International Journal of COPD Dovepress

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Open Access Full Text Article Original Research

Case finding for COPD in primary care: a qualitative

study of the views of health professionals
This article was published in the following Dove Press journal:
International Journal of COPD
28 August 2015
Number of times this article has been viewed

Shamil Haroon Background: Chronic obstructive pulmonary disease (COPD) is common but largely
Rachel E Jordan underdiagnosed. Case-finding initiatives have been evaluated in primary care, but few studies
David A Fitzmaurice have explored the views of service providers on implementing them in practice.
Peymane Adab Aim: To explore the views of primary health care providers on case finding for COPD.
Methods: A total of 20 semi-structured interviews were conducted from March 2014 to
School of Health and Population
Sciences, University of Birmingham, September 2014 among general practitioners, nurses, and managers from practices partici-
Edgbaston, Birmingham, UK pating in a large COPD case-finding trial based in primary care in the West Midlands, UK.
Participants’ views were sought to explore perceived benefits, harms, barriers, and facilitators
to implementing COPD case finding in practice. Interviews were transcribed and analyzed
using the framework method.
Results: Participants felt that case finding improves patient care but also acknowledged potential
harms to providers (increase in workload) and to patients (overdiagnosis). Insufficient resources,
poor knowledge of COPD, and limited access to diagnostic services were viewed as barriers to
diagnosis, while provision of community respiratory services, including COPD specialist nurses,
and support from secondary care were thought to be facilitators. Participants also expressed a
need for more education on COPD for both patients and clinicians.
Video abstract
Conclusion: Care providers believe that early detection of COPD improves patient care
but also has accompanying harms. Barriers to diagnosing COPD, such as insufficient exper-
tise in primary care and limited access to diagnostic services in the community, should be
explored and addressed. The knowledge and attitudes of the public about COPD and its
symptoms should also be investigated to inform future education and awareness-raising
strategies.
Keywords: chronic obstructive pulmonary disease, primary care, diagnosis, qualitative
research

Introduction
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and
Point your SmartPhone at the code above. If you have a
QR code reader the video abstract will appear. Or use: mortality1 and represents a significant cost to health services and society.2 However,
http://youtu.be/Y0R3ENwvoW8 much of the disease burden remains undiagnosed,3 and there has been a policy drive
to identify COPD early through systematic case finding.4 This has been accompanied
by the evaluation of a number of case-finding strategies.5,6 However, there has been a
Correspondence: Peymane Adab;
paucity of research exploring the views of primary care practitioners on these initia-
Rachel E Jordan tives or factors influencing the ability of health services to screen for and diagnose
School of Health and Population Sciences,
COPD.
University of Birmingham, Edgbaston,
Birmingham B15 2TT, UK A study in Tasmania conducted semi-structured interviews and focus groups to
Tel +44 121 414 3777 explore the views of patients with COPD and their general practitioners (GPs) on
Email p.adab@bham.ac.uk;
r.e.jordan@bham.ac.uk factors influencing the diagnosis of COPD.7 This study found that GPs intentionally

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Dovepress © 2015 Haroon et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0)
http://dx.doi.org/10.2147/COPD.S84247
License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further
permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on
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avoided early diagnosis as a result of harboring nihilistic Method

