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Correspondence |

Accuracy of COPD Diagnosis During an Admission: The European Perspective FREE TO VIEW

Jose L. Lopez-Campos, MD; Ady Castro-Acosta, MD; Francisco Pozo-Rodriguez, MD; Sylvia Hartl, MD; C. Michael Roberts, MD
Author and Funding Information

Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

FUNDING/SUPPORT: AUDIPOC study was supported by the Spanish Ministry of Health, Instituto de Salud Carlos III, FIS project numbers: PI07/90129, PI07/90309, PI 07/90486, PI07/90503, PI07/90516, PI07/90721, PI08/90129, PI08/90578, PI08/90251, PI08/90529, PI08/90129, PI07/90403, PI08/90447, PI08/90457, PI08/90486, and PI08/90550, the Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), and the Spanish Society of Respiratory and Thoracic Surgery (SEPAR). The European COPD Audit was supported by the European Respiratory Society.

aUnidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/ Universidad de Sevilla, Seville, Spain

bCIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Seville, Spain

cServicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain

dLudwig Boltzmann Institute of COPD and Respiratory Epidemiology, Department of Respiratory and Critical Care, Otto Wagner Hospital, Vienna, Austria

eBarts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, England

CORRESPONDENCE TO: Jose L. Lopez-Campos, MD, Hospital Universitario Virgen del Rocio, Avda. Manuel Siurot, s/n; 41013 Seville, Spain


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(6):1396-1397. doi:10.1016/j.chest.2017.01.044
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Published online

We read with interest the recent publication in CHEST (June 2017) by Wu et al analyzing the spirometric results from two large databases of patients admitted to the hospital with COPD exacerbation as the primary cause of admission. By matching two databases, admissions and spirometric results, the authors identify cases of COPD exacerbation based on International Classification of Diseases, Ninth Revision, Clinical Modification codes and are able to provide valuable information on the disagreement between clinical and spirometric diagnoses of COPD, finding a considerable number of misdiagnosed cases.

We write first to raise some concerns regarding the lack of detail in the methodology, specifically, the process for matching the two databases, the protocol for identifying readmissions, and the criteria and method used to assess the quality of spirometry in a database. Second, we raise concerns about the lack of recognition of the breadth of previous publications that have highlighted similar issues. The authors benchmark their results with previous studies, mainly in the United States, with the exception of one Spanish series.

Clinical audits are in this respect useful tools for identifying deficiencies in clinical practice, and there is now established European literature in the field of the clinical audit of COPD admissions. We wish to draw to the authors' attention this body of evidence by providing the results of the diagnostic accuracy of the clinical discharge diagnosis measured in the main clinical audits in Europe (Table 1), namely, the European COPD Audit (16,018 cases from 13 European countries), the Spanish AUDIPOC study (5,178 cases in Spain), and the British Audits 2003-2014 (> 31,000 cases combined)., The spirometric confirmation of COPD diagnosis in these studies ranged from 46% (2014 England and Wales audit) to 51% (European COPD Audit), with 12.9% of patients in the European audit with spirometric results having values not compatible with a diagnosis of COPD. These clinical audits differ methodologically from the work of Wu et al in that they do not rely on clinical coding; eligibility for inclusion is made by a senior clinical decision maker on admission and then confirmed clinically at discharge. Second, although in most clinical audits there is a follow-up period of up to 90 days, the recording of spirometry is confirmed by data either predating the admission or acquired during the admission. Third, these audits have for the most part required a record of postbronchodilator spirometry.

Table Graphic Jump Location
Table 1 Distribution of the Diagnosis of COPD
a Refers only to postbronchodilator spirometry.
b Defined as a complete reversibility between preadmission and during admission spirometric examination in available cases.
c Defined by Wu et al as FEV1/FVC, prebronchodilator < 0.7, no postbronchodilator measurements.

Results expressed as absolute frequencies (relative frequencies related to the whole cohort; relative frequencies related to those patients within the same group of spirometry availability). NA = not available.

We suggest that there are two key lessons underlined by the audit data. First, clinicians need to challenge a clinical diagnosis of COPD that is not evidenced by an obstructive pattern on spirometry. Second, we recommend that when such evidence is not available at admission, spirometry should be performed either at the point of discharge or as soon as possible afterward to confirm an accurate diagnosis.

References

Wu H. .Wise R.A. .Medinger A.E. . Do patients hospitalized with COPD have airflow obstruction? Chest. 2017;151:1263-1271 [PubMed]journal
 
Lopez-Campos J.L. .Hartl S. .Pozo-Rodriguez F. .Roberts C.M. . European CA team European COPD Audit: design, organisation of work and methodology. Eur Respir J. 2013;41:270-276 [PubMed]journal. [CrossRef] [PubMed]
 
Pozo-Rodriguez F. .Alvarez C.J. .Castro-Acosta A. .et al Clinical audit of patients admitted to hospital in Spain due to exacerbation of COPD (AUDIPOC study): method and organization. Arch Bronconeumol. 2010;46:349-357 [PubMed]journal. [PubMed]
 
Roberts C.M. .Stone R.A. .Buckingham R.J. .et al Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations. Thorax. 2011;66:43-48 [PubMed]journal. [CrossRef] [PubMed]
 
Price L.C. .Lowe D. .Hosker H.S. .et al UK National COPD Audit 2003: impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation. Thorax. 2006;61:837-842 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 Distribution of the Diagnosis of COPD
a Refers only to postbronchodilator spirometry.
b Defined as a complete reversibility between preadmission and during admission spirometric examination in available cases.
c Defined by Wu et al as FEV1/FVC, prebronchodilator < 0.7, no postbronchodilator measurements.

Results expressed as absolute frequencies (relative frequencies related to the whole cohort; relative frequencies related to those patients within the same group of spirometry availability). NA = not available.

References

Wu H. .Wise R.A. .Medinger A.E. . Do patients hospitalized with COPD have airflow obstruction? Chest. 2017;151:1263-1271 [PubMed]journal
 
Lopez-Campos J.L. .Hartl S. .Pozo-Rodriguez F. .Roberts C.M. . European CA team European COPD Audit: design, organisation of work and methodology. Eur Respir J. 2013;41:270-276 [PubMed]journal. [CrossRef] [PubMed]
 
Pozo-Rodriguez F. .Alvarez C.J. .Castro-Acosta A. .et al Clinical audit of patients admitted to hospital in Spain due to exacerbation of COPD (AUDIPOC study): method and organization. Arch Bronconeumol. 2010;46:349-357 [PubMed]journal. [PubMed]
 
Roberts C.M. .Stone R.A. .Buckingham R.J. .et al Acidosis, non-invasive ventilation and mortality in hospitalised COPD exacerbations. Thorax. 2011;66:43-48 [PubMed]journal. [CrossRef] [PubMed]
 
Price L.C. .Lowe D. .Hosker H.S. .et al UK National COPD Audit 2003: impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation. Thorax. 2006;61:837-842 [PubMed]journal. [CrossRef] [PubMed]
 
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