(Chest. 2000;117:372S-375S.)
© 2000
American College of Chest Physicians
Raising Awareness of COPD in Primary Care*
Norbert F. Voelkel, MD
*
From the Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Denver, CO.
This article was drawn from a discussion following the workshop "COPD: Working Towards a Greater Understanding," held in June 1999. For a complete list of discussion panel participants, see the Appendix.
Correspondence to: Norbert F. Voelkel, MD, Division of Pulmonary Sciences and Critical Care Medicine, 4200 E Ninth Ave, C272, Denver, CO 80262; e-mail: norbert.voelkel{at}uchsc.edu
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Abstract
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COPD is a major cause of mortality and a significant drain on
health-care resources but is widely underdiagnosed in the primary-care
setting. There is an urgent need to raise the profile of the disease
among both primary-care physicians and patients. At the workshop
"COPD: Working Towards a Greater Understanding," a panel of COPD
experts from Europe and the United States discussed ways in which
awareness of COPD could be raised. Access to spirometry, and education
in its use and relevance, was identified as a major goal for
primary-care physicians. Simple questionnaires can promote patient
awareness and provide feedback to physicians. COPD needs to be
identified as not just a disease of smokers.
Key Words: awareness • COPD • diagnosis • prevalence
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Introduction
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COPD
represents a significant drain on health-care resources, yet COPD is
significantly underdiagnosed. If the burden of this disease is to be
reduced over the coming years, it will be essential to improve
awareness and raise the profile of the disease among primary-care
physicians and their patients.
Evidence from the field of cardiovascular medicine demonstrates that a
major public health campaign can successfully raise awareness of risk
factors and can influence treatment patterns. For example, the United
States National High Blood Pressure Education Program, established in
1972, resulted in an increased awareness of hypertension among
patients, from 51% in 1976 to 1980, to 73% in 1988 to 1991, and to
68% in 1991 to 1994. Treatment levels by physicians also have risen,
from 31% in 1976 to 1980, to 55% in 1988 to 1991, and to 53% in 1991
to 1994.1
During the 1980s, the activities of the National
Cholesterol Education Program resulted in an increased awareness and
treatment of hypercholesterolemia. For example, the numbers of adults
who reported having their cholesterol level checked increased from 35
to 65% between 1983 and 1990. In addition, by 1990, > 90% of the
1,600 physicians contacted were aware of the recommendations of the
National Cholesterol Education Program Expert Panel
Report.2
The value of educational activities within the field of respiratory
medicine also has been recognized with the establishment of the
National Lung Health Education Program in 1998.3
"Test
Your Lungs, Know Your Numbers" is an important primary-care and
public education initiative being driven by the National Lung Health
Education Program. For the full potential of this effort to be
realized, however, fundamental mortality and morbidity issues
surrounding COPD will need to be reinforced on an ongoing basis.
The image of COPD has a common, though misguided, perception of being a
self-inflicted disease of elderly smokers. Compounding this poor image,
sufferers often consider symptoms of the disease to be a natural part
of aging and are reluctant to seek medical advice. Primary-care
physicians may commonly express a nihilistic view and approach
regarding the treatment and prognosis of these patients.
At a workshop entitled "COPD: Working Towards a Greater
Understanding," a group of respiratory physicians from the United
States and Europe explored ways of changing the current view of COPD,
focusing on ways of improving its image and raising awareness.
Elevating the profile of this common and debilitating disease among
primary-care physicians and their patients was recognized as the key
route to achieving this objective. This article summarizes the results
of the workshop. Pulmonary specialists, and those who influence primary
care, will play a vital role in disseminating the message that COPD is
an important lung disease the treatment and prognosis of which benefit
from early detection and intervention.
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COPD: The Other Lung Disease
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Internationally, there is great awareness among primary-care
physicians and patients surrounding major lung diseases such as lung
cancer and asthma. However, few recognize "the other lung
disease" COPD, and fewer still are aware that COPD is rapidly
becoming a major global health-care concern.
The importance of COPD as a major, worldwide respiratory health problem
should not be underestimated. In 1990, COPD was estimated to be the
12th greatest burden of disease (measured using disability-adjusted
life-years). By 2020, however, COPD is predicted to rise to fifth
place, after ischemic heart disease, unipolar major depression, road
traffic accidents, and cerebrovascular accidents.4
In 1998, the World Health Organization estimated that 4.2% of deaths
worldwide were due to COPD, making this disease the fifth most common
cause of death.5
By the year 2020, it is estimated that
COPD will become the third most common cause of death.