attitudes toward COPD and misperceiving patient expecta- Study design
tions. Patients reported receiving the diagnosis from other Semi-structured interviews were undertaken with primary
sources and were frustrated by delayed diagnosis. care service providers by the lead investigator (SH). Inter-
Another study by the same authors randomly assigned views were conducted from March 2014 to September 2014
eight practices to deliver either optimized usual care or and were audio recorded and transcribed verbatim. Memos
opportunistic assessment with spirometry for ever smokers were made shortly after each interview to summarize key
aged over 35 years who routinely attend primary care.8 At points and reflections.
the end of the study, focus groups were conducted with par-
ticipating GPs to explore their views on each approach. They Participants
felt that organized follow-up, especially with spirometry, One GP, nurse, and manager were invited from each of the
was essential but would increase an already high workload 54 general practices participating in the TargetCOPD trial.12
and increase costs for patients. They also expressed a need Practices were selected to represent a wide range of popula-
for assistance with interpreting spirometry but felt its use tion and practice characteristics. Eligible participants were
prompted them to record their patients’ smoking status and posted an invitation letter as well as up to two reminders.
initiate discussions about smoking cessation. Some also
questioned the value of diagnosing COPD in the absence Sample size
of a cure. We aimed to recruit five to ten participants of each profes-
Since these studies were published, much has been done sion across at least five general practices with a minimum
nationally and internationally to emphasize the importance of sample size of 20. Eventual sample size was determined by
undiagnosed COPD9 and provide education and guidance on the reaching of theoretical saturation (ie, no new concepts
its diagnosis and management.4,10 For example in the UK, the arising from the data).13,14
Quality and Outcomes Framework, which forms part of the
reimbursement system for primary care, includes a number Interviews
of quality indicators for the diagnosis and management of One-to-one semi-structured interviews were conducted either
COPD, such as the recording of spirometry results for all at practices (n=9) or over the telephone (n=11) using a topic
new diagnoses.11 However, it is unclear whether attitudes prompt (although questions could be asked outside the topic
toward the diagnosis of COPD among health professionals prompt if felt appropriate; Table 1) and had a mean duration
have changed with the introduction of these policies. In all, 54 of 23  minutes (range: 13–38  minutes). Repeat interviews
general practices were recently enrolled in a large pragmatic were not conducted, and transcripts were not returned to
cluster randomized controlled trial in the West Midlands, participants for comment.
UK, comparing the effectiveness and cost-effectiveness
of targeted case finding for COPD against routine care.12 Analysis
Interviews were undertaken with participating health care Interviews were analyzed using the framework method.15 In
providers to gain insights into their views on case finding brief, transcripts were read to identify codes or themes referring
for COPD and to discern factors that might influence their to specific topics. Two transcripts considered to be particularly
ability to make a diagnosis. rich and informative were independently coded by three of the

Table 1 Topic prompt

• Please tell me about any experience you have had looking after patients with COPD.
• What are your thoughts on screening or case finding for COPD?
• How do you think it would be best to identify undiagnosed patients with COPD in the community?
• Does your practice take part in any COPD case-finding activities? Please tell me about this.
• What might be the barriers to case finding and identifying patients with COPD?
• What would help primary care services identify patients with COPD?
• We are developing an electronic tool for GPs that will help them identify which of their patients are at high risk of undiagnosed COPD. Do you
think such a tool would be useful? Do you think it would be used in practice, and if so, in what way?
• Is there anything else you would like to comment about screening or case finding for COPD?
Abbreviation: COPD, chronic obstructive pulmonary disease.

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Dovepress Views of primary care practitioners on case finding for COPD

