[ Correspondence ]
Editor’s Note: Authors are invited to respond to Correspondence that
cites their previously published work. Those responses appear after the
related letter. In cases where there is no response, the author of the
original article declined to respond or did not reply to our invitation.
Accuracy of COPD Diagnosis
During an Admission
The European Perspective
To the Editor:
We read with interest the recent publication in
CHEST (June 2017) by Wu et al1 analyzing the
spirometric results from two large databases of
patients admitted to the hospital with COPD
exacerbation as the primary cause of admission. By
matching two databases, admissions and spirometric
results, the authors identify cases of COPD exacer-
bation based on International Classification of Dis-
eases, Ninth Revision, Clinical Modification codes and
are able to provide valuable information on the
disagreement between clinical and spirometric diag-
noses of COPD, finding a considerable number of
misdiagnosed cases.
We write first to raise some concerns regarding the lack
of detail in the methodology, specifically, the process for
matching the two databases, the protocol for identifying
readmissions, and the criteria and method used to assess
the quality of spirometry in a database. Second, we raise
concerns about the lack of recognition of the breadth of
previous publications that have highlighted similar
issues. The authors benchmark their results with
previous studies, mainly in the United States, with the
exception of one Spanish series.
Clinical audits are in this respect useful tools for
identifying deficiencies in clinical practice, and there is
now established European literature in the field of the
clinical audit of COPD admissions. We wish to draw to
the authors’ attention this body of evidence by
providing the results of the diagnostic accuracy of the
clinical discharge diagnosis measured in the main
clinical audits in Europe (Table 1), namely, the
European COPD Audit2 (16,018 cases from 13
European countries), the Spanish AUDIPOC study3
(5,178 cases in Spain), and the British Audits 2003-2014
(> 31,000 cases combined).4,5 The spirometric
1396 Correspondence
confirmation of COPD diagnosis in these studies ranged
from 46% (2014 England and Wales audit) to
51% (European COPD Audit), with 12.9% of patients in
the European audit with spirometric results having
values not compatible with a diagnosis of COPD. These
clinical audits differ methodologically from the work of
Wu et al in that they do not rely on clinical coding;
eligibility for inclusion is made by a senior clinical
decision maker on admission and then confirmed
clinically at discharge. Second, although in most
clinical audits there is a follow-up period of up to
90 days, the recording of spirometry is confirmed by
data either predating the admission or acquired
during the admission. Third, these audits have for the
most part required a record of postbronchodilator
spirometry.
We suggest that there are two key lessons underlined
by the audit data. First, clinicians need to challenge a
clinical diagnosis of COPD that is not evidenced by an
obstructive pattern on spirometry. Second, we
recommend that when such evidence is not available
at admission, spirometry should be performed either
at the point of discharge or as soon as possible
afterward to confirm an accurate diagnosis.
Jose L. Lopez-Campos, MD
Seville, Spain
Ady Castro-Acosta, MD
Francisco Pozo-Rodriguez, MD
Madrid, Spain
Sylvia Hartl, MD
Vienna, Austria
C. Michael Roberts, MD
London, England
AFFILIATIONS: From Unidad Médico-Quirúrgica de Enfermedades
Respiratorias. Instituto de Biomedicina de Sevilla (IBiS), Hospital
Universitario Virgen del Rocio/ Universidad de Sevilla (Dr Lopez-
Campos); CIBER de Enfermedades Respiratorias (CIBERES),
Instituto de Salud Carlos III (Drs Lopez-Campos, Castro-Acosta, and
Pozo-Rodriguez); Servicio de Neumología, Hospital Universitario 12
de Octubre (Drs Castro-Acosta and Pozo-Rodriguez); Ludwig
Boltzmann Institute of COPD and Respiratory Epidemiology,
Department of Respiratory and Critical Care, Otto Wagner Hospital
(Dr Hartl); and Barts and The London School of Medicine and
Dentistry, Queen Mary, University of London (Dr Roberts).
FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.
FUNDING/SUPPORT: AUDIPOC study was supported by the
Spanish Ministry of Health, Instituto de Salud Carlos III, FIS
project numbers: PI07/90129, PI07/90309, PI 07/90486, PI07/90503,
[ 151#6 CHEST JUNE 2017 ]
TABLE 1 ] Distribution of the Diagnosis of COPD
Wu et al1
Predischarge and Wu et al1 EU COPD Audit AUDIPOC
Postdischarge Prior to Discharge Prior to Admissiona Prior to Admissiona
Variable (n ¼ 826) (n ¼ 826) (n ¼ 16,018) (n ¼ 5,178)
Spirometry not available 271 (32.8) 271 (32.8) 6,587 (41.1) 2,669 (51.5)
No spirometry recorded 175 (21.2; 64.5) 175 (21.2; 64.5)
6,512 (40.7; 98.8) 2,437 (47.1; 91.3)
Unable to perform spirometry 96 (11.6; 35.4) 96 (11.6; 35.4)
Spirometry incompletely NA NA 75 (0.5; 1.1) 232 (4.5; 8.6)
recorded
Successful spirometric 555 (67.2) 449 (54.3) 9,431 (58.9) 2,509 (48.5)
measurements
No airflow obstruction 68 (8.2; 12.2) 46 (5.6; 10.2)
1,226 (7.7; 12.9) 233 (4.5; 9.2)
Reversible obstruction 22 (2.7; 3.9) 13 (1.6; 2.8)
(asthma)b
Confirmed COPD 437 (52.9; 78.7) 366 (44.3; 81.5) 8,205 (51.2; 87.0) 2,276 (44.0; 90.7)
c
Likely COPD 28 (3.4; 5.0) 24 (2.9; 5.3) NA NA

