Comparison of a network of primary care physicians
and an open spirometry programme for COPD
Vaya Konstantikaki1, Konstantinos Kostikas1,*, Markos Minas,
Georgios Batavanis, Zoe Daniil, Konstantinos I. Gourgoulianis,
Respiratory Medicine Department, University of Thessaly Medical School, Larissa, Greece
Received 31 March 2010; accepted 29 June 2010
Background: Early diagnosis of Chronic Obstructive Pulmonary Disease (COPD) remains the
cornerstone for effective management. In this study we compared an open spirometry pro-
gramme and a case-finding programme providing spirometry to high-risk subjects selected
by primary care physicians.
Methods: A network of primary care physicians was created after invitation and all partici-
pants received training on COPD and spirometry. The study team visited 12 primary care
settings in each programme in a 1-year period. Spirometry was performed in all eligible partic-
ipants. COPD diagnosis and classification was based on GOLD guidelines and evaluation by
a chest physician.
Results: Patients with acceptable spirometry were evaluated (n Z 201 in the case-finding and
n Z 905 in the open spirometry programme). The proportion of newly diagnosed COPD was
27.9% in the case-finding programme compared to 8.4% in the open spirometry programme
(p < 0.0001). The numberneeded-to-screen (NNS) for a new diagnosis of COPD was 3.6 in
the case-finding programme compared to 11.9 in the open spirometry programme. The
majority of newly diagnosed patients were classified in GOLD stages I an II. The average cost
for a new diagnosis of COPD was 173V in the open spirometry programme and 102V in the case-
Abbreviations: COPD, Chronic Obstructive Pulmonary Disease; PYS, Pack-Years; FEV1, Forced Expiratory Volume in the 1st second; FVC,
Forced Vital Capacity; GOLD, Global initiative for chronic Obstructive Lung Disease; NNS, Number Needed-to-Screen; OR, Odds Ratio; CI,
Confidence Interval; BMI, Body Mass Index.
* Corresponding author at. Stamouli 3, Karditsa 43100, Greece. Tel.: þ30 6944780616; fax: þ30 2441022370.
E-mail address: firstname.lastname@example.org (K. Kostikas).
1These authors have equally contributed to this manuscript.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/rmed
Respiratory Medicine (2011) 105, 274e281
0954-6111/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved.
Conclusions: A case-finding programme involving primary care physicians was more cost-effec-
tive for the identification of new cases of COPD compared to an open spirometry programme.
The development of networks of primary care physicians with access to good quality spirom-
etry and specialist consultation for early diagnosis of COPD is justified.
ª 2010 Elsevier Ltd. All rights reserved.
Chronic Obstructive Pulmonary Disease (COPD) is a common
cause of morbidity and mortality, representing a significant
burden for the health systems worldwide.1COPD is char-
acterized by airflow limitation that is not fully reversible
and spirometry is essential for the definite diagnosis of this
There is accumulating evidence that early
intervention, including medication3and smoking cessa-
tion,2,4may alter the natural course of the disease, as
expressed by the decline in lung function. Additionally, the
identification of airflow limitation in spirometry may
increase the success rate of smoking cessation interven-
tions.5The above evidence suggests that the early diagnosis
of COPD through spirometry may be beneficial in the clin-
ical course of COPD patients.
Different approaches have been implemented in the
identification of COPD patients, including screening and
case-finding strategies.6e9The common observation in all
such studies is that COPD remains largely underdiagnosed,
with the newly diagnosed COPD cases ranging from 55%10to
population in Greece, we have shown that in a screening
spirometry programme 69% of the COPD cases were newly
mild-to-moderate disease.12Both in that study and in
a previous case-finding study in primary care practices in
and less symptomatic than patients with previously estab-
lished COPD, suggesting that more efficient programmes are
mandatory for the early identification of COPD patients.
It has been previously shown that the implementation of
of COPD, both in screening and in case-finding studies.8,13,14
are not confident in establishing a diagnosis of COPD.15The
fact that only a small fraction of primary care physicians in
most countries both purchase and regularly use office
spirometers, has led experts to suggest that a better alter-
native would be to provide access to spirometry for high-risk
subjects. However, such a strategy has not been directly
compared to a conventional spirometry programme in
a similar population, to the best of our knowledge.