authors (SH, REJ, and PA) and compared to create an initial lifestyle behaviors (eg, exercise), and improved quality of
coding framework. Coding of all subsequent transcripts was life and disease prognosis by enabling earlier access to care.
performed by the lead investigator and built on this framework. Some also felt that it would be cost saving for health services
A framework matrix was then constructed, tabulating quotes in the long term.
by their associated codes and participant type. Emergent
I guess the main advantage of screening is presumably to
themes were then discussed and finalized by three authors.
pick up the disease early so that … I mean COPD is to some
The analysis was performed using NVivo version 10.
extent preventable and particularly if you treat it early and I
guess the biggest advantage is … you can encourage them
Ethical approval to stop smoking … if we treat it early, treat it effectively
Ethical approval was provided by the Solihull National
then hopefully there’ll be fewer hospital admissions and
Research Ethics Service committee (reference: 11/WM/
therefore reducing the costs. [GP 8]
0403). All identifiable data were held on an encrypted
database. Several potential harms were also highlighted, including
the impact on health services, such as increased workload,
Results resources, and costs, as well as on patients, including the risk
Practice and participant characteristics of overdiagnosis, the implications of diagnostic labeling on
A total of 162 care providers were invited to participate, of insurance costs, and creating anxiety.
which 20 participants (ten GPs, seven practice nurses, and
… it’s just that impact on workload really, whether primary
three practice managers) from 16 practices were interviewed
care would just be overwhelmed if we started screening …
(Tables 2 and 3). Practices had a range of patient list sizes
you could end up labelling people, which can have a huge
with most having 5–10,000 patients and the majority serving
impact, and they are fine. [Nurse 6]
relatively socioeconomically deprived populations. Approxi-
mately one-third of practices had been in the case-finding arm
of the trial, and all practices had been involved in recruiting Diagnostic strategies
patients for a large COPD cohort study (the Birmingham Participants mainly reported that patients were investigated
COPD Study). Most GPs (70%) interviewed were male, and for COPD on an opportunistic basis when consulting the
all practice nurses and managers were female. Participants health services, particularly when presenting with suggestive
had been in practice on average for 13 or more years. symptoms. Others discussed using a more active approach
such as screening at smoking cessation clinics. A wide
Views on case finding range of factors were considered to be important triggers
Participants were generally of the opinion that early detection for considering COPD, such as smoking status and a his-
of COPD was beneficial for both patients and health services. tory of asthma. Participants also highlighted the potential
Several participants felt that early detection improved smok- of clinical information systems to help identify and flag
ing cessation, helped instigate positive changes to other high-risk patients.

Also looking at computer data, we can set up searches on

Table 2 Practice characteristics our computers, but it depends on how active people are at
Characteristics of included practices N (%) putting the information on the computer, then we can pull
Total number of practices 16 (100) that information …. [Nurse 4]
Patient list size 0–5,000 5 (31.3)
5,000–10,000 8 (50.0) Spirometry was described as essential for making a
.10,000 3 (18.8) diagnosis of COPD, while screening tests such as handheld
IMD quintile 1 (most deprived) 8 (50.0)
flow meters and respiratory questionnaires were discussed
2 1 (6.3)
3 3 (18.8)
as potentially useful for assessing risk prior to diagnostic
4 4 (25.0) assessment. Some handheld flow meters were reported to
5 (least deprived) 0 (0) feedback lung age, which was highlighted by several par-
Intervention arm Targeted case finding 6 (37.5)
ticipants as being useful for promoting smoking cessation.
Routine care 10 (62.5)
Note: IMD is a measure of socioeconomic deprivation based on postcodes.
Handheld flow meters were also described as quick and easy
Abbreviation: IMD, Index of Multiple Deprivation. to use within a consultation.

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Table 3 Participant characteristics

Characteristics GP Nurse Practice manager Total
Number (%) 10 (50) 7 (35) 3 (15) 20 (100)
Mean age in years (range) 44.7 (31–73) 46.7 (33–54) 57.7 (55–61) 47.4 (31–73)
Male (%) 7 (70) 0 (0) 0 (0) 7 (35)
Mean years in practice (range) 13.7 (2–35) 15.7 (10–25) 16.7 (12–25) 14.9 (2–35)
Abbreviation: GP, general practitioner.

