TargetCOPD: A pragmatic randomised controlled trial of targeted case finding for COPDversusroutine practice in primary care

Abstract

Introduction: Many people with clinically significant chronic obstructive pulmonary disease (COPD) remain undiagnosed worldwide. Methods: Using a pragmatic cluster randomised controlled trial (RCT) among general practices in UK, we compared the effectiveness of a Targeted approach to case finding with routine practice over 1 yr. We also compared effectiveness of opportunistic-only case finding during GP consultations with active case finding (postal and opportunistic). Ever-smoking patients aged 40-79 years, without a diagnosis of COPD reporting indicative respiratory symptoms (chronic cough/phlegm, wheeze or dyspnoea) were invited for post-bronchodilator spirometry. COPD was defined as FEV1/FVC<0.7, in line with current UK guidelines, to ensure comparability. The primary outcome was the probability of detecting a new case of COPD, with clustering of patients (by practice and household) accounted for using multi-level logistic regression. Results: 54 general practices (74,818 eligible patients) were randomised and completed the trial. 1278 (3.9% of patients eligible) were newly diagnosed in the Targeted arm compared with 337 (0.8%) in the routine care arm, adjusted OR 7.45 (95%CI 4.80, 11.55). The active arm was more effective in identifying new cases (n=822, 5.4%) than the opportunistic arm (n=370, 2.4%) (adjusted OR 2.34 (2.06, 2.66). Conclusion: A Targeted case-finding programme is significantly more effective in identifying new cases of COPD than routine care. An approach combining postal with opportunistic questionnaires, followed by spirometry among those reporting relevant symptoms is more than twice as effective as an opportunistic-only approach.