GPs Have Difficulty Distinguishing Between Asthma and COPD

Jill Stein

September 17, 2009

September 17, 2009 (Vienna, Austria) — Significant efforts to help general practitioners (GPs) improve their ability to diagnose and manage asthma and chronic obstructive pulmonary disease (COPD) have apparently not yet paid off, a British team said here at the European Respiratory Society 19th Annual Congress.

"Despite both ownership of spirometers and financial inducements, many GP practices and GPs themselves are still neither able to perform and interpret spirometry competently nor distinguish asthma from COPD with confidence," Ian Jarrold, MSc, research manager at the British Lung Foundation (BLF) in London, said.

Mr. Jarrold presented the results of online questionnaires completed by 776 GPs. The questionnaire aimed to determine whether GPs had difficulty differentiating between asthma and COPD.

The study was prompted by a BLF survey last year, which found that 39% (255 of 654) COPD patients had been told that they had both asthma and COPD. This figure was worrisome, Mr. Jarrold noted, since it is significantly higher than the 15% rate of coexisting asthma and COPD that has been estimated by the National Health Service (NHS).

Results of the new survey showed that 32% of GPs did not know how many patients in their practice had both asthma and COPD. Of GPs who did know how many of their patients had both conditions, a dual diagnosis was made in 15% of patients. It's difficult to determine why there was a discrepancy with the earlier survey in the rates of coexisting asthma and COPD; however, it may be "simply due to the nature of the sample selection and size of the original survey," he said.

A total of 80% of GPs said that distinguishing asthma from COPD was "quite or very challenging."

The data also revealed that 88% of GPs rented or owned spirometers, but that 10% of GP practices did not have staff who were trained to conduct spirometry testing and 14% of GP practices lacked staff who were trained in interpreting spirometry test results.

Only 25% of GP respondents reported that they were trained to conduct spirometry testing themselves, and 26% maintained that their training did not adequately equip them to interpret the results.

Of 100 respiratory specialists who responded to the survey, 65 said that the differential diagnosis between asthma and COPD is very challenging.

In 2004, the NHS introduced a rewards and incentives program, called the Quality and Outcomes Framework (QOF), in which GPs could earn more money by practicing good quality care.

Although a major goal of the program was to improve the standard of care, the current analysis found that 19% of GPs thought that the introduction of the QOF system of remuneration had not changed the quality of diagnosis of COPD and 27% of GPs thought that the quality of care for COPD had not improved under the QOF system.

"With chest problems the number 1 reason for visits to GPs in the United Kingdom, it's surprising that more GPs are not properly trained to conduct and interpret spirometry," Mr. Jarrold said during an interview with Medscape Pulmonary Medicine. "Perhaps of even more concern is the high number of lung specialists who also find distinguishing between asthma and COPD challenging."

"I think the problem is that the diagnosis of asthma versus COPD requires more than spirometry. Spirometry is part of differentiating between asthma and COPD, but there's more to it than that," said Neil Barnes, MBBS, FRCP, professor of respiratory medicine at the London Chest Hospital in the United Kingdom. "And practitioners often don't do the things they need to do in order to distinguish between the 2 diseases," he added.

The problem is compounded by the fact that the 2 diseases often do coexist, Dr. Barnes pointed out.

"Primary-care doctors can definitely improve their ability to diagnose asthma and COPD," he added. "They make mistakes in both directions by incorrectly diagnosing COPD patients as having asthma and asthma patients as having COPD," he said.

"So, for example, they have patients whose major problem is COPD, and they misdiagnose them with asthma," he said. "And the danger there is that you overtreat them, particularly with oral steroids."

He added: "And then you have the opposite problem. You'll have a young person who maybe does spirometry that shows impairment and the patient gets falsely diagnosed as having COPD when, in fact, he has undertreated asthma. So in secondary care, we do spend a lot of time undiagnosing incorrect diagnoses."

Mr. Jarrold and Dr. Barnes have disclosed no relevant financial relationships.

European Respiratory Society (ERS) 19th Annual Congress: Abstract 4561. Presented September 16, 2009.

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