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Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings

Educational Objective
To learn about screening for chronic obstructive pulmonary disease in low- and middle-income countries.

1 Credit CME

JAMA

Published Online: January 11, 2022

Original Investigation

Article Information and Disclosures

Author Affiliations

¹Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida
²Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
³Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland
⁴Now with the National Institutes of Health, Bethesda, Maryland
⁵UCL Respiratory, University College London, London, United Kingdom
⁶Makerere Lung Institute, Makerere University, Kampala, Uganda
⁷Department of Statistical Science, University College London, London, United Kingdom
⁸CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
⁹Department of Community Medicine, Kathmandu Medical College, Nepal
¹⁰Biomedical Research Unit, A.BPRISMA, Lima, Peru
¹¹Centro de Investigación del Envejecimiento (CIEN), Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
¹²Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
¹³Centre for Health Economics, University of York, York, United Kingdom
¹⁴Child Health Research Project, Institute of Medicine Tribhuvan University, Kathmandu, Nepal

GECo Study Investigatorsfor the

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Special Communication

USPSTF Recommendation: Screening for Chronic Obstructive Pulmonary Disease

US Preventive Services Task Force (USPSTF); Albert L. Siu, MD, MSPH; Kirsten Bibbins-Domingo, PhD, MD, MAS; David C. Grossman, MD, MPH; Karina W. Davidson, PhD, MASc; John W. Epling Jr, MD, MSEd; Francisco A. R. García, MD, MPH; Matthew Gillman, MD, SM; Alex R. Kemper, MD, MPH, MS; Alex H. Krist, MD, MPH; Ann E. Kurth, PhD, CNM, MSN, MPH; C. Seth Landefeld, MD; Carol M. Mangione, MD, MSPH; Diane M. Harper, MD, MPH, MS; William R. Phillips, MD, MPH; Maureen G. Phipps, MD, MPH; Michael P. Pignone, MD, MPH
JAMA Clinical Guidelines Synopsis

Screening for Chronic Obstructive Pulmonary Disease

Valerie G. Press, MD, MPH; Adam S. Cifu, MD; Steven R. White, MD
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Effect of a Pulmonary Embolism Diagnostic Strategy in Patients Hospitalized for COPD Exacerbation

David Jiménez, MD, PhD; Alvar Agustí, MD, PhD; Eva Tabernero, MD; Luis Jara-Palomares, MD, PhD; Ascensión Hernando, MD, PhD; Pedro Ruiz-Artacho, MD, PhD; Gregorio Pérez-Peñate, MD, PhD; Agustina Rivas-Guerrero, MD; María Jesús Rodríguez-Nieto, MD, PhD; Aitor Ballaz, MD; Ramón Agüero, MD; Sonia Jiménez, MD; Myriam Calle-Rubio, MD, PhD; Raquel López-Reyes, MD; Pedro Marcos-Rodríguez, MD; Deisy Barrios, MD, PhD; Carmen Rodríguez, MD; Alfonso Muriel, PhD; Laurent Bertoletti, MD, PhD; Francis Couturaud, MD, PhD; Menno Huisman, MD, PhD; José Luis Lobo, MD; Roger D. Yusen, MD; Behnood Bikdeli, MD, MS; Manuel Monreal, MD, PhD; Remedios Otero, MD, PhD; SLICE Trial Group; Andrés Vilas; Diego Aisa; Beatriz González-Quero; Leyre Chasco; Fernando León-Marrero; Santiago de Jorge Domínguez-Pazos; Andrés Quezada; José Ignacio de Granda-Orive; Fahd Beddar-Chaib; Itzíar Fernández-Ormaechea; José Luis Rodríguez-Hermosa; Jorge Carriel-Mancilla; Antonio Emilio Martínez-Verdasco; Javier de Miguel-Díez; María Angustias Quesada; Eduardo Márquez-Martín
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Discriminative Accuracy of the CAPTURE Tool for Identifying COPD in US Primary Care Settings