The aim of the present study was to compare two
different strategies for the diagnosis of COPD in primary
care settings: An open spirometry programme after public
invitation and a case-finding strategy providing spirometry
to high-risk subjects selected by a network of properly
trained primary care physicians. We tested the hypothesis
that the strategy involving primary care physicians would
be more effective than the open spirometry programme.
A cost-effectiveness analysis of the two programmes was
Materials and methods
The study was conducted in 24 primary health care prac-
tices of the National Health System in semirural areas in
Thessaly, Greece, during a 12 month period (November
2008 to October 2009). Spirometry was offered to eligible
participants using two different strategies: (1) an open
spirometry programme based on public invitation and (2)
a case-finding programme where spirometry was offered to
subjects selected by properly trained primary care physi-
cians. In both strategies, all subjects were over 30 years of
age, resided near a primary health care practice, and were
willing to participate in a spirometry programme. Exclusion
criteria were a history of respiratory tract infection during
the 4 weeks prior to inclusion and inability to perform
spirometry. The studywas approved by
Committee of the University Hospital of Larissa and all
subjects provided written informed consent.
Open spirometry programme
During the first week of each month, study coordinators
visited 12 primary care practices for two consecutive days.
Public invitation with local advertisement offering free of
charge spirometry to all subjects with chronic respiratory
symptoms (e.g. cough, sputum production, wheezing or
dyspnea), preceded the spirometry programme in each
practice. A team of the study coordinators (including two
young physicians properly trained in spirometry, a study
nurse and an experienced chest physician) completed
a structured questionnaire for every participant, and then
spirometry was performed in all eligible subjects.
Case-finding programme involving primary care
A network of primary care physicians was organized by the
Respiratory Medicine Department of the University of The-
2-h sessions of training on the diagnosis and management of
COPD. During these sessions, the study coordinators addi-
questionnaires, and provided basic information on the eligi-
bility for spirometry and the interpretation of the results. All
primary care physicians were then asked to identify patients
with a probable diagnosis of COPD in their daily practice and
to complete a validated screening questionnaire for COPD.16
During the first week of each month, a team of the study
coordinators (including a young physician properly trained in
spirometry, a study nurse and an experienced chest physi-
cian), visited 12 primary care practices after prior arrange-
ment with the corresponding primary care physician. All
Open spirometry vs. case-finding in COPD diagnosis275
subjects invited by the primary care physicians were then
evaluated by the study team, who completed a structured
performed in all eligible subjects. In all patients with a COPD
diagnosis, treatment options were discussed both with the
patients and with their attending physicians.
Study questionnaires and details
common respiratory infections, and chronic respiratory
symptoms (i.e. cough, sputum production, wheezing and
dyspnea). A validated screening questionnaire was addi-
involved in the case-finding programme.16Subjects with
considered as smokers, whereas ex-smokers were smokers
who had quit smoking for at least 12 months.17,18Smoking
status was measured in pack-years (PYS).
occupational exposure,history of
Spirometry was performed with a dry spirometer (KoKo
Legend, Ferraris, UK), according to the American Thoracic
Society recommendations.19The spirometric reference
values used were those proposed by the ERS statement.20
Calibration checks were performed every morning, before
the beginning of the spirometry programme. Spirometry
testing was performed by physicians who had undergone
a special training programme by two chest physicians.
Forced expiratory manoeuvers were repeated until three
reproducible acceptable tests were obtained and the best
Forced Expiratory Volume in the 1st second (FEV1), Forced
Vital Capacity (FVC), and FEV1 to FVC ratio (FEV1/FVC)
values were recorded.19A bronchodilator reversibility test
with 400 mg of salbutamol was performed in all patients
with obstructive spirometry, as defined by an FEV1/FVC
ratio <0.70.2An increase in FEV1>12% and >200 mL from
baseline was considered significant.21
Diagnosis of COPD
Three experienced chest physicians who were present
throughout the study (K K, C.H. and G.B.) evaluated the
quality of all spirometries and classified patients with
COPD. The diagnosis of COPD was based on a history of
smoking, compatible symptoms and a post-bronchodilator
FEV1/FVC ratio <0.70. Classification of COPD was based on
post-bronchodilator FEV1(% predicted), according to the
Global initiative for chronic obstructive lung disease (GOLD)
guidelines (Stage I e mild COPD FEV1 ?80.0; Stage II e
moderate COPD 50.0% ? FEV1<80.0%; Stage III e severe
COPD 30.0% ? FEV1<50.0%; Stage IV e very severe COPD
FEV1?30.0% or FEV1<50.0% with respiratory failure).2
The evaluation of the costs of the two programmes included
the cost of two spirometers, the salaries of the study team,
the cost of the spirometries and the cost of the training
sessions for the case-finding programme involving primary
care physicians. The salary estimations were based on
current compensations in the National Health System of
Greece (December 2008).
