Primary Prevention of Chronic Obstructive Pulmonary
Disease in Primary Care
Thys van der Molen1 and Siebrig Schokker1
1
Department of General Practice, University Medical Center Groningen, University of Groningen, The Netherlands
Chronic obstructive pulmonary disease (COPD) is a prevalent disease,
with cigarette smoking being the main risk factor. Prevention is crucial
in the fight against COPD. Whereas primary prevention is targeted on
whole populations, patient populations are the focus of primary care;
therefore, prevention in this setting is mainly aimed at preventing
further deterioration of the disease in patients who present with the
first signs of disease (secondary prevention). Prevention of COPD in
primary care requires detection of COPD at an early stage. An accurate
definition of COPD is crucial in this identification process. The benefits
of detecting new patients with COPD should be determined before
recommending screening and case-finding programs in primary care.
No evidence is available that screening by spirometry results in
significant health gains. Effective treatment options in patients with
mild disease are lacking. Smoking cessation is the cornerstone of
COPD prevention. Because cigarette smoking is not only a major cause
of COPD but is also a major cause of many other diseases, a decline in
tobacco smoking would result in substantial health benefits.
Keywords: COPD; prevention; diagnosis; primary care
The prevalence and burden of chronic obstructive pulmonary
disease (COPD) are recognized to be high, but accurate data
on prevalence are lacking, and varying prevalence rates have
been reported. This might be due to different interpretations of
the definition of COPD. In the consensus report of the Global
Initiative for Chronic Obstructive Lung Disease (GOLD),
COPD is defined as a preventable and treatable disease with
some significant extrapulmonary effects that may contribute to
the severity of symptoms in individual patients. Its pulmonary
component is characterized by airflow limitation that is not fully
reversible. The airflow limitation is usually progressive and
associated with an abnormal inflammatory response of the lung
to noxious particles and gases (1). In a population-based study
in which COPD was diagnosed based on the assessment of lung
function by means of spirometry (GOLD stage II and higher),
prevalences between 8.2 and 19.1% in adults 40 years of age or
older have been found (2). In primary care, much lower
estimates of the prevalence of physician-diagnosed COPD have
been reported (between 1.5 and 3%) (35). A tip-of-the-iceberg
phenomenon with many undetected patientspossibly in need
for treatmentin primary care has been suggested to be
responsible for this difference between estimates. Regarding
this potential underdiagnosis and undertreatment, some impor-
tant issues have to be emphasized.
DEFINING COPD
The definition of COPD is crucial (Figure 1). Although in the
GOLD guidelines a broad definition of COPD is emphasized,
(Received in original form July 11, 2009; accepted in final form August 20, 2009)
Correspondence and requests should be addressed to T. van der Molen, M.D.,
Ph.D., Department of General Practice, University Medical Center Groningen,
A. Deusinglaan 1, 9713 AV Groningen, The Netherlands. E-mail: t.van.der.molen@
med.umcg.nl
Proc Am Thorac Soc Vol 6. pp 704706, 2009
DOI: 10.1513/pats.200907-062DP
Internet address: www.atsjournals.org
many investigators focus only on the lung function component.
In epidemiological research, a postbronchodilator FEV1/FVC
ratio less than 0.70 is often considered as evidence of COPD.
However, defining airway obstruction by the fixed 0.70 cut-off
might result in misclassification. To reduce overdiagnosis in
elderly patients and underdiagnosis in younger adult patients,
the use of the lower limit of normal for FEV1/FVC has been
recommended to define airway obstruction (6, 7). A clinical
diagnosis based on symptoms, age, history of smoking, or contact
with other pollutants is also emphasized in all guidelines. Because
comorbidities are common, comorbidity should also be taken
into account. The GOLD guidelines state that when asthma and
COPD coexist, the asthma component prevails and should be
treated. As a result of this definition of COPD, the population of
interest (age . 45 years, airway obstruction, history of smoking,
and no history of asthma) might be much smaller than estimated
in many studies. In primary care, in The Netherlands and in most
countries in Europe as well as in Canada and Australia, the
majority of patients are individually known by their primary care
provider (PCP). Because most patients stay enlisted to the same
practice for a long time, the PCP is informed about all kinds of
symptoms and diseases in the patient and his or her family. PCPs
are therefore most likely to be aware of the presence of any kind
of obstructive lung disease in individual patients. Due to trends in
international consensus with regard to the diagnosis of these
patients and the lack of recent spirometry data, a number of
patients might be misclassified.
DETECTING PATIENTS WITH COPD
Using the narrow definition of COPD and excluding patients
who already receive treatment, there still may be a considerable
number of patients with undiagnosed COPD. Screening by
means of spirometry might improve the detection of COPD in
primary care. The potential benefits of screening have to be
weighed against potential harms. Moreover, detecting a disease
in an early stage does not automatically improve health out-
comes. Screening is not worthwhile if no adequate treatments are
available. This is crucial because the majority of effectiveness
studies have not included patients with mild to moderate COPD.
Indeed, there is evidence that therapy with bronchodilatorsin
particular with long-acting bronchodilatorsimproves quality of
life in patients with mild to moderate COPD. Trials evaluating
therapies in patients with airflow limitation who do not recognize
or report symptoms have not been performed (8). Consequently,
evidence that early detection and subsequent treatment leads to
relevant health benefits in patients diagnosed with COPD is still
lacking (8, 9). Nevertheless, several attempts have been made to
detect patients using screening or case finding. Recently, Bednarek
and colleagues performed a case-finding study in primary care
using spirometry (10). A total of 1,960 patients over 40 years of
age from a single primary care practice were investigated by
means of a questionnaire, physical examination, and spirometry.
