COPD Is More Than What the Surface Shows

COPD may be overdiagnosed without spirometry in the uninsured

(RxWiki News) An ongoing cough, lots of mucus, shortness of breath – these are all signs of chronic obstructive pulmonary disease (COPD). But to properly diagnose COPD, patients must take a specific breathing test. Without this test, patients could be misdiagnosed.

Spirometry is the standard tool used to diagnose COPD, or chronic obstructive pulmonary disease. It measures how much air patients can inhale and exhale and how fast they can exhale.

In a recent study, researchers set out to identify patients who were misdiagnosed or mistreated for COPD. They found that nearly half of the patients they studied, the majority of whom were uninsured, did not have COPD.

Most of these patients had never undergone spirometry before the study, which suggests that symptoms alone may not be enough to diagnose COPD.

"Ask your doctor about treatment options if you're having trouble breathing."

According to the study authors, led by Christian Ghattas, MD, MSc, a second-year medical resident at Saint Elizabeth Health Center in Youngstown, Ohio, past research has reported on rates of COPD misdiagnosis across multiple countries. However, there have been few studies on these rates among US populations. Furthermore, there is a lack of studies on this disease in uninsured patients, the authors wrote.

COPD is the third leading cause of death in the United States. A 2003 survey found that COPD costs an estimated $4,119 per patient per year and generates an estimated $1,527 in non-medical care costs per patient per year.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has highlighted the important role of spirometry in confirming diagnoses of COPD, the authors wrote.

For their retrospective cohort study, Dr. Ghattas and colleagues used spirometry to confirm diagnoses of COPD in a group of patients being treated at a federally funded clinic.

Of the 80 study participants, 72 had a previous diagnosis of COPD. The remaining eight participants had been on anticholinergic inhalers but had no COPD diagnosis. In other words, they had active COPD symptoms but had never been diagnosed with COPD by a healthcare professional.

Participants had an average age of 52.9 years. A total of 71 percent were uninsured.

Only 17.5 percent (14 patients) said they had previously received a spirometry test.

After conducting spirometry on all of the study participants, the researchers found that 42.5 percent had no airway obstruction. That is, they did not have COPD.

Spirometry also showed that 22.5 percent of the patients had airway obstruction that could be reversed and 35 percent had non-reversible obstruction.

"We were shocked at the percentage," said Dr. Ghattas. What's more, he and his colleagues believe that closer to half of these patients were misdiagnosed. However, they could not confirm this belief because they did not do further study on the patients with reversible obstruction.

"This study confirms that symptoms alone are insufficient to make a COPD diagnosis," said study co-author Magdi H. Awad, PharmD, assistant professor of pharmacy at Northeast Ohio Medical University. "Shortness of breath, cough, and sputum production can indicate other respiratory problems like allergies—or they may be symptoms of heart problems or of simply being overweight."

Drs. Ghatta and Awad recommend that researchers do more studies like theirs but in other settings on different patient groups.

"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."

According to the authors, more research on this topic could reduce the unnecessary medical costs of misdiagnosis and mistreatment.

"It's always a good thing to reduce healthcare spending on treatments that do not improve outcomes," said medical economist Adam C. Powell, PhD, president of Payer+Provider Syndicate.

"When patients are provided with the incorrect course of treatment, they may seek further assistance in managing their misdiagnosed condition. Properly diagnosing patients reduces wasteful spending on medications and wasteful provider visits intended to manage the misdiagnosed condition," said Dr. Powell, who was not involved in the study.

He continued, "This study examines a largely uninsured population, which may be one of the factors driving its findings. While providers typically bear the cost of unreimbursed (or under-reimbursed) testing, they typically do not bear the cost of the drugs that they prescribe. Thus, there may be incentives to under-test and over-prescribe. It remains to be seen whether similar patterns would hold in a more heavily insured environment."

With the results of this study, the Board of Directors of Axess Pointe, the federally funded clinic where the study took place, chose to offer spirometry to their uninsured patients on a sliding scale. Most of these patients will pay just $5 to take the test.

Reducing COPD misdiagnoses not only reduces costs but also stands to serve patients' physical and mental health.

"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."

This research was presented at the American Thoracic Society 2013 International Conference. The study has yet to be published in a peer-reviewed journal.

Review Date: 
May 20, 2013