Fernando J. Martinez, MD, MS; MeiLan K. Han, MD, MS; Camden Lopez, MS; Susan Murray, ScD; David Mannino, MD; Stacey Anderson, MPH; Randall Brown, MD, MPH; Rowena Dolor, MD; Nancy Elder, MD, MPH; Min Joo, MD, MPH; Irfan Khan, MD; Lyndee M. Knox, PhD; Catherine Meldrum, PhD; Elizabeth Peters, BSN, RN; Cathie Spino, ScD; Hazel Tapp, PhD; Byron Thomashow, MD; Linda Zittleman, MPH; Barry Make, MD; Barbara P. Yawn, MD, MSc, MPH; CAPTURE Study Group; Emily White; Cathy Scott; Megan Urbin; Jeffrey Holtzman; Alicia Morris; Anna Smyth; Stefan Jhagroo; Michelle LoPiccolo; Pete Amari; Claudya Greig; Brandon Holmes; Elisha Malanga; Sergio Martinez; Gretchen McCreary; Cara Pasquale; Linda Walsh; Ruth Tal-Singer; Malin Fagerås; Norbert Feigler; Angus Hamblin; Frank Trudo; Erin Tomaszewski; Alberto de la Hoz; Carl Abbott; Shahin Sanjar; Carlos Tafur; Carole Catapano; Kim Gilchrist; Nancy Kline Leidy; Lindsey Amendola; Jose Flores; Grace Ruh; Tammy Harvey; Ashleigh Skipper; Kate Walsh; Lauren Warsocki; Abm Shafayet; Cynthia Pinargotte; Melba Ventuera; Vikash Mandania; Donna Green; Luis Paredas; Erika Barba; Erica Mezzasalma; Lindsey Williams; Jack Westfall; Jen Ancona; Lori Jarell; Megan Kaiser; Christin Sutter; Ranee Chatterjee; Chad Harrell; Taylor Harris; Kimberly Leathers; Beth Mancuso-Mills; Morgan Mangum; Nikita Shah; Bertha Leon; Matthew Leon; Patty Dionicio; Lindsay Shade; Rebecca Beasley; Andrea Price; Cody Oliver; Christy Flynn; Stephen Greenberg; Lindsay Lowe; Laura McAllister; Rina Leonidas; Katherine O’Hare; Kelsey Strout; Jeremy Thomas; Lyle J. Fagnan; Xaviera Martinez-Armenta; Lindsay Shankle; Martha Snow; Valeria Vazquez-Trejo; Lisa Tannikula; Ariel Leifer; Jonathan Radosta; Kyungran Shim; Christina Wells; Diane Garcia; Samantha Madrid; Esther Pacheco; Leonard Romo; Sara Ross; Evelyn Velazquez; Natasha Brown; Gordon Bernard; Deborah Barnbaum; Joao de Andrade; Daren Knoel; Peter Lindenauer; Andre Rogatko; Marinella Temprosa

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Key Points

Question What is the discriminative accuracy of COPD screening instruments in 3 low- and middle-income country settings?

Findings In this cross-sectional study that included 10 709 adults in Nepal, Peru, and Uganda, 3 screening instruments for COPD were feasible to administer and, using postbronchodilator spirometry as the reference standard, yielded area under receiver operating characteristic curves ranging from 0.72 to 0.79.

Meaning This study demonstrated that 3 screening instruments for COPD were feasible to administer in low- and middle-income settings, although further research is needed to assess their performance in other settings and determine whether implementation is associated with improved clinical outcomes.

Abstract

Importance Most of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs), with significant economic effects.

Objective To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings.

Design, Setting, and Participants A cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age- and sex-stratified sample of the population 40 years or older.

Exposures Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [<250 L/min for females and <350 L/min for males]), the COPD in LMICs Assessment questionnaire (COLA-6; range, 0-5; high risk indicated by a score of 4 or more), and the Lung Function Questionnaire (LFQ; range, 0-25; high risk indicated by a score of 18 or less) were assessed against a reference standard diagnosis of COPD using quality-assured postbronchodilator spirometry. CAPTURE and COLA-6 include a measure of PEF.

Main Outcomes and Measures The primary outcome was discriminative accuracy of the tools in identifying COPD as measured by area under receiver operating characteristic curves (AUCs) with 95% CIs. Secondary outcomes included sensitivity, specificity, positive predictive value, and negative predictive value.

Results Among 10 709 adults who consented to participate in the study (mean age, 56.3 years (SD, 11.7); 50% female), 35% had ever smoked, and 30% were currently exposed to biomass smoke. The unweighted prevalence of COPD at the 3 sites was 18.2% (642/3534 participants) in Nepal, 2.7% (97/3550) in Peru, and 7.4% (264/3580) in Uganda. Among 1000 COPD cases, 49.3% had clinically important disease (Global Initiative for Chronic Obstructive Lung Disease classification B-D), 16.4% had severe or very severe airflow obstruction (forced expiratory volume in 1 second <50% predicted), and 95.3% of cases were previously undiagnosed. The AUC for the screening instruments ranged from 0.717 (95% CI, 0.677-0.774) for LFQ in Peru to 0.791 (95% CI, 0.770-0.809) for COLA-6 in Nepal. The sensitivity ranged from 34.8% (95% CI, 25.3%-45.2%) for COLA-6 in Nepal to 64.2% (95% CI, 60.3%-67.9%) for CAPTURE in Nepal. The mean time to administer the instruments was 7.6 minutes (SD 1.11), and data completeness was 99.5%.

