Missed diagnosis and overtreatment of COPD among smoking primary care population in Central Greece: old problems persist

Figures & data

Figure 1 Flowchart of the study selection process.

Notes: *Exclusion criteria: no smoking history, a history of lower or upper respiratory infection or antibiotic treatment within the last month, an operative procedure or acute myocardial infarction within the last 3 months, or inability to perform spirometry. Excluded subjects: 17 nonsmokers, five subjects aged <40 years, 11 subjects with recent respiratory infection, two subjects with recent operative procedure, and eight subjects who did not cooperate with the spirometry procedure.
Abbreviation: PFT, pulmonary function test.

Table 1 Demographic and clinical characteristics of study participants (N=186)

Characteristics	Total (n=186)
Age (years)	62.3±12.6
Gender
Male	127 (68.3)
BMI (kg/m^2)	29.1±5.8
Occupational exposure
Yes	27 (14.5)
Area of residence
Urban	28 (15.1)
Suburban	59 (31.7)
Rural	99 (53.2)
Smoking status
Current smoker	121 (65.1)
Exsmoker	65 (34.9)
Start smoking age (years)	19.7±6.9
Quit smoking age (years)	53.6±13.3
Pack-years of smoking	50±37.8
Respiratory symptoms
Cough	92 (49.5)
Sputum	108 (58.1)
Wheezing	85 (45.7)
Dyspnea	105 (56.5)
mMRC ≥2	41 (22)
CAT ≥10	57 (30.6)
Comorbidities
Yes	153 (82.3)
Hypertension	83 (44.6)
Diabetes	40 (21.5)
Coronary heart disease	22 (11.8)
Hyperlipidemia	65 (34.9)
FeNO (ppb)	8±9.2
ProFEV1%	86±21.3
Inhaled medicationa
No medication	61 (32.8)
SAMA ± SABA	23 (12.3)
LAMA or LABA	20 (10.7)
LAMA/LABA	8 (4.3)
LABA/ICS	45 (24.2)
LAMA + LABA/ICS	19 (10.2)
Other medications	10 (5.5)

Notes: Data are expressed as mean ± standard deviation or as frequency (percentage).

a Previously received medication.

Abbreviations: BMI, body mass index; CAT, COPD assessment test; FeNO, fractional exhaled nitric oxide; FEV₁, forced expiratory volume in 1 second; ICS, inhaled corticosteroid; mMRC, modified Medical Research Council; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; SABA, short-acting β2-agonist; SAMA, short-acting muscarinic antagonist.

Table 2 Comparisons of COPD and non-COPD groups

Characteristics	Non-COPD group (n=153)	COPD group (n=33)	P-value
Age (years)	60.5±12.3	71±10.3	<0.001
Gender
Male	96 (62.7)	31 (93.9)	<0.001
Occupational exposure	25 (16.3)	2 (6.1)	0.128
Smoking status
Current smoker	107 (69.9)	14 (42.4)	0.003
Exsmoker	46 (30.1)	19 (57.6)	0.003
Start smoking age (years)	20.1±7.2	17.9±5.5	0.069a
Quit smoking age (years)	50.6±11.2	60.8±15.5	0.003
Pack-years of smoking	45±33	75±48	<0.001a
Respiratory symptoms
Cough	73 (47.7)	19 (57.6)	0.304
Sputum	82 (53.6)	26 (78.8)	0.008
Wheezing	69 (45.1)	16 (48.5)	0.723
Dyspnea	83 (54.2)	22 (66.7)	0.192
mMRC ≥2	27 (17.6)	14 (42.4)	0.002
CAT	6.7±6.9	10.5±7.6	0.003a
CAT ≥10	43 (28)	14 (42)	0.106
Total CCQ	0.91±0.98	1.68±1.16	<0.001a
Comorbidities
Yes	94 (61.4)	26 (81.3)	0.033
Hypertension	67 (43.8)	16 (48.5)	0.623
Diabetes	30 (19.6)	10 (30.3)	0.175
Coronary heart disease	17 (11.1)	5 (15.2)	0.514
Hyperlipidemia	58 (37.9)	7 (21.2)	0.068
FeNO (ppb)	7.25±7.82	11.68±13.76	0.019a
Pulmonary function test
ProFEV1%	76.5±16.6	65.2±22.5	<0.001
PostFEV1%	90±18.713	68.7±23.6	0.283
Reversibility (positive response)	(8.5)	0 (0)	0.083
Inhaled medicationb
Yes	94 (61.4)	31 (93.9)	0.001

Notes: Data are expressed as mean ± SD or as frequencies (percentages).

a Mann– Whitney U test.

b Previously received medication.

Abbreviations: CAT, COPD assessment test; CCQ, clinical COPD questionnaire; FeNO, fractional exhaled nitric oxide; FEV₁, forced expiratory volume in 1 second; mMRC, modified Medical Research Council; SD, standard deviation.

