Undiagnosed and 'overdiagnosed' COPD using postbronchodilator spirometry in primary healthcare settings: a systematic review and meta-analysis

Abstract

Background: Despite chronic obstructive pulmonary disease (COPD) being a major global cause of mortality and hospitalisation, it is often undiagnosed or inaccurately diagnosed in clinical settings.

Objective: To systematically synthesise all peer-reviewed papers from primary healthcare settings that have reported data on: (1) undiagnosed COPD, that is, patients with respiratory symptoms and postbronchodilator airflow obstruction consistent with COPD, without a formal clinician's diagnosis of COPD either documented in health records or reported by patients and (2) 'overdiagnosed COPD', that is, clinician's diagnosis without postbronchodilator airflow obstruction.

Methods: Studies investigating these diagnostic metrics in patients from primary healthcare clinics (according to predefined inclusion/exclusion criteria) were sourced from Medline and Embase and assessed for bias (Johanna Briggs Institute tools for prevalence studies and case series). Meta-analyses of studies of adequate sample size used random effect modelling stratified by risk factor categories.

Results: Of 26 eligible articles, 21 cross-sectional studies investigated 3959 cases of spirometry-defined COPD (with or without symptoms), and 5 peer-reviewed COPD case series investigated 7381 patients. The prevalence of spirometry-confirmed COPD without a diagnosis documented in their health records was 14%-26% in studies of symptomatic smokers (N=3). 1 in 4 patients taking inhaled therapies (25% (95% CI 22% to 28%), N=2) and 1 in 6 smokers irrespective of symptoms (16% (95% CI 14% to 18%), N=6) fulfilled diagnostic spirometry criteria but did not report receiving a COPD-related diagnosis. In an adequately powered series of COPD cases documented in primary healthcare records (N=4), only between 50% and 75% of subjects had any airflow obstruction on postbronchodilator spirometry performed by study researchers, therefore, COPD was clinically 'overdiagnosed' in 25%-50% of subjects.

Discussion: Although data were heterogeneous and of modest quality, undiagnosed COPD was common in primary healthcare, especially for symptomatic smokers and patients treated with inhaled therapies. In contrast, frequent COPD 'overdiagnosis' may represent treatment of asthma/reversible component or another medical diagnosis.

Prospero registration number: CRD42022295832.

Keywords: COPD epidemiology; Clinical epidemiology.

Figure 1

PRISMA flow diagram. BD, bronchodilator; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Diseases; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Undiagnosed patients with postbronchodilator airflow obstruction in the total population studied (ES) relating to cross-sectional prevalence studies of sufficient sample size, grouped by risk categories. A pooled estimate was only reported in the main text if the degree of heterogeneity (I²) was <75% or if the 95% CIs of all studies within a risk category clearly overlapped. Undiagnosed clinical COPD could be confirmed in the subgroups of symptomatic persons (ie, smokers with symptoms or with symptoms/risk factors) and registries, and these patients did not have a diagnosis of COPD listed in their primary healthcare record. The abbreviation of ‘N’ refers to the total number of participants in the study. COPD, chronic obstructive pulmonary disease.