The immensity of the problem represented by COPD today, and the fact
that it is expected to get worse over the next 2 decades, is a clear
message that needs to be disseminated to primary-care physicians.
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Putting A Face To COPD: Raising The Profile
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Cigarette smoking is well established as the major risk factor for
COPD. However, many smokers may not develop clinically significant
airflow limitation, although it has been estimated that about 10 to
30% of smokers will develop COPD.6
Furthermore, other
evidence suggests that as many as 10% of nonsmokers will develop
the disease,7
perhaps as a consequence of exposure
to air pollution, as a consequence of their genetic susceptibility, or
both. Patients with long-standing asthma also may develop COPD. Thus,
while COPD is a disease of smokers, it is not only a disease
of smokers.
Owing to the large pulmonary function reserve, airflow obstruction can
progress undetected for many years without the development of overt
clinical symptoms of disease. Thus, while many patients diagnosed with
COPD are elderly, a decline in lung function often can be detected in
smokers as young as 40 years of age. Not only should primary-care
physicians therefore consider COPD in younger at-risk patients, they
should also consider investigating airflow obstruction in at-risk
individuals who are not yet complaining of respiratory symptoms.
While COPD patients are viewed traditionally as being either "blue
bloaters" or "pink puffers," guidelines have made efforts to
stress that many patients will fall into neither group.8
The image of COPD does not include, for example, a 42-year-old
nonsmoking woman with 
1-antitrypsin
deficiency, or the 35-year-old male smoker who has a chronic,
productive cough but does not consider these symptoms worthy of
mention to his primary-care physician.
To ensure that COPD is diagnosed at an early stage in patients, before
daily activities become significantly limited, and to ensure that
interventions are initiated where appropriate, it is vital to expand
the perception of the disease beyond its being a disease affecting
smokers and to explain that COPD is a disease that affects people in
their 30s and 40s, and is not solely a disease of the elderly.
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Value of Early Detection: Spirometry Made Simple
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Spirometric measurements of airflow obstruction, primarily
FEV1 and FVC, play a pivotal role in the
objective diagnosis of COPD. However, few primary-care practices have
access to spirometric equipment or the trained technicians required to
produce meaningful results. In their 1997 guidelines, the British
Thoracic Society9
recognized this inadequacy within the
primary-care environment and identified the need to provide open-access
hospital referral to lung function laboratories (similar to the access
to radiographic facilities).
Not only do physicians need access to spirometry, they also need the
motivation to use such equipment or services. Part of this motivation
may come from encouraging physicians to test themselves, in much
the same way they might test their own BP or cholesterol
level, and to become familiar with the various parameters of lung
function and patterns of lung function abnormalities. Thus, the
use of spirometry in primary-care settings needs to focus on the most
important aspects of lung function; in particular, the clinical meaning
of FEV1 and FVC need to be explained simply and
readily.
In cardiovascular medicine, hypertension and hypercholesterolemia are
now well-established risk factors for subsequent cardiovascular events.
In a similar way, it is important to reinforce the importance of
nonsymptomatic airflow obstruction and its association with increased
morbidity and mortality. COPD should be regarded as an indolent disease
process that only produces symptoms when a considerable loss of lung
function has occurred. Most importantly, primary-care physicians need
to understand that spirometry results predict mortality.
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Educating Patients Within Primary Care
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Educating and informing patients, in addition to primary-care
physicians, will help to increase awareness of COPD. By alerting
patients to the factors that may increase their risk of developing COPD
and to the symptoms that they should recognize, they will be prompted
to seek medical attention at an earlier stage in the disease process.
Patient awareness within the primary-care setting should focus not only
on those patients who are symptomatic, but also on those who are at
risk of developing symptomatic COPD in the future. A short and simple
self-administered questionnaire that covers not only symptoms but also
risk factors would be an ideal vehicle to raise patient awareness and
to seek the desired information.
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Conclusions and Recommendations
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Raising awareness of COPD among primary-care physicians so that
the disease is detected during the course of usual medical care
requires a two-pronged approach: education and empowerment. Physicians
need to be educated about the enormous health burden that COPD, the
"other lung disease," represents in terms of morbidity and
mortality. Physicians need to know that symptoms mean something,
especially when present in individuals who do not fit the traditional
picture of a "blue bloater" or a "pink puffer." Physicians need
to be aware that the profile of patients with COPD is not solely
elderly infirm individuals, and they need to understand that smoking is
a major risk factor for developing COPD but is not the only
cause. Overall, a more positive image and perception of patients
with COPD needs to be created, perhaps through a poster campaign or via
an educational pamphlet directed at physicians.
