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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
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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

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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