13 Feb COPD: Editorial Regarding Earlier Diagnosis by Primary Care
MedicalResearch.com: Interview with:
Professor Chris van Weel
Emeritus Professor of Family Medicine/General Practice
Radboud University Nijmegen, The Netherlands
Professor of Primary Health Care Research, Australian National University, Canberra
Background from Professor Chris van Weel
Thank you for the opportunity to respond to your questions. My paper was a commentary to the study of Jones and colleagues, Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort looking at the implications of the study findings.
MedicalResearch.com: What are the main findings of the study?
Answer: Jones and colleagues reported that in the UK, there are many missed opportunities to diagnose COPD. My comments are that this is not a unique UK problem, but a universal one: under-diagnosis or late diagnosis of COPD is a universal problem in most if not all countries in the world.
To understand it, it is important to analyse more in-depth the diagnostic challenge in primary care, for general practitioners(GP)/family physicians (FP). The paper of Jones highlights this diagnostic problem – symptoms of COPD are initially insidious and may fluctuate over time. And from my earlier research it is also clear that patients ‘adept’ their daily activities (less physical activities) and therefore may underplay or even become unaware of, their symptoms.
At the same time, this is a problem for the physician, when encountering these symptoms. As I highlighted in my commentary, GPs/FPs have to pay attention to other possible diseases that might cause these symptoms: pneumonia, heart failure, lung cancer. The ‘low key symptoms’ and the need of applying a broad diagnostic scope together cause what Jones and his colleagues called the ‘missed opportunities’ to diagnose COPD.
MedicalResearch.com: Were any of the findings unexpected?
Answer: The findings of Jones and colleagues are neither new nor unexpected. My commentary has focused on how health care should respond to these findings and here, I think it is time to reconsider our approach. The repeated findings of late diagnosis of COPD and missed opportunities to diagnose it more timely, have resulted in guidelines and recommendations to strengthen the knowledge from respiratory medicine, and make GPs/FPs more aware, more knowledgeable in this field.
My recommendation is to change this, and build the approach on an important finding of Jones et al, in that patients have been in contact with their GP/FP (for respiratory reasons and/or other reasons for encounter) before COPD was diagnosed (continuity of care’). In my commentary I recommend as a solution for a more timely diagnosis, better use of the continuity of care: the diagnostic opportunities did present themselves, and through a better follow-up the GP/FP could build a more detailed picture of the nature of respiratory symptoms, their severity and impact: by revisiting patients’ respiratory symptoms and daily functioning on the next occasion the patient visits the FP/practice – irrespective of what reason for visit the patient may have, therefore independent of the patient presenting again respiratory signs symptoms.
MedicalResearch.com: What should clinicians and patients take away from your report?
Answer: My view therefore, the ‘take-home’ message of the Jones research and my commentary is, that we need more/better primary care for timely diagnosis, and I see COPD here just as a case study: it is also true for other important (chronic) diseases, that all most of the time start with insidious, ‘vague’ signs and symptoms.
Primary health care, with strong well educated and equipped GP’s/FP’s and their teams in the community should be the leading structure of the health care system.
An additional point not to overlook is prevention. The study of Jones focused on diagnosing COPD and so was my commentary. But we should not forget that there are as many opportunities to prevent COPD and prevention may be a better option for people’s health than treatment. Again, primary care can promote disease prevention better than specialty oriented health care.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Answer: In the UK and the Netherlands, where patients are listed with a GP/FP and access all their health care through that GP/FP practice. This structures continuity of care and makes it possible to trace these ‘missed opportunities’ in the primary care patients’ records. Other countries do not (yet) have this structure. There is a urgent need of research in the development in many countries around the world – including the US – on the implementation in the structure of health care of more and better continuity, of more and better primary health care.
Comment by Professor Chris van Weel:
Published online February 13, 2014 http://dx.doi.org/10.1016/S2213-2600(14)70029-3 1
Towards earlier diagnosis of COPD
Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort
Rupert C M Jones MD,Prof David Price MD,Dermot Ryan MD,Erika J Sims PhD,Julie von Ziegenweidt,Laurence Mascarenhas MSc,Anne Burden MSc,David M G Halpin DPhil,Robert Winter MD,Prof Sue Hill PhD,Matt Kearney MRCGP,Kevin Holton,Anne Moger MSc,Daryl Freeman MRCGP,Alison Chisholm MSc,Prof Eric D Bateman PhD,on behalf of The Respiratory Effectiveness Group
The Lancet Respiratory Medicine – 13 February 2014