Demographic data are presented as mean ? standard
deviation (SD). Differences in numerical variables were
evaluated with unpaired t-tests or ManneWhitney U-tests
for normally and skewed data, respectively, whereas
comparisons of proportions were performed using Fischer’s
exact tests. Results from contingency tables regarding
COPD diagnosis were reported as odds ratios (OR) with 95%
Confidence Intervals (CI). Numbers needed-to-screen (NNS)
were calculated as the reciprocal values of prevalence.
Univariate logistic regression analysis was used for the
evaluation of characteristics of the subjects with a new
diagnosis of COPD in the two programmes, with COPD
diagnosis as the dependent variable, and sex, age, Body
Mass Index (BMI), occupational exposure, often respiratory
infections, smoking habit (current, ex or never smokers),
cough, sputum production, wheezing and dyspnea as inde-
pendent variables and results were reported as odds ratios
(OR) with 95% confidence intervals (CI). p-values <0.05
analyzed using SPSS 16.0 for Windows (SPSS Co, Chicago, IL,
USA) and GraphPad Prism 5 (GraphPad Software Inc, La
Jolla, CA, USA).
The flow chart of the participants in the two programmes is
presented in Fig. 1. A significantly higher exclusion rate was
95% CI 3.1%e13.5%; p Z 0.001). The demographics of the
study participants are presented in Table 1. The subjects
and current smokers and presented more often wheezing,
sputum production and dyspnea, compared with the pop-
ulation that attended the open spirometry programme.
Diagnosis of COPD in the two programmes
The proportion of COPD patients in the case-finding pro-
gramme was 36.3% compared to 10.8% in the open
spirometry programme (OR 4.69, 95% CI 3.29e6.70). When
patients with a previous diagnosis of COPD in their records
were excluded, the proportion of new cases of COPD in the
case-finding programme was 27.9% compared to 8.4% in the
open spirometry programme (OR 4.21, 95% CI 2.86e6.21).
However, the proportion of new cases of COPD among COPD
patients did not differ between the two programmes (76.7%
vs. 77.6% for the case-finding and the open spirometry
programme respectively; OR 0.95, 95% CI 0.46e1.96).
The NNS for a single diagnosis of COPD was 2.7 patients
in the case-finding programme compared to 9.2 spirome-
tries in the open spirometry programme. Additionally, the
NNS for a new diagnosis of COPD was 3.6 in the case-finding
276V. Konstantikaki et al.
programme compared to 11.9 in the open spirometry
The distribution of COPD patients, in total and for new
cases, in the two programmes according to GOLD stages,
gender and age groups is presented in Table 2. The majority
of the patients diagnosed with COPD were classified into
GOLD Stages I and II (81.6% and 83.6% for the open
spirometry and the case-finding programme, respectively;
Fig. 2). Similarly, the majority of the new cases of COPD
patients were classified to GOLD Stages I and II (86.8% and
89.3% for the open spirometry and the case-finding pro-
gramme, respectively; Fig. 2). However, no significant
differences were observed between the two programmes.
Additionally, the proportion of new cases of COPD patients
was higher in all age groups in the case-finding programme
compared to the open spirometry programme (p < 0.05 for
all comparisons), with a trend for increase with age in both
programmes (Fig. 3).
