

Among 30,874 participants with a mean age of 56 years, 55.8% were women, and 22.9% were current smokers. Population prevalence of (spirometrically defined) COPD ranged from 3.6% in Barranquilla, Colombia, to 19.0% in Cape Town, South Africa. Only 26.4% reported a previous lung function test, and only 5.0% reported a previous diagnosis of COPD, whereas 9.7% had a postbronchodilator FEV1/FVC < LLN. Overall, 81.4% of (spirometrically defined) COPD cases were undiagnosed, with the highest rate in Ile-Ife, Nigeria (98.3%) and the lowest rate in Lexington, Kentucky (50.0%). In multivariate analysis, a greater probability of underdiagnosis of COPD was associated with male sex, younger age, never and current smoking, lower education, no previous spirometry, and less severe airflow limitation.

CONCLUSIONS

Even with substantial heterogeneity in COPD prevalence, COPD underdiagnosis is universally high. Because effective management strategies are available for COPD, spirometry can help in the diagnosis of COPD at a stage when treatment will lead to better outcomes and improved quality of life. CHEST 2015; 148(4):971-985

Section snippets

Results

Among 30,874 participants aged 56 ± 11.3 years from 44 sites worldwide, 55.8% were women, and 22.9% were current smokers. More detailed information on demographics, smoking status, respiratory symptoms, and postbronchodilator lung function is presented in TABLE 2, TABLE 3.

Only 26.4% of all participants reported a previous lung function test ever and 5.0% a diagnosis of COPD, whereas 9.7% had a postbronchodilator FEV1/FVC < LLN. Population prevalence of COPD ranged from 3.6% in Barranquilla,

Discussion

The results indicate that COPD underdiagnosis is frequent but varied across sites and age-groups. However, this underdiagnosis is not related with COPD prevalence. Although the range of COPD prevalence by site varies fivefold (5.27 times), its underdiagnosis only varies twofold (1.97). Worldwide determinants of COPD underdiagnosis are male sex (except in Spain), younger age, never and current smoking, lower level of education, absence of reported symptoms, lack of previous spirometry, and

Recommendations and Conclusions

More research on strategies to reduce the overwhelming phenomenon of COPD underdiagnosis is needed. COPD underdiagnosis has remained high in many countries, even after years of multiple interventions such as population spirometry and case finding. Apart from primary care as the central venue to screen for COPD, other options might be considered, such as community pharmacies30 or actively searching for COPD associated with the presence of comorbid disease.31,32 Lessons of success in other

Acknowledgments

Author contributions: B. L. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. B. L., J. B. S., M. S., and B. K. contributed to the study conception and design, data analysis and interpretation, and final approval of the manuscript; B. L. and J. B. S. contributed to the drafting of the manuscript; and L. E. V., L. G., P. B., M. M., F. G.-R., K. A., J. A., A.

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    FUNDING/SUPPORT: The initial Burden of Obstructive Lung Disease (BOLD) program was funded in part by unrestricted educational grants to the coordinating center in Portland, Oregon, from Aventis, AstraZeneca, Boehringer Ingelheim GmbH, Chiesi Farmaceutici SpA, GlaxoSmithKline plc, Merck Sharp & Dohme Corp, Novartis AG, Pfizer Inc, Schering-Plough, Sepracor Inc, and the University of Kentucky The BOLD study is currently funded by a grant from The Wellcome Trust [085790/Z/08/Z], which supports the London, England, coordinating center. The Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) was funded by Boehringer Ingelheim GmbH. The Epidemiologic Study of COPD in Spain (EPI-SCAN) study was funded by an unrestricted grant from GlaxoSmithKline Spain. The Prevalence Study of COPD in Colombia (PREPOCOL) was sponsored by an educational contribution from the Colombian offices of Boehringer Ingelheim GmbH and Pfizer Inc (Bogotá, Colombia). Support for the present work was provided by European Respiratory Society Fellowship STRTF 326-2011.

    originally published Online First May 7, 2015

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