Chest
Volume 147, Issue 2, February 2015, Pages 369-376
Journal home page for Chest

Original Research: COPD
Factors Predictive of Airflow Obstruction Among Veterans with Presumed Empirical Diagnosis and Treatment of COPD

https://doi.org/10.1378/chest.14-0672Get rights and content

BACKGROUND

Despite guideline recommendations, patients suspected of having COPD often are treated empirically instead of undergoing spirometry to confirm airflow obstruction (AFO). Accurate diagnosis and treatment are essential to provide high-quality, value-oriented care. We sought to identify predictors associated with AFO among patients with and treated for COPD prior to performance of confirmatory spirometry.

METHODS

We identified a cohort of veterans with spirometry performed at Pacific Northwest Department of Veterans Affairs medical centers between 2003 and 2007. We included only patients with empirically diagnosed COPD in the 2 years prior to spirometry who were also taking inhaled medication to treat COPD in the 1 year prior to spirometry. We used relative risk regression analysis to identify predictors of AFO.

RESULTS

Among patients empirically treated for COPD (N = 3, 209), 62% had AFO. Risk factors such as older age, prior smoking status, and underweight status were associated with AFO on spirometry. In contrast, comorbidities often associated with somatic symptoms were associated with absence of AFO and included congestive heart failure, depression, diabetes, obesity, and sleep apnea.

CONCLUSIONS

Comorbidities associated with somatic complaints of dyspnea were associated with a lower risk of having airflow limitations, suggesting that empirical diagnosis and treatment of COPD may lead to inappropriate treatment of individuals who do not have AFO.

Section snippets

Study Design, Setting, and Subjects

We used data collected from a cohort of US veterans receiving care at one of three Pacific Northwest Department of Veterans Affairs (VA) medical centers. We identified patients who had their first spirometry between January 2003 and December 2007. The index date was defined as the date of first spirometry. The Institutional Review Board of the VA Puget Sound Healthcare System approved this study (IRB project approval number 01386).

Description of the Cohort

There were 14, 541 veterans who had spirometry at one of three VA medical centers during the study period, 5, 148 (35.4%) of whom had a prior diagnosis of COPD. Among patients with a clinical diagnosis of COPD, approximately one-half (n = 2, 830 [55%]) had evidence of AFO on spirometry. Of patients with a clinical diagnosis of COPD, 3, 209 (62.3%) were also treated with inhaled medications (Fig 1). Table 1 shows the characteristics of patients treated for COPD with and without AFO by

Discussion

We found that a little over one-half of patients who receive a clinical diagnosis of and were treated for COPD have AFO on spirometry, raising the concern that patients are being inappropriately treated for a condition that they do not have. The current study is consistent with previous studies that suggested providers diagnose COPD and make treatment decisions based on history and clinical examination despite guideline recommendations to diagnose COPD with spirometry.5, 6 Among veterans being

Conclusions

Empirical diagnosis of COPD often is inaccurate, yet many patients who lack AFO are treated with inhaled medications. Patients with more comorbid illnesses are at greater risk for empirical diagnosis and treatment of COPD in the absence of AFO. Accurate diagnosis and treatment of COPD are important to improve quality of care, patient-centered outcomes, and resource utilization. Implementation of performance-based measures for COPD may improve the accuracy of diagnosis and treatment of patients

Acknowledgments

Author contributions: B. F. C. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. B. F. C. contributed to the study design, data analysis and interpretation, and preparation, review, and approval of the manuscript; L. C. F. and D. H. A. contributed to the design and conduct of the study, data collection, management, analysis, and interpretation, and preparation, review, and approval of the manuscript; and

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    FUNDING/SUPPORT: This study was funded by an American Lung Association Career Investigator Award [CI-51755N]. Drs Collins and Rinne are supported by National Institutes of Health (NIH) [Training Grant T32 HL007287]. Dr Feemster is funded by an NIH National Heart, Lung, and Blood Institute K23 Mentored Career Development Award [K23 HL111116] and by the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D). Dr Au is supported by the VA HSR&D.

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