NIHR DC Discover

NIHR Signal Questionnaires directed at smokers improve detection of chronic lung disease in general practice

Published on 5 October 2016

doi: 10.3310/signal-000311

Practices using questionnaires to identify individuals at risk of chronic obstructive pulmonary disease (COPD) increased the number of new cases found. In particular, posting questionnaires may be more effective than waiting for people to attend the GP surgery.

Many people with COPD may dismiss or ignore symptoms such as chronic cough. Taking a more proactive approach with smokers or ex-smokers and not just waiting until people present with symptoms may mean earlier diagnosis. This can lead to better patient outcomes and reduced healthcare costs.

This large NIHR trial of over 50 general practices found that those which contacted current or ex-smokers, over the age of 40, identified COPD in 4% of them over the course of one year. This compared with a 1% new diagnosis rate among practices following routine care. It was estimated that 21 people had to receive a questionnaire in order to find one new case of COPD.

There may still be scope to use the electronic record in cost effective ways to identify those at most risk.

Share your views on the research.

Why was this study needed?

As many as 900,000 people in the UK are living with COPD, and there are thought to be an additional two million undiagnosed cases. COPD includes the conditions emphysema and chronic bronchitis, which cause the airways to narrow, making it difficult to breathe. There is no cure for COPD, but a number of treatments are available to help manage symptoms.

COPD is estimated to cost the NHS over £800 million, which works out as £1.3 million per 100,000 people. It costs nearly ten times more to treat severe COPD than mild disease.

Prompt diagnosis is important in order to try and limit the damage to the lungs. It is clear though from the number of undiagnosed cases this does not always happen. This study examined two types of intervention that aim to proactively identify people with the condition (targeted case finding) to see which worked best.

What did this study do?

This cluster randomised controlled trial involved 54 general practices in the West Midlands. Eligible patients were current or former smokers who did not have a diagnosis of COPD and were aged 40-79.

Twenty-seven practices (42,029 patients) were randomly assigned to routine practice, and 27 (32,811 patients) to targeted case finding. The latter group was further divided, 15,393 to opportunistic case finding, and 15,394 to active case finding.

Opportunistic case finding meant that eligible patients were given a brief COPD screening questionnaire if they visited the GP surgery, in response to a prompt on their medical record. This short questionnaire was developed in a previous study, and some of the questions are said to have been validated. Active case finding additionally involved posting the questionnaire to patients’ homes with reminders sent at four and eight weeks. Responders reporting symptoms suggestive of COPD were invited to have lung function tests (spirometry).

Routine care adhered to UK guidance, which includes investigating for COPD in adults over 35 who present with symptoms such as a chronic cough or phlegm.

Main outcomes were the percentage of participants diagnosed with COPD within one year and the associated cost.

What did it find?

  • Both targeted case finding interventions were more likely to identify new COPD cases than routine care – 1,278 new cases (4%) compared to 337 new cases (1%). After adjusting for age, ethnicity, and practice level of deprivation, case finding significantly increased the number of new diagnoses (odds ratio 7.45, 95% confidence interval 4.80 to 11.55).
  • Screening questionnaires were completed by only 13% of the opportunistic case finding group, compared with a 38% completion rate in the active case finding group – most of whom had received their questionnaire by post rather than at the GP surgery.
  • Active case finding was the most effective intervention, finding more than twice the number of new cases than opportunistic case finding. Five percent of those allocated to active case finding (822) were diagnosed compared with 2% (370) in the opportunistic group.
  • Comparing both with routine care, active case finding was most cost effective at £333 per additional case identified; £376 for opportunistic case finding.
  • It is estimated that 21 people would need to be targeted with a questionnaire in order to identify one new case.

What does current guidance say on this issue?

NICE 2010 guidance on COPD (currently in the process of update), recommends the diagnosis is considered in people aged over 35 who have risk factors – primarily smoking – and who present with chronic cough, especially if coughing up sputum, wheezing or shortness of breath on exertion. Additional symptoms such as weight loss, ankle swelling or fatigue, should also be questioned. The diagnosis is confirmed by spirometry.

