Determinants of underdiagnosis of COPD in national

journal.publications.chestnet.org971DeterminantsofUnderdiagnosisofCOPDinNationalandInternationalSurveysBerndLamprecht,MD;JoanB.Soriano,MD,FCCP;MichaelStudnicka,MD,FCCP;BernhardKaiser,MSc;LowieE.Vanfleteren,MD,PhD;LouisaGnatiuc,MSc;PeterBurney,MD;MarcMiravitlles,MD;FranciscoGarcía-Rio,MD;KavehAkbari,MD;JulioAncochea,MD;AnaM.Menezes,MD;RogelioPerez-Padilla,MD;MariaMontesdeOca,MD;CarlosA.Torres-Duque,MD;AndresCaballero,MD;MauricioGonzález-García,MD;andSoniaBuist,MD;fortheBOLDCollaborativeResearchGroup,theEPI-SCANTeam,thePLATINOTeam,andthePREPOCOLStudyGroupBACKGROUND:COPDrankswithinthetopthreecausesofmortalityintheglobalburdenofdisease,yetitremainslargelyunderdiagnosed.WeassessedtheunderdiagnosisofCOPDanditsdeterminantsinnationalandinternationalsurveysofgeneralpopulations.METHODS:Weanalyzedrepresentativesamplesofadultsaged40yearsrandomlyselectedfromwell-definedadministrativeareasworldwide(44sitesfrom27countries).Postbroncho-dilatorFEV1/FVC,lowerlimitofnormal(LLN)wasusedtodefinechronicairflowlimitationconsistentwithCOPD.UndiagnosedCOPDwasconsideredwhenparticipantshadpostbron-chodilatorFEV1/FVC,LLNbutwerenotgivenadiagnosisofCOPD.RESULTS:Among30,874participantswithameanageof56years,55.8%werewomen,and22.9%werecurrentsmokers.Populationprevalenceof(spirometricallydefined)COPDrangedfrom3.6%inBarranquilla,Colombia,to19.0%inCapeTown,SouthAfrica.Only26.4%reportedapreviouslungfunctiontest,andonly5.0%reportedapreviousdiagnosisofCOPD,whereas9.7%hadapostbronchodilatorFEV1/FVC,LLN.Overall,81.4%of(spirometricallydefined)COPDcaseswereundiagnosed,withthehighestrateinIle-Ife,Nigeria(98.3%)andthelowestrateinLexington,Kentucky(50.0%).Inmultivariateanalysis,agreaterprobabilityofunderdiagnosisofCOPDwasassociatedwithmalesex,youngerage,neverandcurrentsmoking,lowereducation,nopreviousspirometry,andlesssevereairflowlimitation.CONCLUSIONS:EvenwithsubstantialheterogeneityinCOPDprevalence,COPDunderdiag-nosisisuniversallyhigh.BecauseeffectivemanagementstrategiesareavailableforCOPD,spi-rometrycanhelpinthediagnosisofCOPDatastagewhentreatmentwillleadtobetteroutcomesandimprovedqualityoflife.CHEST2015;148(4):971-985[OriginalResearchCOPD]ManuscriptreceivedOctober12,2014;revisionacceptedApril1,2015;originallypublishedOnlineFirstMay7,2015.ABBREVIATIONS:ATS5AmericanThoracicSociety;BOLD5BurdenofObstructiveLungDisease;EPI-SCAN5EpidemiologicStudyofCOPDinSpain;LLN5lowerlimitofnormal;PLATINO5TheLatinAmericanProjectfortheInvestigationofObstructiveLungDisease;PREPOCOL5PrevalenceStudyofCOPDinColombiaAFFILIATIONS:FromtheDepartmentofPulmonaryMedicine(DrLamprecht),KeplerUniversityHospital,Linz,Austria;FacultyofMedi-cine(DrLamprechtandMrKaiser),Johannes-Kepler-University,Linz,Austria;InstitutodeInvestigación(DrSoriano),HospitalUniversitariodelaPrincesa(IISP),UniversidadAutónomadeMadrid,CatédraUAM-Linde,Madrid,Spain;DepartmentofPulmonaryMedicine(DrStudnicka),ParacelsusMedicalUniversity,Salzburg,Austria;Depart-mentofRespiratoryMedicine(DrVanfleteren),MaastrichtUniversityMedicalCentre,Maastricht,TheNetherlands;ProgramDevelopmentCentre(DrVanfleteren),CIRO1,CentreofExpertiseforChronicOrganFailure,Horn,TheNetherlands;RespiratoryEpidemiologyandPublicHealth(MsGnatiucandDrBurney),ImperialCollege,London,England;ServiciodeNeumología(DrMiravitlles),HospitalUniversitariValld’Hebron,CiberdeEnfermedadesRespiratorias(CIBERES),Barcelona,Spain;ServiciodeNeumología(DrGarcía-Rio),HospitalUniversitarioLaPaz,IdiPAZ,Madrid,Spain;DepartmentofRadiology(DrAkbari),GeneralHospitalLinz(AkhLinz),Linz,Austria;ServiciodeNeumología(DrAncochea),HospitalLaPrincesa,UniversidadAutónomadeMadrid,Madrid,Spain;ProgramadePós-GraduacãoemEpidemiologia(DrMenezes),UniversidadeFederaldePelotas,Pelotas,Brazil;InstituteofRespiratoryDiseases(DrPerez-Padilla),InstitutoNacionaldeEnfermedadesRespiratorias,MexicoCity,Mexico;ServiciodeNeumonología(DrMontesdeOca),HospitalUniversitariodeCaracas,FacultaddeMedicina,UniversidadCentraldeVenezuela,Caracas,Venezuela;DepartamentodeInvestigación(DrsTorres-DuqueandGonzález-García),FundaciónDownloadedFrom:[148#4CHESTOCTOBER2015]Surveyshaveidentifiedimportantdifferencesinthedistributionoftheprevalence,underdiagnosis,andoverdiagnosisofCOPD.1,2Giventheremarkablevaria-tioninthedistributionofCOPD,furtherinvestigationonthecausesofthisheterogeneitymightbehelpfulforamorereasonabledistributionofhealth-careresources.3Inaddition,determinationofsourcesofheterogeneityinCOPDprevalenceandunderdiagnosiscanbebenefi-cialforthesetupofeducationalandpreventioninitia-tivesregardingsmokingandotherriskfactors.4COPDisamajorcauseofmortalityandmorbidityworldwide,withanestimated328,615,000people(168millionmenand160millionwomen)withthiscondition.5-7IntheUnitedStatesalone,6.5%ofadults(approximately13.7million)reportedhavingreceivedadiagnosisofCOPDin2011,andtherewere133,575deaths(63.1per100,000)fromCOPDin2010.8AccuratediagnosisofCOPDisimportanttoinitiatetimelyriskfactormodifi-cationandtherapyamongthosewiththediseasea