Quantification of inaccurate diagnosis of COPD in primary care medicine: an analysis of the COACH clinical audit

Figures & data

Table 1 Characteristics of the 4,307 audited cases

Variables	Average	Inter-regional range	P-value^a
Male gender (n)	3,159 (73.3)	67.9–100	<0.001
Active smoker (n)	1,152 (26.7)	20.7–41.9	<0.001
Tobacco history (pack-years)	44.2 (48.6)	29.9–48.8	0.045
Comorbidities (Charlson)	2.2 (1.4)	1.9–2.4	<0.001
Comorbidities (COTE)	1.1 (1.8)	0.8–1.4	0.003
Comorbidities: sleep apnea (n)	201 (4.7)	0–7.8	<0.001
Comorbidities: eyedrops use (n)	54 (1.3)	0.9–2.8	0.018
Comorbidities: psychiatric drugs (n)	501 (11.6)	6.8–15.8	<0.001
Comorbidities: prostatic hyperplasia (n)	725 (16.8)	8.8–21.7	<0.001
Body mass index (kg/m^2)	29.2 (5.5)	28.4–30.9	0.004
Current FEV1 (mL)^b	1,690 (694)	1,640–1,794	0.744
Current FEV1 (%)^b	64.3 (22.8)	21.0–25.7	0.136

Notes: Data expressed as mean (SD) or absolute (relative) frequencies as needed. Charlson denotes the Charlson comorbidity index.¹⁶ COTE: COPD specific comorbidity test .¹⁷

^aCalculated by Chi–squared test or ANOVA to test for variability.

^bObtained from post-bronchodilator spirometry or pre-bronchodilator, if not available.

Table 2 Validation of the initial diagnostic criteria upon diagnosis

Variables	Average^b	Inter-regional range^c	P-value ^d
Previous exposures^a
Active smoking	2,279 (52.9)	29.4–71.7	<0.001
Passive smoking	95 (2.2)	0.6–5.4	<0.001
Occupational exposures	99 (2.3)	0–7.4	<0.001
Other toxics	26 (0.6)	0–2.3	<0.001
Any toxic exposure	2,327 (54.0)	29.5–72.1	<0.001
Spirometric availability
Only pre-bronchodilator	916 (21.3)	0.2–36.7	<0.001
Post- bronchodilator	589 (13.7)	5.0–23.7	<0.001
No spirometry available	2,426 (56.3)	39.9–69.1	<0.001
Spirometric obstruction
Spirometric obstruction in pre-bronchodilator	652 (15.1)	0.1–25.1	<0.001
Spirometric obstruction in post-bronchodilator	436 (10.1)	2.3–19.7	<0.001
Spirometric obstruction in post or pre-bronchodilator ^e	987 (22.9)	19.7–26.3	0.001
Bronchodilator test available for both FVC and FEV1	88 (2.1)	0–5.1	<0.001
Bronchodilator test positive for both FVC and FEV1	12 (0.3)	0–1.0	<0.001
Correct diagnosis
Exposure + any obstruction ^e	695 (16.1)	8.5–21.2	<0.001

Notes: ^aAs referred in current clinical visit.

^bData expressed as absolute (relative) frequencies.

^cInterregional range indicates the region with the lower and higher average value.

^dCalculated by Chi-square test.

^eSpirometric obstruction detected by post-bronchodilator spirometry and, if not available, by pre-bronchodilator spirometry.

Table 3 Validation of the diagnostic criteria in the audited visit

Variables	Average	Inter-regional range	P-value^a
Previous exposures^b
Active smoking	2279 (52.9)	29.4–71.7	<0.001
Passive smoking	95 (2.2)	0.6–5.4	<0.001
Occupational exposures	99 (2.3)	0–7.4	<0.001
Other toxics	26 (0.6)	0–2.3	<0.001
Any toxic exposure	2327 (54.0)	29.5–72.1	<0.001
Spirometry available in the previous year
Only pre-bronchodilator	264 (6.1)	0–12.7	<0.001
Post-bronchodilator	143 (3.3)	0.4–8.1	<0.001
No spirometry available	3787 (87.9)	76.3–95.3	<0.001
Spirometric obstruction
Spirometric obstruction in pre-bronchodilator	209 (4.9)	0–9.2	<0.0011
Spirometric obstruction in post-bronchodilator	102 (2.4)	0.2–6.6	<0.001
Spirometric obstruction in post or pre-bronchodilator^b	271 (6.3)	2.4–12.1	<0.001
Symptoms
Dyspnea evaluated	820 (19.0)	2.7–31.8	<0.001
Dyspnea present	702 (16.3)	2.5–27.0	<0.001
Cough and sputum recorded	1099 (25.5)	0.9–49.6	<0.001
Cough and sputum present	789 (18.3)	0.9–31.5	<0.001
Correct current diagnosis
Exposure + any obstruction^b	216 (5.0)	1.3–9.2	<0.001
Exposure + any obstruction^b + symptoms	153 (3.6)	0.1–7.4	<0.001

Notes: ^aCalculated by Chi-square test.

^bSpirometric obstruction detected by post-bronchodilator spirometry and, if not available, by pre-bronchodilator spirometry.

Table 4 Multivariable multilevel regression analysis showing factors associated with COPD inaccurate diagnosis

	Empty model	Model 1		Model 2
	OR (95%CI)	OR (95%CI)	P-value	OR (95%CI)	P-value
Constant	0.196 (0.179–0.215)	1.630		1.630
Current smokers		0.001 (0–0.007)	<0.001	0.001 (0.000–0.005)	0.001
Diagnosis of GOLD 1		0.002 (0.001–0.006)	<0.001	0.002 (0.001–0.005)	0.001
Chronic bronchitis evaluated		1.495 (1.047–2.135)	0.027		0.601
Exacerbations recorded		0.530 (0.355–0.793)	0.002		0.115
LAMA-LABA treatment		0.528 (0.305–0.914)	0.023	0.524 (0.271–1.017)	0.055
Long-term oxygen therapy		0.357 (0.165–0.772)	0.009	0.379 (0.161–0.892)	0.026
Adherence evaluation		1.482 (0.967–2.271)	0.071		0.214
Inhaler satisfaction evaluation		0.225 (0.114–0.445)	<0.001	0.257 (0.118–0.561)	0.001
CT scan available		0.382 (0.178–0.820)	0.014	0.313 (0.137–0.717)	0.006
Health status evaluation available		2.950 (1.152–7.553)	0.024		0.539
The center has specialty trainees				2.430 (1.549–3.814)	<0.001
Having a specific schedule for inhaler education				2.678 (1.633–4.392)	0.001
Sputum eosinophils technique available				4.212 (1.705–10.406)	0.002
Total IgE technique available				0.235 (0.131–0.424)	<0.001
6 min walking test available				3.650 (0.982–13.565)	0.053
Tobacco cessation unit available				0.387 (0.188–0.794)	0.010
Domiciliary nebulized therapy available				0.507 (0.328–0.783)	0.002

Note: Empty model: with no explanatory variables. Model 1 including only patient-level variables. Model 2 showing patient and primary care center level variables.

Abbreviations: LABA, long-term β₂ agonists; LAMA, long-term muscarinic antagonists.

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