Characteristics of newly diagnosed COPD patients
in the two strategies
The results of univariate logistic regression analysis for the
evaluation of characteristics related to a new diagnosis of
COPD in the two programmes are presented in Table 3. In
the open spirometry programme, a new diagnosis of COPD
3 , 1=
m a r g
o r p
wte h t
s i so
s t na
a i d
p i c i t r ap
y l r aee
l l A
( f ogh t r o f
emma r g
) s t na
o r py r t em
o r i ps
0 , 1=
p i c i t r a
y r am
) s t na
i r pg n i v l ov n i
a r g
o r p
a i c i sy
gn i d
n i f - es
e r ac
p i c i t r a
e l b a t peccah t iw
s t c
o r i ps
e j bus
y r t e
DPOCh t iws t n e i t ap
e l ba t peccah t i w
s t c
o r i ps
e j bus
y r t e
DPOCh t i ws t n e i t ap
y l su
e i t ap
o i v
e r p
s t na i d
y l su
e i t ap
o i v
e r p
s t na i d
%5 . 6
r o f r ep
mo r i p s
y r o t a r i ps
no i t ce f n i
edu l cxe
a t pec
e r t nece r
•d l u
e l by r t e
a r t•t c7
% 2 . 8 (
r o f r ep
o r i ps
y r o t a r i ps
no i t ce f n i
du l cxe
d l uoc
a t pec
e r t nece r
y r t em
a r t
e l b
Flow chart of the participants and the patients diagnosed with COPD in the two programmes of the study.
Demographic characteristics of the study participants.
Open spirometry programme Case-finding programme
Number of participants
Female gender (%)
62.5 ? 13.5
28.5 ? 8.9
63.5 ? 13.1
27.9 ? 5.1
45.1 ? 31.9
49.1 ? 39.4
59.5 ? 45.9
49.6 ? 31.6
Categorical data are presented as n with percentage in parenthesis, whereas numerical data are presented as mean ? SD.
Open spirometry vs. case-finding in COPD diagnosis 277
was related to male gender, higher age, lower BMI, smoking
habit and the presence of cough, sputum production and
dyspnea. In the case-finding programme involving primary
care physicians, a new diagnosis of COPD was related to
higher age, smoking, and sputum production.
Comparison of the cost-effectiveness of the two
The cost of the two programmes included the salaries of the
study team (an average of 80V for the physicians and 60V
for the nurses per day), the cost of two spirometers
(approximately 1400V each) and the cost of the spirome-
tries (an average of 5V for the consumables and the
maintenance of spirometers), as well as the cost of the
training sessions for the case-finding programme involving
primary care physicians (including the salaries for two half-
days for the study team and the primary care physicians).
The average cost for a diagnosis of COPD was 134V in the
open spirometry programme and 78V in the case-finding
programme, whereas the average cost for a new diagnosis
of COPD was 173V in the open spirometry programme and
102V in the case-finding programme.
In this study we have shown that a case-finding strategy
providing spirometry and specialist evaluation to high-risk
subjects selected by a network of properly trained primary
care physicians is a more cost-effective option for the
identification of new cases of COPD, compared to an open
spirometry spirometry programme after public invitation.
The majority of COPD cases was classified in stages I and II,
however with no significant difference between the two
strategies. Factors associated with new diagnosis of COPD
were identified in both programmes that may facilitate
future case-finding studies involving primary care physi-
cians. This is the first study to our knowledge that compares
directly an open spirometry programme with a case-finding
programme involving a network of primary care physicians
in a semirural population.
Spirometry programmes have been implemented in
various settings in primary care and have effectively iden-
tified new cases of COPD.8,13,14However, recent guidelines
from the American College of Physicians recommend
against spirometry on asymptomatic individuals,22and
current evidence suggests that several asymptomatic
subjects need to be submitted to spirometry to improve
clinically significant end-points.23
In controversy, the
programmes. Numbers in parentheses represent new cases of COPD.
Distribution of new cases and previously diagnosed COPD patients according to gender, age and GOLD stage in the two
Open spirometry programmeNon COPDCase-finding programme Non COPD
Stage IStage IIStage IIIStage IVTotalStage IStage II Stage IIIStage IVTotal
stages in the two programmes.
Distribution of patients according to GOLD COPD
grammes according to age groups.
Proportions of new cases of COPD in the two pro-
278V. Konstantikaki et al.
advanced disease, thus the need for early intervention is
imperative. The provision of spirometers to primary care
physicians in order to identify new cases of COPD in their
practice has been previously used. However, an observa-
tional study in Italy showed that primary care physicians
practically discontinued using their spirometers after 9
months, despite proper training and compensation for each
spirometry.24Another approach from the UK used a nurse-
led community respiratory assessment unit offering quality-
controlled spirometry and diagnostic support for primary
care physicians.25However, such an approach is not
feasible in all settings, especially when the communication
between primary care and specialist physicians is not close.