This study revealed underdiagnosis of COPD in a primary care
setting in Poland, where COPD was diagnosed in 183 patients
(9.3%), of whom only 34 patients had already been diagnosed
with COPD. Most patients identified with screening spirometry
van der Molen and Schokker: COPD Prevention in Primary Care
were diagnosed as having mild to moderate COPD. Neverthe-
less, the majority of these patients were symptomatic, suggest-
ing that these patients might benefit from treatment. The
effectiveness of treatment in patients who do not report
symptoms has not been proven.
In another study by Van Schayck and colleagues (11), the
effectiveness of case finding of patients at risk of developing
COPD in primary care was investigated. Patients between 35
and 70 years of age who visited their doctor were randomly
selected from two practices (approximately 10,400 patients were
enlisted). Lung function was assessed by spirometry in smokers
not using drugs for a pulmonary condition (n 5 201). This study
revealed airway obstruction (FEV1 , 80% of predicted) in 18%
of patients. When smokers were preselected based on respira-
tory symptoms, in particular chronic cough, the percentage of
patients with airway obstruction increased. Smokers with cough
who were older than 60 years of age had a 48% chance of
having airway obstruction. It is unknown how many of these
patients had COPD and whether these patients benefited from
the knowledge of their impaired pulmonary function. Our group
screened a large primary care population by sending out 33,673
letters to patients (4575 years of age) and inviting them to visit
the practice to undergo spyrometry. Patients were asked to
present themselves when they had smoked for more than 10 years.
In total, 3,016 smokers or ex-smokers responded, of whom 1,049
had never undergone spirometry and were not known by their
PCP to have a pulmonary disease. In 992 smokers or ex-smokers,
spirometry data were collected successfully. Few patients were
diagnosed as having moderate or severe COPD (Table 1),
demonstrating that screening is likely to identify a predomi-
nance of patients with mild to moderate airway obstruction,
bringing into question the benefits of such a procedure.
SMOKING CESSATION
Cigarette smoking is the most important risk factor for the
development and progression of COPD. Smoking cessation is
the single most effective intervention to reduce the risk of
705
Figure 1. Chronic obstructive pulmonary disease
(COPD) definition and detection. LLN 5 lower limit
of normal.
developing COPD and to stop its progression (1, 12, 13). If
smokers who are informed about their spirometry results would
be more motivated to quit smoking, screening or case finding by
means of spirometry would be worthwhile. The evidence of
spirometry as an independent motivational tool for smoking
cessation is inconclusive (8, 14). Although recent studies sug-
gest a positive influence of spirometry on smoking cessation
rates (15, 16), definitive conclusions on the beneficial effect of
spirometry cannot be drawn. Until more adequate studies
testing the hypothesis that spirometry is effective in improving
the success rate of smoking-cessation interventions are avail-
able, spirometry-based screening remains debatable.
Smoking harms nearly every organ in the body. Smoking,
therefore, causes many diseases and reduces the health of
smokers in general (17). The burden of smoking-attributable
mortality is high. It is estimated that smoking results in more
than 440,000 premature deaths each year in the United States.
During 2000 to 2004, the three leading specific causes of
smoking-attributable death were lung cancer (128,922 deaths),
ischemic heart disease (126,005 deaths), and COPD (92,915
deaths). Smoking cessation should be advocated in all smokers.
CONCLUSIONS
Despite an overwhelming amount of research, data on the
prevalence of COPD are incomplete and are based on different
TABLE 1. DIAGNOSIS OF CHRONIC OBSTRUCTIVE PULMONARY
DISEASE ACCORDING TO GOLD STAGES (n 5 992)
Diagnosis n (%)
No chronic respiratory symptoms, normal spirometry 581 (59)
GOLD 0:at risk, chronic respiratory symptoms, 180 (18)
normal spirometry
GOLD I: mild COPD 143 (14)
GOLD II: moderate COPD 83 (8)
GOLD III: severe COPD 5 (0.5)
GOLD IV: very severe COPD 0 (0)
706
interpretations of the definition of COPD. Physiologically based
definitions seem to overestimate the numbers. Clinician-diag-
nosed COPD prevalence is much lower and might underesti-
mate the number of patients with COPD. Before screening to
identify patients with COPD in primary care is considered, it
should be clear how we define COPD. Guideline committees
should be challenged to come up with practical definitions based
on history, symptoms, and pulmonary function. Lack of evi-
dence of effective therapy in patients with mild disease in
GOLD stage I and II should be addressed when screening of
COPD is advocated. Smoking cessation or prevention of
smoking is the first preventive strategy for COPD and all other
smoking-related diseases.
Conflict of Interest Statement: T.v.d.M. has received reimbursement for serving
on advisory boards with AstraZeneca ($10,001$50,000), Boehringer Ingelheim
($5001$10,000), GlaxoSmithKline ($10,001$50,000), and MSD ($5001
$10,000). He has received honorarium for lectures with GlaxoSmithKline
($5,001$10,000) and Nycomed ($10,001$50,000) and has received funding
for research from AstraZeneca ($100,001 or more) and MSD ($10,001
$50,000). He also receives royalties from MSD ($10,001$50,000). S.S. does
not have a financial relationship with a commercial entity that has an interest in
the subject of this manuscript.
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