Supplementary appendixThis appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors.

Supplement to: Jones RCM, Price D, Ryan D, et al, on behalf of The Respiratory Effectiveness Group. Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort. Lancet Respir Med 2014; published online Feb 13. http://dx.doi.org/10.1016/S2213-2600(14)70008-6.

Table 1. Definition of comorbidities used to identify comorbidities present prior to diagnosis of COPD

Comorbidity

Comorbidity identified definition

Asthma Diagnostic Code ever Bronchiectasis Diagnostic Code ever Cardiovascular Disease

Diagnostic Code for Heart Failure, Angina or Myocardial Infarction ever

Osteoporosis Diagnostic Code ever

Diabetes Mellitus Diagnostic Code ever prior OR drugs ever

GERD Diagnostic Code in 2 years prior OR diagnostic code ever plus drugs in the 2 years prior

Allergic Rhinitis Diagnostic Code in 2 years prior OR diagnostic code ever plus drugs in the 2 years prior

Rhinosinusitis

Diagnostic Code in 2 years prior

Depression / Anxiety Diagnostic Code in 2 years prior OR diagnostic code ever plus drugs in the 2 years prior

Chronic Pain At least 3 analgesic prescriptions in the 2 years prior

Table 2. Prevalence of comorbidities stratified by GOLD FEV1% impairment band. For each comorbidity the proportion of

patients in each FEV1% impairment band is shown.

Comorbid Diagnosis

Severity of Airflow Obstruction

p value*

GOLD I (FEV1%: ≥80%) Total = 2,882

n (%)

GOLD II (FEV1%: 50 to <80%)

Total = 10,347 n (%)

GOLD III (FEV1%: 30 to <50%)

Total = 5,669 n (%)

GOLD IV (FEV1%: <30%) Total = 3,923

n (%)

Asthma 1,036 (36) 3,524 (34) 1,858 (33) 1,159 (30) <0·0001

Bronchiectasis 110 (3·8) 348 (3·4) 236 (4·2) 126 (3·2) 0·030

Cardiovascular Disease 415 (14) 1,632 (16) 748 (13) 508 (13) <0·0001

Osteoporosis 141 (4·9) 420 (4·1) 193 (3·4) 131 (3·3) 0·002

Diabetes Mellitus 607 (21) 2,180 (21) 1,061 (19) 677 (17) <0·0001

GERD 326 (11) 843 (8·1) 322 (5·7) 222 (5·7) <0·0001

Allergic Rhinitis 253 (8·8) 783 (7·6) 318 (5·6) 214 (5·5) <0·0001

Sinusitis 148 (5·1) 418 (4·0) 145 (2·6) 92 (2·3) <0·0001

Depression / Anxiety 577 (20) 1,780 (17) 763 (13) 599 (15) <0·0001

Chronic Pain 1,308 (45) 4,479 (43) 2,139 (38) 1,403 (36) <0·0001

Any comorbid diagnosis 2,313 (80) 8,060 (78) 4,074 (72) 2,738 (70) <0·0001

For each severity the denominator population is shown at the top of the column. Any comorbid diagnosis indicates the proportion of patients

with at least one comorbid diagnosis at the time of COPD diagnosis.

*Chi-square test

Table 3. Number of patients with comorbidities at time of COPD diagnosis. The

results indicate the average number of patient with comorbidities between

1990 to 2009, the number of patients in year 1990, and in the year 2007. *This is

the mean of the total number of patients in each year.

Mean prevalence

over 1990–2009

(n=1943*)

Prevalence

in 1990

(n=842)

Prevalence in

2007

(n=1465)

Asthma 659 281 451

Bronchiectasis 73 53 53

Cardiovascular Disease* 289 55 211

GERD 126 5 104

Osteoporosis 66 87 87

Diabetes Mellitus 355 106 333

Sinusitus 55 0 66

Chronic Pain 774 145 696

Depression and Anxiety 307 62 272

Allergic Rhinitis 128 34 91

Due to small patient numbers in 2008 and 2009, results for these years were inconsistent

with the general trend over time and therefore results for 2007 are reported here instead.

*Cardiovascular disease was defined as a diagnosis of heart failure, angina, or myocardial

infarction.

Figure 1. Population stratified by sex and GOLD FEV1 impairment band.

'ALL' shows proportion of males and females irrespective of whether an FEV1% value

was available (n = 38,859) and ‘Known FEV1%' shows proportion of males and females

with a known FEV1% value (n = 22,821); p value indicates level of significance for the

difference between males and females chi-square test 

   

Figure 2. The proportion of patients per year having one or more missed

opportunities in terms of consultations for lower respiratory symptoms (A),

lower respiratory prescribing consultations (B), chest x-rays performed (C) or

outpatient consultations (D) during the 20 years preceding COPD diagnosis

Note the change in y-axis scale for figures C and D. The dotted line indicates the proportion

of patients having two or more events in a year. Due to small numbers, the proportion of

patients having hospitalisations is not shown. Time 0 indicates time of COPD diagnosis.