In the present study we have investigated an alternative
approach, providing high quality spirometry along with
specialist interpretation of patients to a network of primary
care physicians that received a brief training in COPD by
expert chest physicians. This approach has proven valid,
since it increased by 4 times the chance of identifying new
cases of COPD in the population that was evaluated.
Moreover, less spirometries were performed and the
exclusion rate was half of that of the open spirometry
programme, and this may be attributed to the active
participation of primary care physicians.
In a similar population we have previously shown that
spirometry screening revealed a large proportion of undiag-
nosed COPD patients12; however, the only differences
between newly and previously diagnosed COPD patients was
that the former were younger and less symptomatic, sug-
gesting that they were difficult to be identified. In the
present study we attempted to overcome this problem by
inviting primary care physicians to identify possible candi-
dates for a diagnosis of COPD from the patients they saw in
their everyday practice. Interestingly, even in this strategy,
one out of four subjects with COPD selected by primary care
physicians had a previous diagnosis of COPD, in a similar
manner with the open spirometry programme. A possible
explanation for the referral of subjects with a previous
diagnosis of COPD in their records may reflect the nihilistic
views26and the absence of confidence for the diagnosis of
this disorder in a significant proportion of primary care
In another study from our group in a similar population it
has been shown that the management of COPD patients by
primary care physicians frequently does not comply with
international guidelines.27Therefore, in the present study,
the chest physicians that evaluated COPD patients provided
collaboration with the patients’ family doctors. Another
factor that further supports the need for an active
involvement of primary care physicians is that newly diag-
nosed COPD patients are less symptomatic12,13which may
reflect the fact that COPD patients often underestimate
their symptoms.28The results of the present study suggest
that family doctors may overcome this characteristic by
a more global evaluation of patients, especially when they
are actively involved in COPD diagnosis.
remains a subject of great debate.8,22,23The reports of the
cost per diagnosis range from 5 to 10V for the identification
of a smoker with airflow obstruction in a case-finding pro-
gramme in the Netherlands8to over 2000 per diagnosis of
obstructive airway diseases in an opportunistic spirometry
programme by visiting trained nurses in Australia.29
Profound differences among health care system costs and
A consistent finding of our study was, however, the fact
that, using the same resources in a similar population, the
case-finding programme involving the network of primary
care physicians resulted in a 40% lower cost per diagnosis of
COPD, compared to the open spirometry programme. The
modest cost of approximately 100V per new diagnosis of
COPD, the majority being classified in mild-to-moderate
disease, has to be considered against the extreme costs of
advanced disease.30Another advantage of this programme
that has to be estimated in the overall cost is the fact that
beyond the diagnosis of COPD an experienced chest physi-
cian provided advice on the treatment of those patients,
and this may further lead to more proper management of
COPD in primary care settings. The results of this approach
remain to be revealed in the follow-up of those patients in
Taken into account all the parameters discussed, we
believe that the effectiveness of our case-finding pro-
gramme involving primary care physicians has multiple
aspects. Firstly, the primary care physicians received
a special training, including the implementation of the
GOLD guidelines,2and this may have improved their skills in
the management of their COPD patients. Secondly, this
for such discrepancies.
diagnosed COPD patients in the two programmes.
Univariate logistic regression analysis for the evaluation of the characteristics related to new cases vs. previously
VariablesOpen Spirometry ProgrammeCase-Finding Programme
OR (95% CI) OR (95% CI)
3.82 (1.48e9.89) *
1.04 (1.01e1.07) *
0.88 (0.81e0.96) *
2.41 (1.51e3.85) *
2.22 (1.15e4.27) *
2.05 (1.07e3.93) *
2.45 (1.27e4.73) *
1.05 (1.02e1.08) *
2.58 (1.33e5.01) *
2.23 (1.18e4.2) *
1.10 (0.53e1.91) *
*Statistically significant differences.
Open spirometry vs. case-finding in COPD diagnosis279
programme has identified more effectively new cases of
COPD and at a lower cost, compared to the open spirometry
programme, and the majority of those patients were diag-
nosed at early stages of the disease. Finally, the identifi-
cation of patients at early stages of COPD may be of great
importance, since patients with stage II COPD may benefit
more from smoking cessation interventions and early
A possible limitation of the present study is the selection
biases related to the different design of the two strategies.