Results expressed as absolute frequencies (relative frequencies related to the whole cohort; relative frequencies related to those patients within the same
group of spirometry availability). NA ¼ not available.
a
Refers only to postbronchodilator spirometry.
b
Defined as a complete reversibility between preadmission and during admission spirometric examination in available cases.
c
Defined by Wu et al as FEV1/FVC, prebronchodilator < 0.7, no postbronchodilator measurements.

PI07/90516, PI07/90721, PI08/90129, PI08/90578, PI08/90251, PI08/

90529, PI08/90129, PI07/90403, PI08/90447, PI08/90457, PI08/
90486, and PI08/90550, the Centro de Investigación Biomédica en
Red de Enfermedades Respiratorias (CIBERES), and the Spanish
Society of Respiratory and Thoracic Surgery (SEPAR). The European
COPD Audit was supported by the European Respiratory Society.
CORRESPONDENCE TO: Jose L. Lopez-Campos, MD, Hospital
Universitario Virgen del Rocio, Avda. Manuel Siurot, s/n; 41013
Seville, Spain; e-mail: lopezcampos@separ.es
Copyright Ó 2017 American College of Chest Physicians. Published
by Elsevier Inc. All rights reserved.
DOI: http://dx.doi.org/10.1016/j.chest.2017.01.044
Acknowledgments
Role of sponsors: The sponsor had no role in the design of the study,
the collection and analysis of the data, or the preparation of the
manuscript.
References
1. Wu H, Wise RA, Medinger AE. Do patients hospitalized with COPD
have airflow obstruction? Chest. 2017;151(6):1263-1271.
2. Lopez-Campos JL, Hartl S, Pozo-Rodriguez F, Roberts CM; European
CA team. European COPD Audit: design, organisation of work and
methodology. Eur Respir J. 2013;41(2):270-276.
3. Pozo-Rodriguez F, Alvarez CJ, Castro-Acosta A, et al.
Clinical audit of patients admitted to hospital in Spain due
to exacerbation of COPD (AUDIPOC study): method and
organization [in Spanish]. Arch Bronconeumol. 2010;46(7):
349-357.
4. Roberts CM, Stone RA, Buckingham RJ, et al. Acidosis, non-invasive
ventilation and mortality in hospitalised COPD exacerbations.
Thorax. 2011;66(1):43-48.
5. Price LC, Lowe D, Hosker HS, et al. UK National COPD Audit 2003:
impact of hospital resources and organisation of care on patient
outcome following admission for acute COPD exacerbation. Thorax.
2006;61(10):837-842.
Response
To the Editor:
We appreciate the interest and observations of
Dr Lopez-Campos et al regarding our article1 recently
published in CHEST on spirometric confirmation of
COPD in patients hospitalized for COPD
exacerbation.
Having used an electronic medical record for 20 years,
the Veterans Healthcare System data bank allows
simpler methods. Stored individual medical records of
inpatient and outpatient service include discrete
spirometric measurements. All spirometry is performed
in a central pulmonary function testing laboratory by
trained certified pulmonary function testing technicians
under the direction of pulmonary physicians, with each
test reviewed by a senior pulmonary physician before
release. Each enrolled patient had a unique identifier
that allowed synchronization of information between
clinical and spirometric databases. Readmissions were
readily identified and eliminated by using the unique
identifiers.
The European COPD Audit was the first European
transnational prospective audit of COPD care and
required highly complex methodology to collect,
protect, and incorporate data across differing health-
care systems, countries, and languages, most without

journal.publications.chestnet.org 1397