If someone has got appropriate symptoms, a smoking his- man-time implication so unless it’s well-resourced it’s not
tory, and a low FEV1 over V6, then we’ll bring them in for going to happen. [GP 6]
formal spirometry … overall I think it’s not an unreasonable
There was also felt to be a significant lack of knowledge
way to triage the people into proper spirometry. I think
and expertise on COPD in primary care. This included poor
the key thing is not to make the diagnosis on the handheld
understanding of spirometry; difficulties distinguishing
stuff. [GP 7]
between COPD, asthma, and COPD–asthma overlap disease;
Most participants felt that the use of electronic risk pre- and underrecognition of the signs of COPD.
diction tools would be useful for identifying patients at high
I suspect as a profession, we’re not very good at picking
risk of undiagnosed COPD and even to help communicate
up early signs of COPD either … Partly because we, again,
risk to patients. Ease of use, provision of technical support,
attribute a lot of their symptoms to their social habits –
integration with existing clinical information systems, and the
smoking, lack of activity, environment. [GP 3]
generation of automated prompts on electronic health records
were seen as important factors for their implementation. Limited access to diagnostic services was also cited
as a barrier, particularly in smaller practices, which often
I think it’s because we (nurses) always like something to
lack provision of in-house spirometry. Challenges to pro-
refer to and we like to use tools, and I think sometimes that
viding spirometry included costs of equipment and train-
helps just to show the patient as well. Because we use a tool
ing, quality assurance, and availability of appropriately
to assess cardiovascular risk … I found it useful, because
trained staff.
it illustrates to them for example if they’re a smoker you
can calculate their risk as a smoker, and then show them if … you can’t refer for spirometry, the only thing we could
you weren’t a smoker it would be this … So that’s a visual possibly do is buddy up with other practices, but not every
thing for them to see. [Nurse 5] practice has a practice nurse available to do spirometry or
has a spirometry machine. [Practice Manager 1]
A number of participants also highlighted the importance
of being able to refer to secondary care, particularly for more However, some participants did comment on the
challenging clinical presentations. One single-handed GP gradual improvement of diagnostic testing for COPD in the
also commented on the need to refer patients to secondary community.
care for medicolegal protection. It’s getting better I think. I think there was a phase where
people were just doing spirometry willy-nilly without
Barriers to case finding for COPD necessarily having the right equipment, the training to use
Limitation of time, finances, and resources were seen it properly. I think there has been a lot of improvement,
as important barriers to implementing case finding and particularly over the last couple of years with the accredi-
diagnosing COPD. Participants felt that primary care ser- tation …. [GP 3]
vices were already stretched to capacity managing patients
Several patient-related factors were also described as
with established COPD and a lack of additional funding
barriers to diagnosing COPD. These included poor atten-
and resources would prohibit the implementation of case
dance in primary care and late presentation with advanced
finding.
disease. Patients were perceived to sometimes try to cope
… just managing the patients who are already on the COPD with symptoms for as long as possible without consulting the
register is a hell of an onerous task anyway so going out health services until suffering an acute exacerbation. Some
and case finding … there’s a cost implication, there’s a felt that patients often underrecognized the significance of

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Dovepress Views of primary care practitioners on case finding for COPD

their symptoms or were not always forthcoming about them generally perceived to be low. Participants also discussed the
or their smoking habits. importance of sharing diagnostic services between practices,
which was especially important for smaller practices with
… a lot of patients have symptoms but they just think that’s
limited service capacity.
what they should have because they’re smokers so they
don’t often seek advice. [Nurse 7] … if say a patient was suspected with COPD and I’ve
sent them off for spirometry, we normally send them off
There was also a view that awareness of COPD among the
to a local service where they have this spirometry, and I
general public was low, that patients were more likely to be
guess luckily for us we do have a respiratory consultant
aware of the more severe stages of the disease, and that smok-
reporting the spirometry findings as well which gives us
ers with undiagnosed COPD often have low expectations of
recommendations. [GP 8]
their health. They also felt that communicating information
about COPD was challenging. The importance of educating patients and the public
about COPD, including ethnic minority populations, was
If you said to the average man on the street, “What’s
also discussed. This included communicating the symptoms
COPD?” they wouldn’t even know what it was … when
of COPD, disseminating information at a community level,
you do try to explain it to them, you get people going into
and use of social marketing and mass publicity.
panic mode then because it doesn’t sound very nice …
there’s just not enough educational publicity surrounding it. I think more patient education, more information out there,
[Practice Manager 1] more publicity … I think it’s got to be in the media really
… If you’ve got these sort of symptoms then see your GP,
Cultural barriers were also discussed, which present chal- get it checked … [Practice Manager 1]
lenges to communicating risk as well as making a diagnosis
because of underrecognition of exposures more common
Perceptions of patients’ responses to
in the developing world, such as indoor air pollution from
cooking fuels.
receiving a diagnosis of COPD
Patients’ responses to being diagnosed with COPD were
I think there is a linguistic barrier; increasing numbers of perceived to be quite variable. Most participants felt that
patients are from ethnic minorities and getting them up and patients accepted their diagnosis and worked with their
looking at them, and actually understanding where their clinicians to improve their lifestyle behaviors, particularly
exposure has been …. You get all the little Asian ladies who in relation to smoking. Patients were perceived to sometimes
cooked on open fires indoors and have COPD from that, even be relieved by the diagnosis, since this allows them to
but then they’re not smokers … So I think there’s a lot of attribute a cause to their chronic symptoms.
cultural things going on here. [GP 7]
I’ve not really had any genuine reluctance to accept a diag-
nosis … I think they take on board what they have been told
Facilitators for diagnosing COPD … take on board the fact that by making lifestyle changes,
Training of health professionals was seen as one of the key they can significantly slow the progress of the process they
facilitators for case finding and diagnosing COPD. Particular have started. [GP 4]
importance was attributed to spirometry training and acquir-
However, it was acknowledged that patients were often
ing a diploma in COPD, which several participating nurses
shocked and upset by the diagnosis, particularly if they
had already achieved.
had family members who had severe disease, and also that
… two of our nurses are going to do a spirometry course to there were implications for insurance costs and potentially
become more up-to-date and obviously qualified in doing employment. Some felt that patients were occasionally very
spirometry, then we could offer more access to spirometry reluctant to accept the diagnosis, particularly when they had
and possibly set up a breathing clinic …. [Nurse 4] no wish to give up smoking.

