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A Grave Misdiagnosis
Due to a common confusion with asthma, many people afflicted with Chronic Obstructive Pulmonary Disorder (COPD) are not receiving the treatment they need. This is according to Dr. David Price, the principal study investigator in a joint UK-US effort. The findings were presented at the fourteenth annual congress for the European Respiratory Society (ERS).
The study asked randomly-selected patients in Denver, Colorado and Aberdeen, UK for their participation. Five hundred ninety-seven patients responded; each patient had prior diagnoses or a medication history suggestive of an obstructive lung disease. Every patient was at least forty years old. Using a spirometer, a hand-held device much like a Breathalyzer™ that calculates lung capacity and airflow, researchers found that 235 patients had COPD, approximately 40% of the patients under observation. Of these 235:
- 51.5 percent were previously diagnosed with asthma.
- 10.6 percent were never diagnosed with any sort of obstructive lung disease.
- 37.9 percent were previously diagnosed with COPD component diseases like emphysema and chronic bronchitis but not COPD itself.
Both asthma and COPD result in a coarsening of airway walls. It is this coarsening that restricts airflow and causes the similar shortness of breath, wheezing and coughing. However, asthma is treated with a therapy involving beta-agonists and corticosteroids form the basis of the therapies available to treat asthma while COPD is treated with a therapy of corticosteroids and anticholinergics. With asthma, the damage to the airways is by and large reversible. Yet with COPD, the damage to the airways is by and large irreversible because COPD is caused almost entirely by smoking--the right treatment can only hope to lessen COPD's day-to-day consequences. Smoking causes 80 to 90 percent of COPD cases. Indeed, a misdiagnosis avoids the very necessary discussion about quitting smoking.
Even in America alone, the consequences of this continuing misdiagnosis are very real. The Department of Health and Human service reports that COPD is the fourth leading cause of death in America, claiming 117,522 lives annually. Worse, mortalities owing to COPD have increased over the past three decades. None of America's five other leading causes of death have such a dubious distinction. Not surprisingly, COPD places an enormous strain on America's health care system: In 2002, the total estimated cost of COPD was $32.1 billion dollars with $18 billion spent on direct costs like hospitalizations and visits to the doctor.
In the face of these sobering numbers, why has COPD continued to be misdiagnosed?
The first problem is doctors--primary care physicians, not specialists--still do not know exactly what they are looking for. As shown in Dr. Price's findings, doctors will oftentimes confuse COPD for asthma. Or they may diagnose a patient with emphysema or chronic bronchitis, stopping short of an outright COPD diagnosis, which is a one-two punch of both diseases.
The second problem is doctors are still not using the right equipment to make the necessary diagnosis: spirometers can accurately indicate COPD but they still remain underused--perhaps because doctors are not looking for COPD in the first place. It is estimated that less than half of primary care physicians perform spirometry and only 25% have a spirometer to begin with.
The third problem may be an application of outdated education: whereas earlier medical consensus assumed old white men were most at risk for COPD, the reality of the present situation is much more complex. Among white women, the COPD death rate has tripled in the past two decades--from approximately 20 per 100,000 to 60 per 100,00. By 2000, more white women died from COPD than white men for the first time. COPD also threatens African Americans, once thought less susceptible. Indeed, the prevalence of COPD within the African American community has increased over the past two decades, just as it has for white women.
These continuing misdiagnoses come at a time of possible innovation in the treatment of COPD. The day after Dr. Price's abstract, Dr. Daniel Dusser presented his findings that a new generation of drugs can significantly lessen the deteriorations of health associated with COPD. Specifically, tiotropium decreased mild exacerbations by 17% and increasingly severe exacerbations by 35%. Inhaled corticosteriods are currently the drugs of choice when treating COPD--in Dr. Price's study 52.8% patients received corticosteriods while a mere 3.5% received tiotropium.
On November 17th, the Global Initiative for Chronic Obstructive Lung Disease is sponsoring a world COPD day. Its slogan is, "Don't Ignore COPD!" Judging from Dr. Price's findings, doctors as well as patients ought heed this advice.
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