Such biases may be related to the unwillingness of certain
individuals for participation in an open spirometry pro-
gramme and to the personal beliefs of primary care physi-
cians regarding the diagnosis of COPD. We have tried to
minimize these selection biases by the preceding local
advertisement that provided detailed information about
the open spirometry programme and by offering special
training to the primary care physicians involved in the case-
finding programme. We cannot overlook the possibility of
“false negative” cases, representing subjects that were not
investigated but with a COPD diagnosis if they had been
examined. However, we believe that this may represent
more of a problem in the open spirometry programme,
compared to the strategy involving trained primary care
physicians, and this might further support our findings.
Another possible limitation is the fact that our cost-effec-
tiveness analysis data may not be generally applicable,
since they represent local conditions that apply to our
settings. However, our study results clearly show that the
relative cost of a new diagnosis of COPD in the case-finding
programme involving primary care physicians was lower
compared to the open spirometry programme. This is even
more important since the same physicians and study nurses
were involved in both programmes, using the same equip-
ment and evaluating similar populations visiting primary
care practices in the same area.
In conclusion, a case-finding programme involving
primary care physicians was more effective for the identi-
fication of new cases of COPD and at a lower cost compared
to an open invitation spirometry programme in a semirural
population. The results of the present study justify the
development of networks of primary care physicians with
access to good quality spirometry and specialist respiratory
physicians in their practices for the identification of new
cases of COPD in primary care.
The authors wish to thank the following primary care physi-
patients in their practices: Ioannis Antonopoulos, Ioanna
Avakian, Eleni Galata, Vassileios Gizlis, Vassileios Hamos, Ili-
ana Kerani, Lampros Kontovos, Despoina Mpaklatsi, Filippos
Peltekis, Maria Psima, Violeta Roka, Fani Sarigianni, Pan-
agiotis Theologis. Additionally, they would like to thank the
following physicians for their active participation in the
spirometry programme: Stavroula Toukmatzi, Kalliopi Agge-
lou, Eleni Apostolidou, Georgios Daniilidis, Eirini Goudouva,
Kyriaki Liadaki, Foteini Malli, Zisis Mpalmpouzis, Foteini
Mpardaka, Parthena Mystridou, Rita Pata, Elli Tagtalianidou,
Vilka Theologi, Rita Tsaroucha, Ioanna Verou, and Georgios
Xafis. Finally, they wish to thank Ms. Eleni Papariga, Ms. Eleni
Souloukou and Ms. Anna Toutoudaki for secretarial support
throughout the study.
Conflicts of interest
The authors declare that there are no conflicts of interest.
The authors declare that there are no sources of funding.
1. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic
obstructive pulmonary disease surveillanceeUnited States,
1971e2000. MMWR Surveill Summ 2002;51:1e16.
2. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the
diagnosis, management, and prevention of chronic obstructive
pulmonary disease: GOLD executive summary. Am J Respir Crit
Care Med 2007;176:532e55.
3. Decramer M, Celli B, Kesten S, Lystig T, Mehra S, Tashkin DP.
Effect of tiotropium on outcomes in patients with moderate
chronic obstructive pulmonary disease (UPLIFT): a prespecified
subgroup analysis of a randomised controlled trial. Lancet
4. Anthonisen NR, Connett JE, Murray RP. Smoking and lung
function of lung health study participants after 11 years. Am J
Respir Crit Care Med 2002;166:675e9.
5. Gorecka D, Bednarek M, Nowinski A, Puscinska E, Goljan-
Geremek A, Zielinski J. Diagnosis of airflow limitation
combined with smoking cessation advice increases stop-
smoking rate. Chest 2003;123:1916e23.
6. Lundback B, Lindberg A, Lindstrom M, et al. Not 15 but 50% of
smokers develop COPD?eReport from the obstructive lung
disease in Northern Sweden studies. Respir Med 2003;97:
7. Zielinski J, Czajkowska-Malinowska M, Sankowski Z, et al. Early
detection of COPD by high risk population spirometric
screening. Pneumonol Alergol Pol 2000;68:217e25.
8. Van Schayck CP, Loozen JM, Wagena E, Akkermans RP,
Wesseling GJ. Detecting patients at a high risk of developing
chronic obstructive pulmonary disease in general practice:
cross sectional case finding study. BMJ 2002;324:1370.
9. Stratelis G, Jakobsson P, Molstad S, Zetterstrom O. Early
detection of COPD in primary care: screening by invitation of
smokers aged 40e55 years. Br J Gen Pract 2004;54:201e6.
