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University of Pavia Pavia, Italy
Correspondence to: Isa Cerveri, MD, Division of Respiratory Diseases, IRCCS Policlinico S. Matteo, University of Pavia, Via Taramelli, 5, 27100 Pavia, Italy; e-mail: i.cerveri{at}libero.it
To the Editor:
We read with interest the article by Zieliñski and Bednarek (March 2001)1 and the subsequent communications to the editor in a recent issue of CHEST (May 2002).2 We agree with Gourgoulianis et al2 that, besides smokers, other high-risk populations for COPD are ethnic minorities and people with occupational exposure.
In accord with other authors,3 4 we believe that limiting screening to high-risk groups will detect only a part of the population with airflow obstruction, while the clinical setting could provide a tremendous opportunity for a widespread program of early detection of airflow obstruction. However, even in this way, this pressing problem is only partially faced. The recently published guidelines on COPD (Global Initiative for Chronic Obstructive Lung Disease)5 underline that the presence of chronic cough and sputum production before airflow obstruction (stage 0) offers a unique opportunity to identify subjects at risk of COPD and to intervene before the disease has become a health problem. Because updated information on the prevalence of these indicators in the general population is scant and because in the last decades environmental, behavioral (particularly smoking habits), and socioeconomic conditions have changed fast throughout the world, ad hoc population-based studies are needed in the different countries. On the basis of this information, active interventions to prevent the disease in the future, such as effective smoking cessation and clean air programs, could be specifically addressed. In order to plan screening programs by mass spirometry, it is essential to know the true dimension of the bottom of the iceberg.
References
Institute of Tuberculosis and Lung Diseases Warsaw, Poland
Correspondence to: Jan Zeiliñski, MD, FCCP, Department of Respiratory Medicine, Institute of Tuberculosis and Lung Diseases, Plocka 26, 01–138 Warsaw, Poland; e-mail: j.zielinski{at}igichp.edu.pl
To the Editor:
We very much appreciate comments of Cerveri and colleagues related to our article on the early diagnosis of COPD.1 We agree that updated estimates of COPD prevalence would be very helpful in planning widespread programs of early diagnosis of the disease. Several such studies have been performed in recent years.2 3 4 They confirmed that COPD affects approximately 10% of adult population in developed countries. One may expect that only 20 to 30% of that population have received diagnoses and undergo regular treatment. Seventy percent remain unaware of the disease. This is an enormous number of people, probably beyond the scope of the best programs of early diagnosis.
Considering limited resources for a preventive medicine in many countries, such programs are obliged to adopt the strategy of an optimal cost-effectiveness ratio. We are fully aware that there are multiple risk factors for COPD. However, 90% of all cases of COPD are smoking related,5 and smokers should remain the main target of such programs.
Programs of early diagnosis of COPD may be classified into case-finding programs6 7 8 or population screening.1 In both programs, there is an agreement that the disease should be looked for in the high-risk subjects. Opinions diverge as the lower limit of age of screened subjects is concerned. It varies from 35 years7 to 45 years.6 We think that the age cutoff point is an economic issue; the higher the age of a person screened, the better the cost-effectiveness ratio.
The case-finding method seems to be very cost-effective. Necessary investments are limited to purchase of a simple spirometer and training of a person performing spirometric measurements. However, the quality of spirometric measurements is crucial for reliability of the program.9
Van Schayck et al7 calculated that a primary care physician may diagnose one case of COPD weekly in a case-finding program. Assuming that one physician takes care of 2,000 adult patients, there would be approximately 800 to 1,000 patients in one practice to be screened to find approximately 200 subjects likely to have COPD. It would take 8 to 10 years to make a diagnosis in all of them. The question remains how to persuade a busy family doctor to perform such an additional work for a very long period of time. A study of patients in a university ambulatory health-care system found underutilization of spirometry for patients with respiratory symptoms compatible with COPD.10 Only 42% of such patients underwent spirometry. In the National Health and Nutrition Examination Survey III study, > 80% of subjects with respiratory symptoms had visited a physician during the previous 12 months but did not undergo spirometry.2
High-risk population screening programs1 are targeting smokers who do not see their family physician for years. The costs of such programs are also low. In our program, spirometry combined with an antismoking advice cost $8 (US dollars) per person screened.
Early diagnosis seems to be an easier part of the programs aiming to reduce morbidity and mortality from COPD. Much more difficult is to make a smoker with early COPD to stop smoking. The current treatments are still unsatisfactory.11 More effective methods of helping smokers addicted to nicotine are urgently needed.
References
This article has been cited by other articles:
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  I. Cerveri, S. Accordini, A. Corsico, M.C. Zoia, L. Carrozzi, L. Cazzoletti, M. Beccaria, A. Marinoni, G. Viegi, and R. de Marco Chronic cough and phlegm in young adults Eur. Respir. J., September 1, 2003; 22(3): 413 - 417. [Abstract] [Full Text] [PDF]
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