With the progressive aging of the population in most developed countries, both the health-care systems and health-care professionals need to develop new strategies for the care of multi-pathological chronic patients, including a global vision and adequate coordination of treatments and services. Chronic obstructive pulmonary disease (COPD) is one of the most important causes of this morbidity and mortality, and its prevalence and consequences are increasing. Projected predictions indicate that in 2020 it will be the fifth cause of years of life with disability. In this article, we review the problems that are most frequently associated with treating chronic COPD patients in primary health care.

In the early years of the 21st century, we have seen the consequences of the important demographic changes that have occurred in most developed countries. In Europe, the percentage of people over the age of 65 was 16% in the year 2000, and it is calculated to reach 27% in 2050, although in Spain this percentage may reach 35%.1 One immediate consequence is the increase in chronic diseases and the use of healthcare services as well as the increase in patients who present multiple chronic diseases. In 2006, Spaniards over the age of 65 had an average of 3 chronic problems or diseases.2

This reality has also led to the evolution of the concept of “chronic patients”, in such a way that today it does not refer to patients affected by one single disease, but instead refers those with various chronic pathologies. Age and the presence of several diseases in these patients affect their anatomy and result in fragility, which is defined as a clinical syndrome in which there is a higher risk for deteriorated functionality, associated with comorbidity and disability. Fragility is estimated to appear in 10.3% of the Spanish population over the age of 65.3

The consensus document of 2011 about care for patients with chronic diseases, written by the Spanish societies of internal medicine (SEMI) and family and community medicine (semFYC),2 summarizes the common characteristics of these diseases into seven points (Table 1). These are well-documented in current primary-care studies which once again confirm the profile of chronic patients as those of older age, with multiple pathologies and a high consumption of medication.4

Chronic diseases are diverse, with varied combinations among them, and they affect individuals to different degrees. The individual clinical symptoms of each require its own approach, while persons affected by several entities require a complete vision and proper coordination of treatments and services. In addition, the strategy for care of new chronic patients should not be centered around the episodic care of exacerbations. Instead, they should be oriented towards proactive plans centered on the patients, arising from adequate strategic direction and with the involvement of clinicians, which integrate prevention, social health-care and the family network.5 In a recent review about chronic patient care in complex situations,6 the authors pose the need to construct integrated care scenarios based on multidimensional approaches as a shift in gear from the purely clinical treatment focus. In recent years and in various countries, different approaches have arisen that deal with the problem of chronicity. The most important is the Chronic Care Model, initiated more than 20 years ago by Wagner et al. at the MacColl Institute for Healthcare Innovation in Seattle (USA), which has given evidence of improved health results by simultaneously implementing the interventions of all the participating elements.7

The previously mentioned Spanish consensus document for caring for patients with chronic diseases is defined as an “expression of the alliance between health-care professionals and administrations with patients in order to face the changes needed in the organization of the National Health-Care System for it to meet the needs of patients with chronic diseases”.2 The document intends to raise awareness among the population, professionals and health-care administrations in order to facilitate and promote innovative initiatives that are arising in the area of micromanagement, promoting a health-care system based on integral, continuous and intersectorial care, while reinforcing the paradigm of an informed, active and committed patient who controls the reins of his/her disease.

COPD represents one of the most important causes of morbidity and mortality in the majority of occidental countries and, unlike what happens with cardiovascular diseases, its mortality has not diminished.8 Projections indicate that in the year 2020, COPD will be the fifth cause of years of life lost and of years of life with disability.9 The EPI-SCAN10 observational, epidemiologic, cross-sectional, and multicenter study based on a Spanish population shows a prevalence of COPD in Spain of 10.2% in the population aged 40–80,11 with a notable geographic variability in its prevalence and between sexes, which was not explainable by tobacco consumption alone.12

