COPD: A Talkative Disease in Need of Talking “Points”

Theoretical Background and research questions/hypothesis: Recent estimates from the Centers for Disease Control and Prevention indicate some 13 million Americans have chronic obstructive pulmonary disease (COPD), but 24 million suffer from impaired lung function—indicating a significant underdiagnosis of COPD. This research aimed to explore how practicing primary care physicians and nurse practitioners view this underdiagnosis and—more importantly—generate theories on how to close that gap, based on their frontline perspectives. 

Methods and Results (informing the conceptual analysis):  Conducted 10 interviews; half among primary care physicians and half among nurse practitioners. All recruited health care providers (HCPs) were required to see patients at risk for COPD on a regular basis (i.e., at least 5/year). Interview guides built upon previous qualitative research among these audiences and were designed to understand provider-patient relationships when dealing with those at risk for COPD, early diagnosis, reasons for underdiagnosis, and what could close the underdiagnosis gap. Interviews revealed three primary commonalities when it comes to treating patients at risk for COPD:

1. HCPs see the value of early diagnosis.
2. HCPs can treat only what they see/hear in the examination room.
3. When HCPs are actually testing and treating COPD, their patients are predominately current smokers and are typically in “middle stages” of COPD—meaning opportunities for earlier diagnosis existed but were missed.

HCPs believe they should and can diagnose COPD earlier since early diagnosis leads to more treatment options and improved outcomes, but they can only move to testing if they see or hear that their patients are symptomatic.  As a result, getting to the diagnosis stage depends heavily on the conversations between the HCP and patient, much more so than other diseases with lower thresholds to testing.  With early stage COPD, patients disregard their symptoms as a sign of aging or smoking and often do not realize that these symptoms need to be tracked to confirm a COPD diagnosis and begin treatment.  Additionally, if at-risk patients visit HCPs about other issues, those issues are the foci of the visit, so COPD conversations do not occur.

Conclusions:  To address underdiagnosis, these HCPs would welcome easier ways to increase opportunities to discuss COPD with patients. Early discussions can uncover the need for testing or at least get COPD symptoms on patients’ radar to identify future issues.  But the utility of these early discussions depends largely on the patient’s ability to recognize and track their symptoms in a way that allows the HCP to understand and react upon in initial conversations. 

Implications for research and/or practice:  For many diseases, the path to diagnosis is relatively straightforward.  Standard blood pressure checks and weight measurements, for example, can initiate the need to test for serious conditions.  In the case of COPD, HCPs have limited exposure to the symptoms that could signal the need for testing early in the process.  Future efforts should explore how HCPs can better engage their at-risk patients about COPD.  Doing so could result in a key first step in reducing the underdiagnosis gap.