Study finds COPD is over-diagnosed among uninsured patients

(Press-News.org) ATS 2013, PHILADELPHIA ─More than 40 percent of patients being treated for COPD at a federally funded clinic did not have the disease, researchers found after evaluating the patients with spirometry, the diagnostic "gold standard" for chronic obstructive pulmonary disease.

"While there have been many studies of the under-diagnosis of COPD, there has not been a U.S.-based study that has quantified the problem of over-diagnosis," said Christian Ghattas, MD., MSc, a second-year medical resident at Saint Elizabeth Health Center in Youngstown, Ohio, who will present the research at ATS 2013. "And yet, the cost of treating someone for COPD is high."

A survey published in 2003 in Respiratory Medicine found the average cost of treating a patient with COPD in the United States was $4,119 per year.

Dr. Ghattas and Magdi H. Awad, Pharm.D, assistant professor of pharmacy at Northeast Ohio Medical University conducted their descriptive, retrospective study at Axess Pointe, a federally qualified health center in Akron, Ohio. FQHCs receive federal grants to support care for communities that have large numbers of uninsured and Medicaid patients.

Between February 2011 to June 2012, researchers evaluated 80 patients had been given either a diagnosis of COPD or had been prescribed an anticholinergic inhaler, a therapy used to treat COPD symptoms, usually by a primary health care providers. Among those who received the diagnosis were three patients under the age of 35 and five patients who had never smoked—members of demographic groups unlikely to have COPD. Despite the Global Obstructive Lung Disease (GOLD) recommendation that no COPD diagnosis be made without spirometry, only 17.5 percent of patients had been given the test.

As part of this study, all 80 patients underwent spirometry performed by trained professionals following American Thoracic Society recommendations. Results showed that 42.5 percent of patients had no obstruction at all, so by definition, did not have COPD. Another 23 percent had reversible obstruction, more characteristic of asthma than COPD. Only 35 percent of the patients had non-reversible obstruction, a defining characteristic of COPD.

Dr. Ghattas said he and his colleagues undertook the study because he had known patients with a COPD diagnosis who came to his clinic and were seen in the emergency department clutching their inhalers, but never seeming to get better.

"We were shocked at the percentage," Dr. Ghattas said, adding that the true rate of misdiagnosis was probably closer to half. Although they did not evaluate the 23 percent with reversible obstruction further, the investigators felt certain that many of those patients were misdiagnosed with COPD.

"This study confirms that symptoms alone are insufficient to make a COPD diagnosis," said Dr. Awad.. "Shortness of breath, cough, and sputum production can indicate other respiratory problems like allergies—or they may be symptoms of a heart problems or of simply being overweight"

The average age of a study participant was 53 years, with a 38-year-smoking-pack history. Most of the participants were female (60 percent), Caucasian (88.8 percent) and uninsured (71.3 percent).

Both Drs. Ghattas and Awad believe that studies like theirs should be conducted in other settings with different patient populations.

"Although the number of patients in our study was small, I believe this study is representative of an uninsured and underserved patient population," Dr. Ghattas said, "However, the findings might be different among patients who are insured. They might be higher or lower—we simply don't know."

Such studies, the investigators agree, are likely to pay for themselves by reducing unnecessary medical expenses. Presented with the results of this study, the Axess Pointe Board of Directors, decided to offer spirometry to uninsured patients on a sliding scale, with most patients paying just $5 for the test.

When it comes to properly diagnosing COPD, the benefits to patients' physical and mental health may be even greater than the savings to the healthcare system, the researchers believe.

"It is obviously detrimental to be on medications that won't work for you," said Dr. Ghattas. "You won't feel better—and that by itself can take a psychological toll— and you may experience side effects that can compromise other aspects of your health."

### * Please note that numbers in this release may differ slightly from those in the abstract. Many of these investigations are ongoing; the release represents the most up-to-date data available at press time.

Abstract 40323 Misdiagnosis And Mistreatment Of Chronic Obstructive Pulmonary Disease In An Underserved Patient Population
Type: Scientific Abstract
Category: 09.07 - COPD: General (CP)
Authors: C. Ghattas1, A. Dai2, M.H. Awad2; 1Saint Elizabeth Health Center - Youngstown, OH/US, 2Northeast Ohio Medical University College of Pharmacy - Rootstown, OH/US

Abstract Body INTRODUCTION Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the U.S. with an estimated worldwide prevalence of 10% in people over the age of 40. The annual financial implications of this disease in the U.S. has been estimated at $4119 (USD) per patient, producing a non-medical care costs of $1527 (USD). Risk factors for COPD include advanced age and socioeconomic status, which may create a reluctance to diagnose and treat patients, given prognosis. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) emphasized the importance of spirometry in confirming diagnosis. Spirometry has the distinct advantage of being a reproducible measurement of lung function and is superior to peak expiratory flow because of greater reliability and specificity. While cross-national studies have documented the rates of COPD misdiagnosis among patients in primary care settings, U.S. studies have been scarce. Studies investigating this disease in uninsured patients are lacking. OBJECTIVE The purpose of this study is to identify patients who are misdiagnosed and/or mistreated for COPD in a federally qualified health center. METHODS A descriptive, retrospective cohort study was conducted from February 2011 through June 2012. Spirometry was performed by trained personnel following the American Thoracic Society recommendations, using the SpiroCard PC Spirometer program® (Cardiac Science Burdick, Waukesha, Wisconsin). Patients were referred for spirometry to confirm previous COPD diagnosis or for uncontrolled COPD symptoms. Airway obstruction was defined as FEV1/FVC less than 0.7. Reversibility was defined as a post bronchodilator increase in FEV1 greater than 200 mL and greater than 12 percent. RESULTS A total of 80 patients treated for a previous diagnosis of COPD (n = 72) or have been on anticholinergic inhalers (n = 8) with no COPD diagnosis were evaluated. Average age was 52.9 years; 71% were uninsured. Three patients were previously diagnosed with COPD under the age of 35; 5 have never used tobacco products (Table.1). Spirometry results for these patients were inconsistent with COPD. Only 17.5 percent (14/80) of patients reported previous spirometry. Spirometry revealed that 42.5% had no obstruction, 22.5% had reversible obstruction, and 35% had a non-reversible obstruction. CONCLUSION Symptoms and smoking history are insufficient to accurately diagnose COPD. Prevalence of COPD misdiagnosis in uninsured patient populations might be higher than previously reported in other settings. Confirming previous COPD diagnosis with spirometry is essential to avoid unnecessary and potentially harmful side effects of medication. Additionally, spirometry can provide cost avoidance. END