In recent years, the concept of the disease has gone from focusing on COPD as an obstructive pulmonary disease to defining it as a disease that is also systemic and in which the comorbidities play a transcendental role.8 The concept, which has been included in most of the consensus documents and clinical guidelines, is supported by numerous studies that show that COPD patients have a significantly higher risk of having ischemic heart disease, cerebrovascular disease, and diabetes, among others, and a very high risk of premature mortality.13 COPD patients seem to die earlier due to cardiovascular causes or neoplasm, and later, if they survive, due to respiratory causes. Comorbidities should be contemplated and treated in order to improve the survival of COPD patients.14 At the same time, several studies show how COPD is one of the main comorbidities in patients with other chronic diseases, reaching for example 20%–25% of cases in heart failure.15,16 The presence of COPD increases the risk for hospitalization in other pathologies, and in hospital-discharge studies, COPD appears as the main or secondary diagnosis in between 3.5 and 8.5%.17

Just as some of the more prevalent chronic diseases that frequently accompany COPD, there are some aspects that are very important for its management which we will deal with throughout this paper:

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  Risk factors for COPD still exist, even though they are avoidable. In this disease, smoking is still an important health problem and almost 30% of the population are active smokers.18

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  There are important levels of underdiagnosis and little diagnostic precision,19 with limited or inadequate use of the corresponding diagnostic tests, which in this case is spirometry.

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  The profile of chronic patients: seniors with multiple pathologies and high consumption of medications.

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  Decompensation is a determining factor in the natural history of these diseases. In the case of COPD, exacerbation clearly affects survival and causes repeated hospitalizations.

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  Mobilization of numerous health-care resources, both in economic expense as well as the high number of office visits.

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  The need to consider integral care, including health education, rehabilitation, self-help, and the implication of patients in decision-making.20,21

The main national and international scientific societies, with their clinical practice consensus guidelines, have made recommendations for quality clinical practice.8,22–24 As for the diagnosis of COPD, they emphasize the detection and quantification of smoking and performing spirometry.25 The study of the lung function is of utmost importance both in the diagnosis as well as in the management of the disease, and spirometry is an essential exploration.26 Spirometry parameters have also shown a prognostic value due to their relationship with mortality.27–29 According to the quality health-care standards recommended by some experts, it is considered acceptable to correctly diagnose COPD (patient over the age of 40, exposure to a risk factor like smoking, post-bronchodilator FEV1/FVC<0.7) in at least 60% of the patients labeled as COPD.30 But, more than the diagnosis, it is the evaluation of severity that has classically been established by the degree of decline in FEV1, although the incorporation of more global evaluations such as the BODE index, which also include lung function, body mass, the degree of dyspnea, and the walk test, have demonstrated better clinical predictive capacity.24

Lung function tests are necessarily generalized for the early detection and secondary prevention of the disease, the identification of all those affected and the establishment of the severity of each patient. The objective is early, adequate treatment of the disease and to prevent its unfavorable evolution by optimizing pharmacological treatment. This not only provides a clear opportunity for improving the quality care of respiratory-disease patients, but is also a challenge to promote the extensive use of spirometry while still guaranteeing its quality.31–33

Despite all this, spirometry is still underused for the diagnosis and follow-up of COPD and there is much variability in its use, both in primary care as well as hospital care. The high levels of underdiagnosis, higher than 70%, are the first consequence of this fact.12 Recent data reveal that in the primary care setting, only half of the patients with suspicion for COPD have spirometry to confirm the diagnosis.34 Nevertheless, the diagnosis of COPD in the hospital setting is also not up to par, and the underuse of spirometry is the most frequent reason for this deficiency. The audit by Pellicer et al. in 10 hospitals of the Community of Valencia showed that 54% of the patients with COPD diagnosis did not have spirometry before hospital discharge.25 The registry of spirometries in the primary care patient files is also inadequate: the study by Monteagudo et al. detected that minimal forced spirometry values (FVC, FEV1, and FEV1/FVC ratio) are not usually recorded, nor are data from bronchodilator tests, and many times the reference values used are not stated and only the FEV1 values are recorded.