Table 3 Comparisons of newly diagnosed and known COPD patients

Characteristics	Newly diagnosed COPD group (n=14)	Known COPD group (n=19)	P-value
Age (years)	65.7±9.6	74.8±9.2	0.009
Gender
Male	12 (85.7)	19 (100)	0.089
Smoking status
Current smoker	9 (64.3)	5 (26.3)	0.029
Exsmoker	5 (35.7)	14 (73.7)	0.029
Quit smoking age (years)	50.5±13.2	65.2±14.7	0.049
Respiratory symptoms
Cough	8 (57.1)	11 (57.9)	0.966
Sputum production	9 (64.3)	17 (89.5)	0.080
Wheezing	7 (50.0)	9 (47.4)	0.881
Dyspnea	7 (50.0)	15 (78.9)	0.081
mMRC ≥2	3 (21.4)	11 (57.9)	0.036
CAT score	8±5.9	12.3±8.2	0.394
Total CCQ	1.2±0.8	2±1.3	0.033
Symptom CCQ	1.6±1	2.1±1.2	0.204
Mental CCQ	0.7±1	1.5±1.5	0.073a
Functional CCQ	1.0±0.8	2.2±1.7	0.013
Vaccination
Influenza	2 (14.3)	14 (73.7)	0.001
Streptococcus pneumoniae	3 (21.4)	8 (42.1)	0.213
FeNO (ppb)	7.8±7.7	13.5±16.4	0.646a
GOLD classification
Stage I	5 (35.7)	3 (15.8)	0.382
Stage II	7 (50)	9 (47.4)
Stage III	2 (14.3)	6 (31.5)
Stage IV	0	1 (5.3)
GOLD groups 2016
A	8 (57.1)	6 (31.6)	0.379
B	4 (28.6)	7 (36.8)
C	0	2 (10.5)
D	2 (14.3)	4 (21.1)
GOLD groups 2017
A	8 (57.1)	8 (42.1)	0.495
B	5 (35.7)	7 (36.8)
C	0	0
D	1 (7.1)	4 (21.1)
Inhaled medication
No medication	2 (14.3)b	0	0.083
Only bronchodilators	7 (50.0)b	6 (31.6)
Bronchodilators + ICS	5 (35.7)b	13 (68.4)

Notes: Data are expressed as mean ± SD or as frequencies (percentages).

a Mann– Whitney U test.

b Previously received medication.

Abbreviations: CAT, COPD assessment test; CCQ, clinical COPD questionnaire; FeNO, fractional exhaled nitric oxide; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; mMRC, modified Medical Research Council; SD, standard deviation.

Table 4 Demographics and clinical characteristics of all COPD patients according to different GOLD stages (I–IV) and different 2017 GOLD COPD groups (A–D)

Characteristics	GOLD stages			2017 GOLD groupsb
	Stage I (n=8)	Stage II (n=16)	Stage III/IVa (n=9)	Group A (n=16)	Group B (n=12)	Group D (n=5)
Age (years)	73.8±8.2	67.4±11.3	74.8±8.8	70.4±12.6	70.9±6.3	72.8±11.9
Gender
Male	7 (87.5)	15 (93.8)	9 (100)	16 (100)	11 (91.7)	4 (80)
Smoking status
Current smoker	5 (62.5)	6 (37.5)	3 (33.3)	7 (43.8)	5 (41.7)	2 (40)
Exsmoker	3 (37.5)	10 (62.5)	6 (66.6)	9 (56.2)	7 (58.3)	3 (60)
Quit smoking age (years)	64±9.2	56.5±18	67.2±11.7	57.4±13.6	62.4±16.2	65.5±21
Pack-years of smoking	80±42.4	62.3±42.9	92.2±58.1	79.4±48.2	75±53	59±36.5
Respiratory symptoms
Cough	6 (75)	8 (50)	5 (55.5)	9 (56.2)	8 (66.7)	2 (40)
Sputum production	6 (75)	12 (75)	8 (88.8)	12 (75)	10 (83.3)	4 (80)
Wheezing	2 (25)	9 (56.2)	5 (55.5)	7 (43.8)	6 (50)	3 (60)
Dyspnea	4 (50)	10 (62.5)	8 (88.8)	7 (43.8)	10 (83.3)*	5 (100)*
mMRC ≥2	4 (50)	5 (31.2)	5 (55.5)	0	9 (75)**	5 (100)**
CAT score	11.5±9.4	8.1±6.4	13.9±6.9	4.9±3.2	15.1±7.4**	17.2±5.1**
Total CCQ	1.6±1.5	1.2±0.8	2.5±1*	0.9±0.7	2.2±1.2**	2.8±0.8**
FeNO (ppb)	9.9±9	11.9±17.1	13±11.8	9.4±7.6	14.8±20.4	11.6±11.5
Newly diagnosed	5 (62.5)	7 (43.8)	2 (22.2)	8 (50)	5 (41.7)	1 (20)

Notes: Data are expressed as mean ± SD or as frequencies (percentages).

a Stage IV included only one patient.

b None of the subjects were allocated to GOLD 2017 group C and reported to be consistently the least prevalent group according to 2017 GOLD update.

* A statistically significant difference with a P-value of <0.05.

** A statistically significant difference with a P-value of <0.001.

Abbreviations: CAT, COPD assessment test; CCQ, clinical COPD questionnaire; FeNO, fractional exhaled nitric oxide; GOLD, Global Initiative for Chronic Obstructive Lung Disease; mMRC, modified Medical Research Council; SD, standard deviation.