Access to community respiratory services, including I think because it is a big shock, it is a big diagnosis, as I
specialist COPD nurses, and support from secondary care and said it’s got lots of implications with insurance. I think it
community outreach were also seen as important, particularly frightens patients as well because they look at the worst case
since expertise on respiratory medicine in primary care was scenario and associations with oxygen … [GP 2]

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Discussion management. Effective communication of the diagnosis is

Main findings thus an important component of patient care.
Case finding for COPD is to some extent already occurring
in primary care, and some health care providers believe that Relationship to other studies
this will benefit patient care at the expense of applying high Like Walters et al,7,8 our study found that additional workload
workload and cost pressures on the health service as well as and resource requirements associated with case finding, as
risking overdiagnosis and creating anxiety among patients well as poor knowledge and confidence with spirometry
(Figure 1). Primary care providers are opportunistically interpretation, are likely to be barriers to diagnosing COPD
diagnosing patients when presented with a suggestive clini- in primary care. However, unlike their study, our participants
cal history, while others are keen to undertake active case did not express views of therapeutic nihilism. Instead, they
finding using a range of approaches. largely felt that early intervention was likely to improve
However, some important barriers to case finding were patient outcomes. Patients with COPD participating in a
identified – limited service capacity, insufficient expertise on qualitative study in Sweden that explored their perspectives
COPD and interpretation of spirometry, and restricted (but on receiving a diagnosis suggested that they would prefer the
improving) access to diagnostic services. Perceived poor diagnosis to be given at an early stage.16 This also aligns with
awareness of COPD and its symptoms among the public and findings by Walters et al7 and the views expressed by health
the difficulty of communicating a diagnosis of COPD were professionals in our study. A recent analysis of a large pri-
also seen as barriers. mary care database by Jones et al showed that opportunities
Investing in the training of health care professionals on to diagnose COPD in primary care are frequently missed.17
COPD and spirometry; improving access to community This was acknowledged by participants in our study, and a
respiratory services, including specialist COPD/respiratory number of reasons for this were postulated, including health
nurses; and education campaigns to improve awareness service and patient-related factors, such as underrecognition
of COPD in the general population were all suggested to of symptoms.
improve the identification of patients with undiagnosed The importance of support from secondary care was also
COPD. highlighted by participants. In the Netherlands, an observa-
Finally, health care professionals recognize that receiving tional analysis of an asthma/COPD service to provide spe-
a diagnosis of COPD can be an upsetting and life-changing cialist support to GPs for diagnosing and managing patients
event and patients’ health beliefs and their response to with chronic respiratory diseases suggested that this support
the diagnosis can play an important role in subsequent was feasible and effective in improving patient outcomes.18

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Figure 1 Summary of themes discussed by participants.