10. Dales RE, Aaron SD, Vandemheen KL, Mehdizadeh A, Clinch J.
The prevalence of airflow obstruction in rural primary care.
Respir Med 2006;100:754e9.
11. Fukuchi Y, Nishimura M, Ichinose M, et al. COPD in Japan: the
Nippon COPD Epidemiology study. Respirology 2004;9:458e65.
12. Minas M, Hatzoglou C, Karetsi E, et al. COPD prevalence and
the differences between newly and previously diagnosed COPD
patients in a spirometry program. Prim Care Respir J; 2010 Jun
7 [Epub ahead of print].
13. Vandevoorde J, Verbanck S, Gijssels L, et al. Early detection of
COPD: a case finding study in general practice. Respir Med
14. Buffels J, Degryse J, Heyrman J, Decramer M. Office spirom-
etry significantly improves early detection of COPD in general
practice: the DIDASCO Study. Chest 2004;125:1394e9.
15. Halpin DM, O’Reilly JF, Connellan S, Rudolf M. Confidence and
understanding among general practitioners and practice nurses
in the UK about diagnosis and management of COPD. Respir
280V. Konstantikaki et al.
16. Martinez FJ, Raczek AE, Seifer FD, et al. Development and Download full-text
initial validation of a self-scored COPD Population Screener
Questionnaire (COPD-PS). COPD 2008;5:85e95.
17. Tzanakis N, Anagnostopoulou U, Filaditaki V, Christaki P,
Siafakas N. Prevalence of COPD in Greece. Chest 2004;125:
18. Lindberg A, Bjerg A, Ronmark E, Larsson LG, Lundback B.
Prevalence and underdiagnosis of COPD by disease severity and
the attributable fraction of smoking report from the obstruc-
tive lung disease in Northern Sweden studies. Respir Med 2006;
19. Standardizationof Spirometry.
Thoracic Society. Am J Respir Crit Care Med 1995;152:
20. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R,
Yernault JC. Lung volumes and forced ventilatory flows. Report
Working Party Standardization of lung function tests, European
community for steel and coal. Official statement of the Euro-
pean respiratory Society. Eur Respir J Suppl 1993;16:5e40.
21. Bateman ED, Hurd SS, Barnes PJ, et al. Global strategy for
summary. Eur Respir J 2008;31:143e78.
22. Qaseem A, Snow V, Shekelle P, et al. Diagnosis and manage-
ment of stable chronic obstructive pulmonary disease: a clin-
ical practiceguideline from
Physicians. Ann Intern Med 2007;147:633e8.
23. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB.
Screening for chronic obstructive pulmonary disease using
spirometry: summary of the evidence for the U.S. Preventive
Services Task Force. Ann Intern Med 2008;148:535e43.
24. Lusuardi M, De Benedetto F, Paggiaro P, et al. A randomized
controlled trial on office spirometry in asthma and COPD in stan-
a comparative evaluation Italian study. Chest 2006;129:844e52.
25. Hassett R, Meade K, Partridge MR. Enhancing the accuracy of
respiratory diagnoses in primary care: a report on the estab-
lishment of a community respiratory assessment unit. Prim
Care Respir J 2006;15:354e61.
26. Walters JA, Hansen EC, Walters EH, Wood-Baker R. Under-
diagnosis of chronic obstructive pulmonary disease: a qualita-
tive study in primary care. Respir Med 2008;102:738e43.
27. Minas M, Dimitropoulos K, Pastaka C, Papadopoulos D,
Markoulis N, Gourgoulianis KI. Global initiative for chronic
obstructive lung disease for chronic obstructive pulmonary
disease: GOLD opportunity for lung disorders. Prev Med 2005;
28. Rennard S, Decramer M, Calverley PM, et al. Impact of COPD in
North America and Europe in 2000: subjects’ perspective of
confronting COPD international survey. Eur Respir J 2002;20:
29. Walters JA, Hansen EC, Johns DP, Blizzard EL, Walters EH,
Wood-Baker R. A mixed methods study to compare models of
spirometry delivery in primary care for patients at risk of
COPD. Thorax 2008;63:408e14.
30. Halpin DM. Health economics of chronic obstructive pulmonary
disease. Proc Am Thorac Soc 2006;3:227e33.
Open spirometry vs. case-finding in COPD diagnosis 281