Easy access to spirometry is essential for an objective diagnosis of
COPD, but physicians will need to understand what the data mean and
what should happen after diagnosis. Thus, spirometric measurements and
their clinical relevance need to be explained in simple terms. Again,
an educational pamphlet can be used for this purpose. Use of a simple
questionnaire (Table 1
) can help promote awareness among patients and can provide feedback to
physicians about the scale of the problem within their clinics.
Importantly, primary-care physicians need to be motivated to make a
difference. They need to understand what impact early diagnosis and
early intervention will have on their patients’ current and future
conditions. Physicians need to feel empowered to make a difference, and
they need to know what that difference will be.
To date, smoking cessation is the only intervention that has been
documented consistently to modify the rate of decline of lung function,
even in relatively young smokers with only mild and moderate airflow
obstruction.10
However, it is essential that COPD
intervention does not equate solely with stopping patients from
smoking. Initiatives aimed at increasing awareness of COPD and the
subsequent diagnosis of COPD must focus on what can be done
for the patient, for example, in terms of improving lung function,
symptoms, and quality of life, rather than on what cannot be
done.
The early identification of COPD will no doubt improve the patient’s
general well-being and the primary-care physician’s ability to improve
longitudinal care. Increasing primary-care physician and patient
awareness, hopefully, will provide a political force to discover and
investigate new and effective disease-modifying interventions.
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Appendix 1
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The discussion panel consisted of the following participants:
N.F. Voelkel, MD (Denver, CO); T.L. Petty, MD, Master FCCP (Denver,
CO); D.W. Mapel, MD, MPH, FCCP (Albuquerque, NM); S.S. Hurd, PhD
(Bethesda, MD); P. Stang, PhD (Blue Bell, PA); G. Viegi, MD (Pisa,
Italy); R. Pauwels, MD, FCCP (Ghent, Belgium); S.I. Rennard, MD, FCCP
(Omaha, NE); P.M.A. Calverley, MD (Liverpool, UK); S. Sethi, MD
(Buffalo, NY); J.A. Nadel, MD (San Francisco, CA); and W. MacNee,
MD (Edinburgh, UK).
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References
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Burt, VL, Cutler, JA, Higgins, M, et al (1995) Trends in the prevalence, awareness, treatment and control of hypertension in the adult US population: data from the health examination surveys, 1960 to 1991. Hypertension 26,60-69[Abstract/Free Full Text]
-
Schucker, B, Wittes, JT, Santanello, NC, et al (1991) Change in cholesterol awareness and action: results from national physician and public surveys. Arch Intern Med 151,666-673[Abstract]
-
. National Lung Health Education Program Executive Committee. (1998) Strategies in preserving lung health and preventing COPD and associated diseases: National Lung Health Education Program (NLHEP). Chest 113(suppl),123S-163S[ISI][Medline]
-
Murray, JL, Lopez, AD (1996) Global burden of disease (vol I). World Health Organization Geneva, Switzerland.
-
. World Health Organization. (1999) The world health report 1999: making a difference. World Health Organization Geneva, Switzerland.
-
Fletcher, C, Peto, R, Tinker, C, et al (1976) The natural history of chronic bronchitis and emphysema. ,272 Oxford University Press New York, NY.
-
Stang, P (2000) The prevalence of COPD: using smoking rates to estimate disease frequency in the general population. Chest 117(suppl),378S-383S
-
Siafakas, NM, Vermeire, P, Pride, NB, et al (1995) Optimal assessment and management of chronic obstructive pulmonary disease (COPD): the European Respiratory Task Force. Eur Respir J 8,1398-1420[CrossRef][ISI][Medline]
-
. British Thoracic Society. (1997) BTS guidelines for the management of chronic obstructive pulmonary disease: the COPD Guidelines Group of the Standards of Care Committee of the BTS. Thorax 52(suppl),S1-S28[Free Full Text]
-
Anthonisen, NR, Connett, JE, Kiley, JP, et al (1994) Effects of smoking intervention and the use of inhaled anticholinergic bronchodilator on the rate of decline of FEV1: the Lung Health Study. JAMA 272,1497-1505[Abstract]
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Abstract
Introduction
