A Clinical Interventional Study Into Airways Disease Case Finding and Complex Case Management

Background Chronic Obstructive Pulmonary Disease (COPD) COPD is a disease of the lungs characterised by airway inflammation leading to airflow obstruction. It is a progressive and largely preventable disease caused by the inhalation of noxious gases generally through cigarette smoking. Patients experience persistent symptoms including breathlessness, reduced exercise tolerance and an increase in the production of mucus in the airways. The impact of the disease to the individual is substantial in terms of physical disability and psycho-social issues.

Patients with COPD can experience an exacerbation of their disease, defined as a sudden worsening of symptoms above and beyond the individual's normal daily variation. COPD exacerbations are the second most common cause of emergency hospital admissions in the UK, with an estimated 94,000 admissions per annum. Indeed, COPD is one of the most expensive inpatient conditions in the UK, costing the National Health Service (NHS) over £800 million in direct healthcare costs. COPD is also set to become the third leading cause of death worldwide by the year 2030, surpassed only by heart disease and stroke. Despite this high level of mortality, public awareness of COPD is low in the United Kingdom (UK): around 89% of the general public have never heard of COPD.

Under-diagnosis of COPD Evidence suggests that 13% of people over 35 have COPD but many are diagnosed late and most are currently undiagnosed. Almost a third of patients admitted to hospital with a COPD exacerbation had not been diagnosed. Opportunities for early diagnosis of COPD are missed in primary care: a recent study demonstrated that 85% of patients had consulted primary care with lower respiratory symptoms in the five years immediately before their diagnosis of COPD. The insidious onset of COPD means undiagnosed patients may unconsciously modify their way of life, and only present to primary care in the later stages of disease. Furthermore, smokers, who constitute a substantial portion of the target population for case finding, have been shown to hold self-exempting beliefs and thus may be less likely to present to primary care. In addition, many patients visit their GP for problems related to COPD, such as chest infections and breathlessness, but the correct diagnosis is not made.

The importance of early diagnosis of COPD National health policy initiatives in the UK underscore improved diagnosis as a priority Early diagnosis of COPD followed by optimisation of treatment has potential cost savings for the NHS of more than £1 billion over 10 years . Prevention strategies (smoking cessation, dietary, exercise promotion, self-management and vaccination) can be targeted on this group of patients to maintain and improve health, and appropriate pharmacologic therapies (that can improve symptoms, exercise tolerance and quality of life and reduce the risk of exacerbations) commenced in newly identified people if appropriate. A recent systematic review of the literature concluded that a combination of a screening questionnaire and micro-spirometry seems to demonstrate the best overall screening test accuracy, but there has been little uptake of this strategy in UK primary care and doubts remain as to its feasibility and cost-effectiveness. However, whilst a variety of approaches to case finding have been trialled world-wide published studies have been variable in quality and the most effective, economical method of screening has yet to be identified. The National Institute for Health and Clinical Excellence (NICE) and the Department of Health (DoH) in the UK have recommended both systematic and opportunistic case finding to diagnose symptomatic patients . The UK National Screening Committee concurs, explicitly recommending case finding (defined as targeting patients with symptoms suggestive of COPD) rather than screening (defined as identifying apparently healthy people who may be at increased risk of COPD). A recent All Party Parliamentary Group report on Respiratory Deaths (APPG RD) concluded that tools to aid health care professionals to case find for COPD need to be developed in order to prioritise for use at national level.

Case-finding: identifying symptomatic but not yet diagnosed patients 'TargetCOPD' is an ongoing NIHR funded randomised controlled trial comparing the cost-effectiveness of two alternative case-finding approaches for identifying undiagnosed COPD. Both approaches rely on patient self-reported questionnaires to identify symptoms; one opportunistically administered, the other systematically administered. 'TargetCOPD' should provide some useful information on case-finding using questionnaires. However, evidence suggests that alternative approaches to case finding such as electronic searches based on routine primary care data may be a valuable tool for identifying symptomatic patients with as yet undiagnosed COPD. However, further validation of electronic case-finding strategies is required.