Division of Pulmonary and Critical Care, Miller School of Medicine, University of Miami, Miami, Florida.
Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
JAMA. 2022 Jan 11;327(2):151-160. doi: 10.1001/jama.2021.23065.
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.
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.
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.
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.
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%.
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.
慢性阻塞性肺疾病（COPD）在全球的发病率和死亡率主要发生在中低收入国家（LMIC），造成了重大的经济影响。
评估 3 种使用问卷和呼气峰流速（PEF）的仪器在 3 个中低收入国家环境中用于 COPD 筛查的区分准确性。
设计、设置和参与者：2018 年 1 月至 2020 年 3 月在尼泊尔半城市巴克拉特布尔、秘鲁利马和乌干达纳卡塞克进行了横断面分析，对 40 岁及以上的人群进行了随机年龄和性别分层抽样。
使用三种筛查工具，即初级保健中用于识别未诊断呼吸疾病和加重风险的 COPD 评估工具（CAPTURE；范围为 0-6；得分 5 或更高，或得分 2-5 且 PEF 较低[女性<250 L/min，男性<350 L/min]）、中低收入国家 COPD 评估问卷（COLA-6；范围为 0-5；得分 4 或更高）和肺功能问卷（LFQ；范围为 0-25；得分 18 或更低），以经过质量保证的支气管扩张剂后肺活量测定作为参考标准来诊断 COPD。CAPTURE 和 COLA-6 包括对 PEF 的测量。
主要结局是工具在识别 COPD 方面的区分准确性，通过接受者操作特征曲线（ROC）下面积（AUCs）和 95%CI 来衡量。次要结局包括灵敏度、特异性、阳性预测值和阴性预测值。
在同意参加研究的 10709 名成年人中（平均年龄为 56.3 岁（SD，11.7）；50%为女性），35%有吸烟史，30%目前暴露于生物燃料烟雾中。3 个地点未加权 COPD 的患病率分别为尼泊尔 3534 名参与者中的 18.2%（642/3534）、秘鲁 3550 名参与者中的 2.7%（97/3550）和乌干达 3580 名参与者中的 7.4%（264/3580）。在 1000 例 COPD 病例中，49.3%有临床意义的疾病（全球倡议慢性阻塞性肺病分类 B-D），16.4%有严重或非常严重的气流阻塞（1 秒用力呼气量<50%预计值），95.3%的病例以前未被诊断。筛查工具的 AUC 范围从秘鲁 LFQ 的 0.717（95%CI，0.677-0.774）到尼泊尔 COLA-6 的 0.791（95%CI，0.770-0.809）。灵敏度范围从尼泊尔 COLA-6 的 34.8%（95%CI，25.3%-45.2%）到尼泊尔 CAPTURE 的 64.2%（95%CI，60.3%-67.9%）。仪器的平均使用时间为 7.6 分钟（SD 1.11），数据完整性为 99.5%。
本研究表明，COPD 筛查仪器在 3 个中低收入国家环境中实施是可行的。需要进一步研究以评估在其他中低收入国家环境中的仪器性能，并确定实施是否与改善临床结果有关。