   

Figure 3. Stratification of comorbidities by airflow obstruction severity at time

of diagnosis of COPD (GOLD I and GOLD II airflow obstruction combined into

FEV1% ≥50%; GOLD III and GOLD IV airflow obstruction combined into FEV1%

< 50%).

Severity was based on FEV1% measured either prior to or within 10 years of diagnosis of

COPD (n = 22,821). One or more, two or more, and three or more comorbidities indicate the

proportion of patients with one or more, two or more, and three or more comorbidities at the

time of COPD diagnosis

   

Figure 4. The number of missed opportunities in primary care: consultations

for lower respiratory symptoms (A); lower respiratory prescribing

consultations (B); chest x-rays performed (C) and; secondary care outpatient

consultations (D). All performed in the two years immediately preceding COPD

diagnosis

Note change in y-axis scale for figures C and D.

   

Figure 5. Trends in the proportion of patients in each category of severity

(based on FEV1 impairment) recorded previously, or within ten years of a

diagnosis of COPD. Bars represent the proportion in that category for a single

year.

Results are shown for patients diagnosed in 1994 through to 2009 (left to right), where each

bar represents the proportion of patients within the individual GOLD impairment band for

each year. Due to small numbers (less than 100 patients with an FEV1 value per year),

results are not shown for 1990 to 1993. For each GOLD impairment band, the horizontal line

indicates the average percentage of patients for all years combined.

Figure 6. Trends in the proportions of patients with none, or one or more

comorbidities prior to or at time of diagnosis of COPD for the years 1990

through to 2009 (left to right). Bars represent the percentage of patients in that

category for a single year.

   

Members of Respiratory Effectiveness Group:

Maarten an den Berge: The Netherlands

Antonio Anzueto: US

Alvar Augusti: Spain

Mona Bafadhel: UK

Vibeke Backer: Denmark

Peter J Barnes: UK

Eric D Bateman: South Africa

Allan Becker: Canada

Leif Bjermer: Sweden

Chris Brightling: UK

Guy Brusselle: Belgium

Sonia Buist: US

Peter Calverley: UK

Niels H. Chavannes: The Netherlands

George Christoff: Bulgaria

Leonard B. Bacharier: US

John Blakey: UK

Sinthia Bosnic-Anticevich: Australia

Jean Bousquet: France

Andy Briggs: UK

Randall Brown: US

Jonathan Campbell: US

Henry Chystyn: UK

Noreen M. Clark: US

Gene Colice: US

Alexandra Dima: The Netherlands

Michelle N. Eakin: US

Nemr Eid: US

Göran Ericksson: Sweden

Daryl Freeman: UK

Andy Griggs: UK

Kevin Gryffudd-Jones: UK

Theresa Guilbert: US

John Haughney: UK

Liam Heaney: UK

Janet Holbrook: US

Stephen Holgate: UK

Elliot Israel: US

Christer Janson: Sweden

Christine Jenkins: Australia

Rupert Jones: UK

Lynn Josephs: UK

Alan Kaplan: Canada

Jerry Krishnan: US

Peter Lange: Germany

Federico Lavorini: Italy

Karin Lisspers: Sweden

Barry Make: US

Richard Martin: US

Andrew McIvor: Canada

Marc Miravitlles: Spain

Ken Ohta: Japan

Teoh Oon Hoe: Singapore

Alberto Papi: Italy

Nikos Papadopoulos: Greece

Hae-Sim Park: South Korea

Ian Pavord: UK

Stephen P Peters: US

Wanda Phipatanakul: US

Hilary Pinnock: UK

Emilio Pizzichini: Brazil

Todor Popov: Bulgaria

Dirkje S. Postma: The Netherlands

David Price: UK

Cynthia Rand: US

Helen Reddel: Australia

Nicolas Roche: France

Miguel Román Rodríguez: Spain

Dermot Ryan: UK

Malcolm Sears: Canada

Sally Singh: UK

Iain Small: UK

Joan B Soriano: Spain

Björn Ställberg: Sweden

Stanley J. Szefler: US

Paolo Tassinari: Venezuela

Mike Thomas: UK

Steve Turner: UK

Omar Usmani: UK

Wim van Aalderen: The Netherlands

Thys van der Molen: The Netherlands

Eric van Ganse: France

Joergen Vestbo: Denmark

Johann Christian Virchow: Germany

Claus Vogelmeier: Germany

Chen Wang: China

Andrew Wilson: UK

Robert Wise: US

Gary Wong: Hong Kong

Osman Yusuf: Pakistan

NS Zhong: China