In the primary care setting, which is where the majority of COPD patients are seen, quality spirometries are necessary. It is essential for the personnel performing the spirometries to be well trained, and a continuous quality control program is needed.35–37 Given the importance of the technical aspects related with correct spirometry procedure and evaluation, different national and international scientific societies have proposed recommendations and guidelines for uniform spirometry, improving the quality of the spirometric results.30,38–40 In addition, different standards have been published for preparing the techniques and work dynamics for the use of spirometers.39,41,42 However, as has been commented, the health-care reality is far from ideal, and it is currently still difficult to talk about quality care when referring to spirometry. Recently published studies still show limited accessibility to the test, limited training in the use of the techniques and difficulties for the classification of chronic respiratory diseases,25,34,43,44 as well as limited compliance with the recommendations proposed by the consensus of experts.45

The pertinence of screening in COPD with spirometry is still controversial. The recommendations vary depending on the estimated risk population,46–48 and the recommendations currently most widely used include ordering spirometry in patients older than 40 with an accumulated history of smoking and respiratory symptoms.49 Screening in asymptomatic ex-smokers or smokers raises more doubts. A study done in our setting found 20% of COPD cases in asymptomatic patients, but other authors have observed sensitively lower levels.50,51 The COPD strategy of the National Health-Care System recommends pilot studies to evaluate the efficiency of the early detection programs in smokers without respiratory symptoms.52 The impact of screening with spirometry as an effective intervention for reaching better results in smoking cessation also does not currently have conclusive evidence,46 but the results of a randomized clinical assay done recently suggests that early identification may help in specific interventions that are able to improve the smoking cessation rate.53

The consequences of the use of spirometry in the treatment of COPD are also debated in the scientific literature. There are intervention studies that prospectively evaluate the impact of the introduction of spirometry in the management of patients with COPD in primary care. These have demonstrated an improvement in the management of these patients, better approach of the differential diagnosis, increased frequency of anti-smoking or quitting advice and modification in the treatment especially in the use of corticosteroid therapy.54,55 In the study done in Catalonia by Monteagudo et al.,34 it has been observed that the use of spirometry in the follow-up of patients with COPD is associated with a higher number of visits to the family medicine practitioner and interconsultations with the pulmonologist, more registered exacerbations and complications and, although fewer hospitalizations are observed, this does not seem to translate into an improvement in the integral management of COPD patients as defined in the clinical practice guidelines (treatment compliance, rehabilitation, physiotherapy, vaccination, diet, nursing control visits), nor was it associated with a change in therapeutic approach among primary care physicians.

Comorbidity is defined as the group of alterations and disorders that can be associated with COPD for one reason or another and which, to a greater or lesser degree, have an impact on the disease, patient prognosis, and mortality.56 There may be several causes, among these age and the effects of smoking, and the exact mechanism is not well understood, although it has been proposed that it might be systemic inflammation and its mediators.57

Senior COPD patients tend to have more complications due to the greater risk of concomitant diseases, such as cardiovascular diseases, lung cancer, diabetes, chronic renal disease, depression, and osteoporosis, all of which contribute to the high mortality associated with COPD. But it is precisely the comorbidities and age that have repeatedly been exclusion criteria in most research, and this has made it difficult to estimate the prognostic capacity of comorbidities in COPD. In recent years, however, several studies have paid more attention to this older age group and some conclude that COPD patients have an average of 9 comorbidities as well as a very limited understanding of their disease.58 This leads one to believe that possibly the management of the disease in this age group requires different strategies.59 And despite everything, it is still not clear whether comorbidities in COPD patients are independent processes or if COPD favors them.

Higher risk for lung cancer and cardiovascular diseases has also been reported in the initial phases of the disease. Here again, the question is raised as to whether they are merely related with the smoking risk factor, or if likewise it is the disease itself that favors other entities.

The studies are numerous and the percentages are variable, but as shown by a very recent study in primary care, more than 65% of COPD patients also have heart failure, more than one-fourth some type of psychiatric diagnosis, 17% diabetes mellitus, almost 6% osteoporosis and the same percentage have neoplasm,60 which is very significant data for describing this association of pathologies.

Briefly, we will review some of the most frequent comorbidities.