Questionnaires, PEF Identify COPD in Patients in Low- and Middle-Income Countries

The screening tools were found to be feasible measurements and took just 7.6 minutes to complete on average.

Chronic obstructive pulmonary disease (COPD) is a costly global health problem, but a new study has shown that simple assessments can successfully identify patients at high risk of the disease.

The study, published in the Journal of the American Medical Association, was conducted in 3 low- and middle-income countries (LMICs): Nepal, Peru, and Uganda. Although COPD is a worldwide concern, previous research has indicated 90% of deaths from the disease occur in LMICs.

Investigators wanted to better understand the feasibility of screening patients in LMICs for COPD using low-cost methods. Specifically, they decided to look at the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) tool, the COPD in LMICs Assessment questionnaire (COLA-6), and the Lung Function Questionnaire (LFQ). The first 2 (CAPTURE and COLA-6) were designed to be paired with a measurement of peak expiratory flow (PEF); the LFQ was designed to stand alone.

“Screening tools for COPD have been shown to have reasonable diagnostic accuracy in high-income countries, but due to better population health and treatment in these settings, this has tended to identify milder disease, not requiring much intervention,” explained the study’s principal investigator, John Hurst, MBBS, PhD, of University College London, in a press release.

Hurst said the screening tools had not yet been sufficiently studied as a diagnostic tool in LMICs.

To change that, Hurst and colleagues enrolled 10,709 patients from the 3 countries into a study. The patients had a mean age of 56.3 years, and half were female. About one-third (35%) had a history of smoking, and 30% reported currently being exposed to biomass smoke.

The investigators found that rates of COPD varied significantly between the sites, with 18.2% of participants in Nepal found to have COPD, compared with 7.4% of patients in Uganda and 2.7% in Peru. Of 1000 COPD cases identified in the study, the vast majority (95.3%) were previously undiagnosed, and half (49.3%) were considered clinically important (with Global Initiative for Chronic Obstructive Lung Disease classifications between B and D). Many patients (16.4%) had severe or very severe airway obstruction, Hurst and colleagues found.

The analysis showed that all 3 screening tools were quick and feasible to administer, taking just 7 to 8 minutes on average. The results suggest the tools could be used to identify more patients with COPD, even in low-income settings.

“Our findings support the accuracy and feasibility of using simple screening tools to identify people affected by COPD living in diverse low- and middle-income settings,” Hurst said.

Hurst added that he was “alarmed” by the high rate of clinically important cases, particularly since most patients did not realize they had COPD.

“In addition, only a minority of people had a history of smoking, further highlighting the poor conditions, exacerbated by biomass smoke, that people in low- and middle-income countries are living,” he said.

Although the study affirmed the value of these screening tools, the investigators said more research will be needed to find out if the screening tools can be incorporated into routine medical exams in LMICs, whether such incorporations are cost-effective, and whether better screening will eventually lead to improved outcomes.


Siddharthan T, Pollard SL, Quaderi SA, et al. Discriminative accuracy of chronic obstructive pulmonary disease screening instruments in 3 low- and middle-income country settings. JAMA. published online January 11, 2021. doi:10.1001/jama.2021.23065

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