Research in context
Evidence before this study
Chronic obstructive pulmonary disease (COPD) is substantially underdiagnosed worldwide. Mass population screening with spirometry is not recommended, although early identification of undiagnosed patients with clinical disease is generally supported because COPD has substantial patient, health-care, and societal burden, which could potentially be lessened through timely diagnosis. We undertook a comprehensive systematic review of the effectiveness of case-finding studies, published in 2015, using synonyms for the search terms COPD, case-finding screening tests in MEDLINE and Embase with no language restrictions. We found 39 published studies, but few included a comparator group. Only one randomised controlled trial has compared a case-finding approach with routine care to identify clinically significant COPD, identifying that opportunistic administration of a screening questionnaire at practice visits was twice as effective as routine care. Non-comparative studies suggest that high yields could be achieved from active case finding with mailed questionnaires to high-risk patients. No previous trial has compared the clinical and cost-effectiveness of alternative approaches to case finding in a real-life primary care setting.
Added value of this study
To our knowledge, TargetCOPD is the first randomised controlled trial to assess the effectiveness and cost-effectiveness of active case finding for COPD compared with opportunistic case finding and to compare these approaches with routine care. In 54 general practices, we found that when targeting ever-smokers aged 40–79 years, active case finding was more than twice as effective as opportunistic case finding, and that together, these targeted approaches were more than seven times as effective as current routine care. Active case finding was also more cost-effective than opportunistic case finding.
Implications of all the available evidence
In a real-life setting, active case finding comprising an initial mailed questionnaire followed by spirometry should be recommended for identifying undiagnosed COPD in primary care. An important proportion of these previously undiagnosed patients have significant breathlessness, and earlier identification and management with effective treatments including inhalers and pulmonary rehabilitation has the potential to improve their health. This trial provides the evidence for guidelines, which was previously lacking.