Conclusions and Relevance This study demonstrated that screening instruments for COPD were feasible to administer in 3 low- and middle-income settings. Further research is needed to assess instrument performance in other low- and middle-income settings and to determine whether implementation is associated with improved clinical outcomes.

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Article Information

Corresponding Author: John R. Hurst, MB, ChB, PhD, UCL Respiratory, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, United Kingdom (j.hurst@ucl.ac.uk).

Accepted for Publication: December 6, 2021.

Author Contributions: Drs Hurst and Barber had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Siddharthan and Pollard were joint first authors. Drs Checkley and Hurst were joint senior authors.

Concept and design: Siddharthan, Pollard, Barber, Kirenga, Miranda, Checkley, Hurst.

Acquisition, analysis, or interpretation of data: Siddharthan, Pollard, Quaderi, Rykiel, Wosu, Alupo, Barber, Cardenas, Chandyo, Flores-Flores, Kirenga, Miranda, Mohan, Ricciardi, Sharma, Das, Shrestha, Soares, Checkley, Hurst.

Drafting of the manuscript: Siddharthan, Pollard, Checkley, Hurst.

Critical revision of the manuscript for important intellectual content: Siddharthan, Pollard, Quaderi, Rykiel, Wosu, Alupo, Barber, Cardenas, Chandyo, Flores-Flores, Kirenga, Miranda, Mohan, Ricciardi, Sharma, Das, Shrestha, Soares, Checkley, Hurst.

Statistical analysis: Barber, Ricciardi, Checkley, Hurst.

Obtained funding: Siddharthan, Pollard, Barber, Kirenga, Miranda, Checkley, Hurst.

Administrative, technical, or material support: Siddharthan, Pollard, Quaderi, Rykiel, Wosu, Alupo, Chandyo, Flores-Flores, Kirenga, Miranda, Sharma, Shrestha, Checkley, Hurst.

Supervision: Siddharthan, Pollard, Quaderi, Rykiel, Wosu, Alupo, Barber, Chandyo, Flores-Flores, Kirenga, Miranda, Sharma, Das, Shrestha, Soares, Checkley, Hurst.

Conflict of Interest Disclosures: Dr Hurst reported receiving personal fees from AstraZeneca for educational and advisory work, nonfinancial support from AstraZeneca to attend meetings, personal fees from Boehringer Ingelheim for educational and advisory work, nonfinancial support from Boehringer Ingelheim to attend meetings, and grants from Nutricia, who provided product for a study of nutritional support in chronic obstructive pulmonary disease, unrelated to the current study. No other disclosures were reported.

Funding/Support: This study was funded by the Medical Research Council (grant MR/P008984/1) and the National Institutes of Health (grants K23HL126946 [Dr Siddharthan], D43 TW009340 [Dr Flores-Flores], and 1D43TW011502-01 [Dr Flores-Flores]).

Role of the Funder/Sponsor: The Medical Research Council and the National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions expressed in this article are the authors’ own and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the US government.

Additional Contributions: We gratefully acknowledge the contributions of the field research teams and participants in the trial, the trial steering committee, the Medical Research Council, and the Global Alliance for Chronic Disease research network. Additionally, we thank Sonia Buist, MD (Oregon Health & Sciences University) for her review of this manuscript. Dr Buist did not receive compensation for her contribution.

Group Information: A list of the GECo Study Investigators is available in Supplement 4.

Additional Information: This research was conducted while Dr Pollard was employed at Johns Hopkins University.

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Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings

USPSTF Recommendation: Screening for Chronic Obstructive Pulmonary Disease

Screening for Chronic Obstructive Pulmonary Disease

Effect of a Pulmonary Embolism Diagnostic Strategy in Patients Hospitalized for COPD Exacerbation

Screening for Chronic Obstructive Pulmonary Disease

Discriminative Accuracy of the CAPTURE Tool for Identifying COPD in US Primary Care Settings

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