Use of the Spirometric "Fixed-Ratio" Underdiagnoses COPD in African-Americans in a Longitudinal Cohort Study

Elizabeth A Regan; Melissa E Lowe; Barry J Make; Jeffrey L Curtis; Quan Grace Chen; Michael H Cho; James L Crooks; Katherine E Lowe; Carla Wilson; James K O'Brien; Gabriela R Oates; Arianne K Baldomero; Gregory L Kinney; Kendra A Young; Alejandro A Diaz; Surya P Bhatt; Meredith C McCormack; Nadia N Hansel; Victor Kim; Nicole E Richmond; Gloria E Westney; Marilyn G Foreman; Douglas J Conrad; Dawn L DeMeo; Karin F Hoth; Hannatu Amaza; Aparna Balasubramanian; Julia Kallet; Shandi Watts; Nicola A Hanania; John Hokanson; Terri H Beaty; James D Crapo; Edwin K Silverman; Richard Casaburi; Robert Wise

doi:10.1007/s11606-023-08185-5

Use of the Spirometric "Fixed-Ratio" Underdiagnoses COPD in African-Americans in a Longitudinal Cohort Study

J Gen Intern Med. 2023 Oct;38(13):2988-2997. doi: 10.1007/s11606-023-08185-5. Epub 2023 Apr 18.

Authors

Elizabeth A Regan¹, Melissa E Lowe², Barry J Make³, Jeffrey L Curtis^{4

5}, Quan Grace Chen⁶, Michael H Cho⁷, James L Crooks^{8

9}, Katherine E Lowe¹⁰, Carla Wilson¹¹, James K O'Brien³, Gabriela R Oates¹², Arianne K Baldomero¹³, Gregory L Kinney⁹, Kendra A Young⁹, Alejandro A Diaz¹⁴, Surya P Bhatt¹⁵, Meredith C McCormack¹⁶, Nadia N Hansel¹⁶, Victor Kim¹⁷, Nicole E Richmond⁹, Gloria E Westney¹⁸, Marilyn G Foreman¹⁸, Douglas J Conrad¹⁹, Dawn L DeMeo⁷, Karin F Hoth^{20

21}, Hannatu Amaza²⁰, Aparna Balasubramanian¹⁶, Julia Kallet²², Shandi Watts²², Nicola A Hanania²³, John Hokanson⁹, Terri H Beaty²⁴, James D Crapo³, Edwin K Silverman⁷, Richard Casaburi²⁵, Robert Wise¹⁶

Affiliations

¹ Department of Medicine, National Jewish Health, Denver, CO, USA. Regane@NJHealth.org.
² Duke Cancer Center, Biostatistics, Duke University Medical Center, Durham, NC, USA.
³ Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA.
⁴ Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
⁵ Pulmonary & Critical Care Medicine Section, Veterans Affairs Medical Center, Ann Arbor, MI, USA.
⁶ Edwards Lifesciences, Irvine, CA, USA.
⁷ Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA.
⁸ Division of Biostatistics and Bioinformatics and Department of Immunology and Genomic Medicine, National Jewish Health, Denver, CO, USA.
⁹ Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
¹⁰ Cleveland Clinic Lerner College of Medicine of Case Western Reserve School of Medicine, Cleveland, OH, USA.
¹¹ Research Informatics Services, National Jewish Health, Denver, CO, USA.
¹² University of Alabama at Birmingham, Birmingham, AL, USA.
¹³ Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA.
¹⁴ Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁵ Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
¹⁶ Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹⁷ Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
¹⁸ Pulmonary and Critical Care Medicine, Morehouse School of Medicine, Atlanta, GA, USA.
¹⁹ Department of Medicine, University of California San Diego, La Jolla, CA, USA.
²⁰ Department of Psychiatry, University of Iowa, Iowa City, IA, USA.
²¹ Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, USA.
²² Department of Medicine, National Jewish Health, Denver, CO, USA.
²³ Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
²⁴ Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
²⁵ Rehabilitation Clinical Trials Center, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.

Abstract

Background: COPD diagnosis is tightly linked to the fixed-ratio spirometry criteria of FEV₁/FVC < 0.7. African-Americans are less often diagnosed with COPD.

Objective: Compare COPD diagnosis by fixed-ratio with findings and outcomes by race.

Design: Genetic Epidemiology of COPD (COPDGene) (2007-present), cross-sectional comparing non-Hispanic white (NHW) and African-American (AA) participants for COPD diagnosis, manifestations, and outcomes.

Setting: Multicenter, longitudinal US cohort study.

Participants: Current or former smokers with ≥ 10-pack-year smoking history enrolled at 21 clinical centers including over-sampling of participants with known COPD and AA. Exclusions were pre-existing non-COPD lung disease, except for a history of asthma.

Measurements: Subject diagnosis by conventional criteria. Mortality, imaging, respiratory symptoms, function, and socioeconomic characteristics, including area deprivation index (ADI). Matched analysis (age, sex, and smoking status) of AA vs. NHW within participants without diagnosed COPD (GOLD 0; FEV₁ ≥ 80% predicted and FEV₁/FVC ≥ 0.7).

Results: Using the fixed ratio, 70% of AA (n = 3366) were classified as non-COPD, versus 49% of NHW (n = 6766). AA smokers were younger (55 vs. 62 years), more often current smoking (80% vs. 39%), with fewer pack-years but similar 12-year mortality. Density distribution plots for FEV₁ and FVC raw spirometry values showed disproportionate reductions in FVC relative to FEV₁ in AA that systematically led to higher ratios. The matched analysis demonstrated GOLD 0 AA had greater symptoms, worse D_LCO, spirometry, BODE scores (1.03 vs 0.54, p < 0.0001), and greater deprivation than NHW.

Limitations: Lack of an alternative diagnostic metric for comparison.

Conclusions: The fixed-ratio spirometric criteria for COPD underdiagnosed potential COPD in AA participants when compared to broader diagnostic criteria. Disproportionate reductions in FVC relative to FEV₁ leading to higher FEV₁/FVC were identified in these participants and associated with deprivation. Broader diagnostic criteria for COPD are needed to identify the disease across all populations.

Keywords: COPD; deprivation; diagnosis; fixed ratio; spirometry.

Publication types

Comparative Study
Multicenter Study
Research Support, N.I.H., Extramural

MeSH terms

Black or African American
Cohort Studies
Cross-Sectional Studies
Forced Expiratory Volume
Humans
Longitudinal Studies
Middle Aged
Pulmonary Disease, Chronic Obstructive* / diagnosis
Pulmonary Disease, Chronic Obstructive* / epidemiology
Smoking / adverse effects
Spirometry
Vital Capacity
White

Abstract

Publication types

MeSH terms

Grants and funding