Undiagnosed COPD, asthma linked to worse quality of life, more health care use
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Key takeaways:
- In a cohort of individuals with respiratory symptoms, 21% had undiagnosed COPD or asthma.
- Researchers found poorer outcomes in the undiagnosed cohorts vs. healthy controls.
Compared with healthy individuals, having undiagnosed COPD or asthma negatively impacted quality of life and led to higher health care usage, according to results published in American Journal of Respiratory and Critical Care Medicine.
“The detection of undiagnosed COPD or asthma at an earlier stage of disease may enable early interventions to manage disease progression and improve patient outcomes,” Emily Gerstein, research student at the Ottawa Hospital Research Institute, and colleagues wrote.
In a multicenter population-based case-finding study in Canada, Gerstein and colleagues assessed adults with undiagnosed COPD/asthma to compare symptoms, quality of life, health care use and work productivity with that of patients with diagnosed COPD/asthma and healthy individuals (controls).
Researchers identified those with undiagnosed COPD/asthma in a cohort of 2,857 individuals with respiratory symptoms using pre- and post-bronchodilator spirometry. From this population, 330 individuals (11.5%) met diagnostic criteria for COPD and 265 (9.3%) met the criteria for asthma.
The COPD-focused analysis included the previously identified 330 individuals with undiagnosed COPD (mean age, 66.1 years; 63% men; mean BMI, 28.6 kg/m2), 231 healthy individuals (mean age, 61.5 years; 58% men; mean BMI, 28.4 kg/m2) and 101 patients with diagnosed COPD (mean age, 67.3 years; 66% men; mean BMI, 29.9 kg/m2).
The asthma focused analysis included the 265 individuals with undiagnosed asthma (mean age, 58.7 years; 56% men; mean BMI, 30.7 kg/m2) identified above, the same 231 healthy individuals and 97 patients with diagnosed asthma (mean age, 60.9 years; 44% men; mean BMI, 31.9 kg/m2).
Undiagnosed vs. healthy controls
Between those with undiagnosed COPD/asthma and healthy individuals, researchers found worse outcomes in the undiagnosed cohorts.
COPD Assessment Test (CAT) total scores showed that respiratory symptom burden had a greater negative impact on health status and daily activities of those with undiagnosed asthma vs. healthy individuals (adjusted mean difference, 11.8; 95% CI, 10.6-13), as well as those with undiagnosed COPD (adjusted mean difference, 13.1; 95% CI, 11.7-14.4).
Health-related quality of life, assessed using the St. George’s Respiratory Questionnaire (SGRQ) total score, was also worse among individuals with undiagnosed asthma (adjusted mean difference, 31; 95% CI, 28.3-33.8) and individuals with undiagnosed COPD (adjusted mean difference, 32.6; 95% CI, 29.4-35.9) vs. healthy individuals.
Further, both sets of undiagnosed individuals had poorer global health status than healthy individuals when evaluated via the 36-item Short Form Health Survey (SF-36) total score (adjusted mean difference: asthma, –15.9; 95% CI, –18.8 to –13.1; COPD, –20; 95% CI, –23.3 to –16.7), according to researchers.
In the past 12 months, only 9% of healthy individuals had a physician visit for breathing difficulties, whereas 33% of individuals with undiagnosed asthma and 26% of those with undiagnosed COPD reported a visit.
Lastly, researchers observed poorer work productivity and an impaired ability to do regular daily activities among those with undiagnosed asthma/COPD vs. healthy individuals.
More individuals with undiagnosed COPD vs. healthy individuals missed work (14% vs. 2%; P = .002). The proportion of individuals who missed work was similar between the undiagnosed asthma group and the healthy control group.
Undiagnosed vs. diagnosed patients
According to researchers, symptoms (CAT scores), quality of life (SGRQ scores), global health status (SF-36 scores), health care use and work absenteeism did not significantly differ between the undiagnosed and diagnosed asthma cohorts.
In contrast, researchers observed several better outcomes in the undiagnosed COPD group vs. the diagnosed COPD group, as shown through:
- total CAT scores (adjusted mean difference, –1.7; 95% CI, –3.3 to –0.1);
- total SGRQ scores (adjusted mean difference, –5; 95% CI, –9.1 to –0.9);
- total SF-36 scores (adjusted mean difference, 4.1; 95% CI, 0.1-8);
- proportions of individuals who visited a physician (26% vs. 37%; P = .04);
- proportions of individuals hospitalized (1% vs. 10%; P < .001); and
- proportions of individuals with a respiratory illness-related ED visit (6% vs. 23%; P < .001).
In terms of future research, Gerstein and colleagues wrote that results from a trial including individuals with undiagnosed COPD/asthma assessing intensive early treatment with guideline-based treatment vs. standard care will be shared in 2024.
“This trial aims to determine if early intensive treatment for undiagnosed obstructive lung disease provides clinical benefit,” Gerstein and colleagues wrote.
Perspective
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Underdiagnosis of obstructive lung disease (OLD) remains a major impediment in identifying airway inflammation early and halting disease progression. In this study, Gerstein and colleagues randomly recruited 2,857 patients with symptoms consistent with OLD. After spirometry evaluation, 595 patients were diagnosed with COPD or asthma. It is unsurprising that compared to healthy controls, those with undiagnosed OLD had worse lung function, greater symptom burden, more health care utilization and greater loss of work productivity.
When comparing undiagnosed patients with those with an established diagnosis, we see some interesting divergences between the two diseases. Patients with undiagnosed asthma had somewhat lower lung function but had similar symptom burden and health care contact; additionally, they were less likely to be on appropriate medical management with an inhaled corticosteroid. In comparison, those with undiagnosed COPD, while less likely to be on long-acting bronchodilators, actually had better health-related quality of life and were less likely to seek physician consultation or emergency medical care compared with those with a previous diagnosis of COPD.
The U.S. Preventative Services Task Force (USPSTF) currently recommends against performing screening spirometry to diagnose COPD in asymptomatic individuals. However, this study suggests that milder symptoms may delay diagnosis and starting treatment. Effective screening increases our ability to intervene early in the disease course to preserve lung function, improve quality of life and reduce health care utilization.
This current study employed a random screening protocol to identify almost 600 individuals with undiagnosed OLD from a screening population of more than 38,000 individuals. While this method is not cost effective for wider practice, there are more efficient ways to screen in primary care settings, such as the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease & Exacerbation questionnaire along with peak expiratory flow. Together, these demonstrate excellent sensitivity for identifying symptomatic individuals who would benefit from therapy, especially those at high risk such as those with tobacco, occupational or biomass fuel exposures.
On the other hand, while many questionnaires exist for assessing asthma control, studies on screening specific populations at risk for asthma are lacking and assessments are triggered more by the onset of symptoms. Likewise, the USPSTF offers no guidance for asthma screening. A history of atopy, residency in areas of high air pollution and parental smoking are among the many risk factors that have been identified for the development of asthma.
The authors note that an extension of this current study will be address how disease modifying therapy will benefit these previously undiagnosed cases of OLD. Future research can also incorporate this early intervention approach with a screening protocol tailored for these higher risk populations.
References:
Global Initiative for Asthma. Global strategy for asthma management and prevention, 2023. www.ginasthma.org. Updated July 2023.
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD (2024 report). www.goldcopd.org.
Martinez FJ, et al. Am J Respir Crit Care Med. 2017;doi:10.1164/rccm.201603-0622OC.
USPSTF. Final recommendation summary: COPD: Screening. www.uspreventiveservicestaskforce.org. Updated May 2022.
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