Abbreviation: COPD, chronic obstructive pulmonary disease.

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Dovepress Views of primary care practitioners on case finding for COPD

Interestingly, participants did not comment on the potential Conclusion

role of telemedicine for improving the diagnosis of COPD in The diagnosis of COPD in primary care may be improved by
primary care, which may be a potentially useful resource. For increasing access to community respiratory services and
example, Bonavia et al19 in Italy demonstrated the feasibility investing in the training of health professionals on COPD and
and acceptability of telespirometry (where spirometry results spirometry. The benefits and harms of case finding should
were electronically transferred to pulmonary specialists and be empirically assessed in longitudinal studies to evaluate
reports returned to primary care) among a large sample of the overall effectiveness of detecting COPD early. Finally,
GPs (n=937) for diagnosing COPD. the knowledge and attitudes of the public about COPD and
its symptoms should be investigated to inform future edu-
Strengths and limitations cation and awareness-raising initiatives and help those with
We sampled a variety of stakeholders to acquire a range of undiagnosed disease access the appropriate care.
both clinical and nonclinical perspectives. Participants were
from a number of practices with a wide range of character- Acknowledgments
istics, including those who had participated in both the case We would like to acknowledge all the participants who
finding and routine care arms of the TargetCOPD trial.12 agreed to be interviewed, the transcribers Samuel Davies and
Patients were not interviewed as part of this study, so Adrienne Dunn, the Bliss team for their support, and Joanne
the views expressed were from a care provider perspective O’Beirne-Elliman for assisting with the ethics application.
and may not necessarily reflect what patients personally This paper presents independent research funded by the
experience. Transcripts were not returned to participants National Institute for Health Research (NIHR). The views
for validation of the themes, and the interpretation of the expressed are those of the authors and not necessarily those
transcripts could have been influenced by the prior beliefs of of the NHS, the NIHR, or the Department of Health.
the authors who are all involved in the evaluation of COPD
case finding. Similarly, participating health care providers Author contributions
may possibly have been more engaged in the management PA, REJ, and SH conceived the idea for this study. SH wrote
of COPD than non-participants, and their views may have the protocol with input from PA and REJ and applied for
been biased toward proactive COPD diagnosis and treatment. ethical approval. SH recruited the participants, conducted
The findings of this study should therefore be interpreted in the interviews, and coded the transcripts. PA and REJ coded
this light. two transcripts to validate the initial coding framework. SH
developed the themes that were discussed and verified by
Implications for policy, practice, and PA and REJ. SH wrote the paper with input from PA, REJ,
research and DAF. PA, REJ, and DAF are principal investigators of
Improving the diagnosis of COPD in primary care will likely the TargetCOPD trial. All authors contributed toward data
require investment in community respiratory services and analysis, drafting, and critically revising the paper and agree
training of health professionals on COPD and performance to be accountable for all aspects of the work.
and interpretation of spirometry. Further research should
explore public perceptions of COPD, including awareness Disclosure
of symptoms. Greater awareness may improve the likelihood REJ, PA, and DAF are principal investigators of the Tar-
that patients with undiagnosed disease access the appropri- getCOPD trial, which investigates the effectiveness and cost-
ate services. effectiveness of case finding for COPD in primary care. SH is
The benefits and harms of case finding highlighted in conducting a PhD on case finding for COPD in primary care
this study should be evaluated empirically in the long-term and is funded by an NIHR doctoral fellowship (DRF-2011-
follow-up of case-finding trials. The findings of this study 04-064). The authors report no other conflicts of interest in
should also be compared to the views of patients, and the issues this work.
and implications surrounding the receipt of a diagnosis should
be explored, addressing both the benefits and harms. The References
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