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The waiting game

GPs 'should check COPD registers' as thousands may be misdiagnosed

GPs should check their COPD registers, say researchers, after an audit found patients may be misdiagnosed.

Checks of Welsh GP records carried out by the Royal College of Physicians found most patients did not have a gold-standard spirometry test record and of those that did a quarter had a result which suggested they did not actually have COPD.

The audit, done in 2014/15, in 61% of practices in Wales, found that only 19% of COPD patients had a post-bronchodilator FEV1/FVC recorded, the researchers reported in the British Journal of General Practice.

Among these patients, 25% had incompatible spirometry (FEV1/FVC≥0.70, suggesting they may have been misdiagnosed.

Potential reasons may include issues around correct use of read codes, patients being diagnosed in secondary care, and difficulty accessing tests, the researchers said.

The results have already led to several funded initiatives to improve COPD care in Wales, including an optional practice audit as part of QOF, training offered to more than 1,000 nurses and a quality tool due to be launched later this year to help GPs identify patients who may need review.

But the researchers said similar audits done in individual CCGs in England suggest the problem is not confined to Wales and encouraged practices to check their records.

English practices did not take part in the RCP audit and there is no national programme although some CCGs have opted to fund work on COPD, the BMA said.

The researchers calculated that at the time of the audit, as many as 16,000 patients may have been misdiagnosed in Wales.

They also estimated that the total cost of inhalers prescribed for audit patients with incompatible spirometry and no known asthma was approximately £1m/per year. 

Study leader Dr Marie Fisk from the University of Cambridge said the reasons for the results they found were complex and included the fact that in some patients spirometry is not the right test to do and that interpretation of tests was difficult. 

The researchers concluded that ‘a concerted effort to determine an accurate diagnosis in these patients is urgently needed’ to reduce potential harm and medical costs and there was no reason to think the situation in England would be different.

‘Some of the clinical team have run similar audits in their English CCGs and found similar results so yes we would recommend every English practice runs searches of its QOF register to find who has not had post BD spirometry and who has had it but has a result with FEV1/FVC ratio =>0.7.’

She added that Wales had taken the results very seriously and put in place a range of interventions. 

Dr Jerome Donagh, a GP in Bridgend and a member of the Wales Respiratory Health Interest Group, said part of the findings were related to data issues including inappropriate coding.

Also that diagnoses were commonly made in secondary care then recorded in GP systems and was not just an issue for primary care to address.

But that in response to the findings they have already made changes.

‘GPs were offered three of five topics to focus on as part of QOF and one of those was COPD where GPs were asked to look at their register and if needed bring people in or flag up on their file that they needed a review.

‘Also 1,000 nurses and healthcare assistants have now done spirometry training and there are another 200 on the waiting list and that has made a huge difference.’

‘Wales is probably leading on this in the UK now.’

A tool to help GPs manage their COPD registers which will also include training videos is set to go live later this year in Wales, he added.

Dr Peter Saul, co-chair of RCGP Wales said they welcomed the audit but GPs are under a huge amount of strain and other members of the practice team can take on this work where appropriate.

‘In the case of spirometry, given the pressures on the GP workforce, it is important that other members of the multidisciplinary team are given the relevant training that is required to carry out these tests.’

Readers' comments (10)

  • This audits findings do not surprise me at all- I see the misinterpretation of spirometry results frequently, and Dr Marie Fisk is probably holding back when she charitably states that interpretation of results can be difficult. Dr Peter Saul is missing this crucial point when he talks about MDT members being given relevant training to carry out the tests.

    This is, I believe, fully representative of the superficial nature of the GP approach which stems from a lack of knowledge consequent to inadequate training. The fact that at present Pulse is hosting an article about the media portraying GPs unfavourably should ideally lead to some self-reflection by the good and great of the profession.

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  • IDGAF above --- I have now reflected as suggested . In view of the endless redefinition of COPD and its diagnosis/monitoring /treatment by specialist hospital doctors and nurses, perhaps it is time for them to take this hugely difficult
    disease area back under secondary care ??? Alternatively , stop the relentless crap research which seems to be purely to bolster CVs , sell drugs, and get free holidays to an "educational" event overseas and tell patients 1. stop smoking 2. do some exercise 3. use your inhaler when you've decided the first 2 are too difficult. ( Trelegy for all ?? )

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  • With Colin on this. My beloved local hospital as just seen a patient (middle aged life long smoker) who in a few short hours chose the 111 to 999 to A/E to Ambulatory Medical Day Unit under the medics for his first recorded wheezy chest infection which is now classified as acute exacerbation of COPD. Discharged on steroids and Ab with advice to get inhalers and lung functions from GP ASAP which may be a tad problematic as vaguely recall oral steroids mean can't have lung functions for about 6-8 weeks

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  • Colin Malcomson @ 12.01.

    Before going off on a tangent, note the issue alluded to in the article are the spirometric features necessary to diagnose COPD and not regarding monitoring or treatment.I'm not sure that these have changed particularly. And smoking does not have to be a habit indulged in to get COPD- think alpha 1 antitrypsin deficiency. And before you say "But that is ever so rare", that is no reason to not entertain the possibility of COPD in a non-smoker if the history is suggestive.

    Iain Chalmers 2.31pm.

    Maybe the patients Cxray showed hyperinflation and coarsened bronchovascular markings suggesting COPD, or a careful history may have been taken which elicited progressive breathlessness and morning cough producing white spit which the patient hadn't thought to trouble you about.

    I've said it before and I will say it again- GPs are less than great at doing the basics well, and have a poor ability to analyse all the relevant information comprehensively.

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  • IDGAF as you say they should then be cared for under the expert care of our nice shiny scrub suited colleagues in secondary care then.

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  • 1. If you don't fund work adequately, it may not be done to the highest standard.
    2. GPs just a bit busy at the moment, perhaps this could go on the list of stuff other people think we should do for free; towards the bottom.
    3. The definition of copd changes, there is a spectrum on which people impose somewhat arbirary cut-offs. Other than stopping smoking, intervention is not great.

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  • already given up hope NI GP

    agree with everything said above regarding confusion and ever changing guidance re diagnosis but the elephant in the room is QOF.COPD is paid as second only to diabetes for points GPs are only human and will find it counter intuitive to hunt down possible mis diagnosis that results in less money.Remove QOF and its perverse incentives to diagnose and shift to a set payment for the job (salary)

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  • It’s the same in psychiatry. Patient misdiagnosed in primary care because they are doing their best with lack of resources and may not have any specific psych training but secondary care won’t take anyone unless they are dangling or waving knives.

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  • they just need to quit the fags and get some exercise and not too bothered what you call it.

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  • COPD with a reversible component/ asthma on a background of COPD.... makes no damn difference they all end up treated with everything in the formulary so why bother IRL

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