In England, there are several Quality Outcome Framework indicators for COPD, such as the percentage of patients with a Medical Research Council shortness of breath grade ≥3 (getting short of breath on walking or performing daily activities), and who needed their blood oxygen levels measured at any time within the preceding 12 months. The National COPD Audit Programme includes audits on hospital and rehabilitation services for people with COPD.

What are the implications?

Postal questionnaires are a relatively simple way to try and ensure people who may have COPD receive a diagnosis sooner rather than later. Reaching out to people who are at risk rather than waiting for them to come to GP practices appears to be the key. However, various issues remain to be explored. This includes patient acceptability of mailed questionnaires, and the long-term impact of screening and early identification on COPD prognosis and overall healthcare costs.

To increase the effectiveness of this intervention it may be worth considering a tighter target in terms of demographics and patient characteristics, as well as other ways of using the electronic record to target those at most risk.

Citation and Funding

Jordan RE, Adab P, Sitch A, et al. Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial. Lancet Respir Med. 2016. [Epub ahead of print].

This project was funded by the National Institute for Health Research Programme Grants for Applied Research project number RP-PG-0109-10061.

Bibliography

British Lung Foundation.What is COPD? London: British Lung Foundation; 2014.

Jordan RE, Adab P, Jowett S, et al. TargetCOPD: a pragmatic randomised controlled trial of targeted case finding for COPD versus routine practice in primary care: protocol. BMC pulmonary medicine. 2014 Oct 4;14(1):1.

NHS Choices.Chronic obstructive pulmonary disease. London: Department of Health; 2015.

NHS Choices.Spirometry. London: Department of Health; 2015.

NHS Medical Directorate. COPD commissioning toolkit. London: Department of Health; 2012.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

Why was this study needed?

As many as 900,000 people in the UK are living with COPD, and there are thought to be an additional two million undiagnosed cases. COPD includes the conditions emphysema and chronic bronchitis, which cause the airways to narrow, making it difficult to breathe. There is no cure for COPD, but a number of treatments are available to help manage symptoms.

COPD is estimated to cost the NHS over £800 million, which works out as £1.3 million per 100,000 people. It costs nearly ten times more to treat severe COPD than mild disease.

Prompt diagnosis is important in order to try and limit the damage to the lungs. It is clear though from the number of undiagnosed cases this does not always happen. This study examined two types of intervention that aim to proactively identify people with the condition (targeted case finding) to see which worked best.

What did this study do?

This cluster randomised controlled trial involved 54 general practices in the West Midlands. Eligible patients were current or former smokers who did not have a diagnosis of COPD and were aged 40-79.

Twenty-seven practices (42,029 patients) were randomly assigned to routine practice, and 27 (32,811 patients) to targeted case finding. The latter group was further divided, 15,393 to opportunistic case finding, and 15,394 to active case finding.

Opportunistic case finding meant that eligible patients were given a brief COPD screening questionnaire if they visited the GP surgery, in response to a prompt on their medical record. This short questionnaire was developed in a previous study, and some of the questions are said to have been validated. Active case finding additionally involved posting the questionnaire to patients’ homes with reminders sent at four and eight weeks. Responders reporting symptoms suggestive of COPD were invited to have lung function tests (spirometry).

Routine care adhered to UK guidance, which includes investigating for COPD in adults over 35 who present with symptoms such as a chronic cough or phlegm.

Main outcomes were the percentage of participants diagnosed with COPD within one year and the associated cost.

What did it find?

  • Both targeted case finding interventions were more likely to identify new COPD cases than routine care – 1,278 new cases (4%) compared to 337 new cases (1%). After adjusting for age, ethnicity, and practice level of deprivation, case finding significantly increased the number of new diagnoses (odds ratio 7.45, 95% confidence interval 4.80 to 11.55).
  • Screening questionnaires were completed by only 13% of the opportunistic case finding group, compared with a 38% completion rate in the active case finding group – most of whom had received their questionnaire by post rather than at the GP surgery.
  • Active case finding was the most effective intervention, finding more than twice the number of new cases than opportunistic case finding. Five percent of those allocated to active case finding (822) were diagnosed compared with 2% (370) in the opportunistic group.
  • Comparing both with routine care, active case finding was most cost effective at £333 per additional case identified; £376 for opportunistic case finding.
  • It is estimated that 21 people would need to be targeted with a questionnaire in order to identify one new case.

What does current guidance say on this issue?

NICE 2010 guidance on COPD (currently in the process of update), recommends the diagnosis is considered in people aged over 35 who have risk factors – primarily smoking – and who present with chronic cough, especially if coughing up sputum, wheezing or shortness of breath on exertion. Additional symptoms such as weight loss, ankle swelling or fatigue, should also be questioned. The diagnosis is confirmed by spirometry.

In England, there are several Quality Outcome Framework indicators for COPD, such as the percentage of patients with a Medical Research Council shortness of breath grade ≥3 (getting short of breath on walking or performing daily activities), and who needed their blood oxygen levels measured at any time within the preceding 12 months. The National COPD Audit Programme includes audits on hospital and rehabilitation services for people with COPD.

What are the implications?

Postal questionnaires are a relatively simple way to try and ensure people who may have COPD receive a diagnosis sooner rather than later. Reaching out to people who are at risk rather than waiting for them to come to GP practices appears to be the key. However, various issues remain to be explored. This includes patient acceptability of mailed questionnaires, and the long-term impact of screening and early identification on COPD prognosis and overall healthcare costs.

To increase the effectiveness of this intervention it may be worth considering a tighter target in terms of demographics and patient characteristics, as well as other ways of using the electronic record to target those at most risk.

Citation and Funding

Jordan RE, Adab P, Sitch A, et al. Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial. Lancet Respir Med. 2016. [Epub ahead of print].

This project was funded by the National Institute for Health Research Programme Grants for Applied Research project number RP-PG-0109-10061.

Bibliography

British Lung Foundation.What is COPD? London: British Lung Foundation; 2014.

Jordan RE, Adab P, Jowett S, et al. TargetCOPD: a pragmatic randomised controlled trial of targeted case finding for COPD versus routine practice in primary care: protocol. BMC pulmonary medicine. 2014 Oct 4;14(1):1.

NHS Choices.Chronic obstructive pulmonary disease. London: Department of Health; 2015.

NHS Choices.Spirometry. London: Department of Health; 2015.

NHS Medical Directorate. COPD commissioning toolkit. London: Department of Health; 2012.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial

Published on 18 July 2016

Jordan, R. E.,Adab, P.,Sitch, A.,Enocson, A.,Blissett, D.,Jowett, S.,Marsh, J.,Riley, R. D.,Miller, M. R.,Cooper, B. G.,Turner, A. M.,Jolly, K.,Ayres, J. G.,Haroon, S.,Stockley, R.,Greenfield, S.,Siebert, S.,Daley, A. J.,Cheng, K. K.,Fitzmaurice, D.

Lancet Respir Med , 2016

BACKGROUND: 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. METHODS: 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. FINDINGS: 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 ( pound333 vs pound376 per case detected, respectively). INTERPRETATION: 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. FUNDING: National Institute for Health Research.

Spirometry is a machine used to diagnose and monitor various lung conditions, including COPD and asthma. During the test people take a full in-breath and then breathe out completely down a tube as hard and fast as they can. The machine takes various measures, including how much air they can forcibly breathe out during the first second of exhalation (forced expiratory volume 1, FEV1), and how much air in total their lungs can hold (forced vital capacity, FVC).

Expert commentary

Finding the missing millions of people who are believed to be undiagnosed with COPD is crucial. Being able to deliver care and treatment as early as possible improves outcomes and in many cases prevents irreversible lung damage. Evidence to determine the most effective ways of identifying undiagnosed COPD, is a great step towards ensuring we identify COPD as early as possible to improve outcomes for patients.

Dr Penny Woods, Chief Executive, British Lung Foundation