Nov - Dez - English

iagnostic

accuracy

respiratory

diseases

primary

health

units

ssoc

ras

2014; 60(6):599-612

609

Pulmonary tuberculosis

Few studies about tuberculosis that fulfilled the inclu-

sion criteria were encountered (Table 1). Only one repor-

ted the degree of suspicion of diagnosis or knowledge on

the part of general practitioners and specialists, though

this was not the main focus of the article and not direc-

tly assessed,

while the other studies only assessed the

knowledge or degree of suspicion of tuberculosis by ge-

neral practitioners.

17-19

Asthma

In the case of asthma, only two studies evaluated the diag-

nostic ability of general practitioners through a follow

up evaluation by experts (Table 1).

20,21

The first, conducted in Sweden in 1994 included pa-

tients aged over 18 years visiting general practitioners in

selected PHC, verifying the frequency of errors in relation

to asthma diagnosis by general practitioners. The patients

with this diagnosis established in the medical records

were invited to be examined by allergists. The diagnoses

were discussed by a group that included a general practi-

tioner and a nurse, in addition to the allergist. One hun-

dred and twenty-three patients fulfilled the inclusion cri-

teria and were invited to another consultation. 86 of

these (70%) accepted the invitation. At the end, 51/86

(59%) had their asthma diagnosis confirmed, six (7%) were

diagnosed with an asthma-COPD association and 29

(34%) did not have asthma, i.e. they were initially wron-

gly diagnosed.

The second, also conducted in Sweden, investigated

whether the low level of asthma diagnoses was due to un-

derdiagnosis in PHC, as well as assessing the validity of

the first asthma diagnosis by general practitioners. Over

the course of three months in 1997, all patients seeking

medical assistance at PHC units in the district of Lund

with upper or lower respiratory tract infections, prolon-

ged cough, allergic rhinitis, dyspnea or a first positive

diagnosis of asthma were recorded (n=3,025). Ninety-ni-

ne were diagnosed with asthma and reassessed by pulmo-

nologists. The results indicated that 23.5% of patients

were mistakenly considered as asthmatic by general prac-

titioners.

Three other articles were evaluated: one assessed the

concordance between the clinical diagnosis of asthma un-

dertaken previously by the general practitioner with the

spirometry results;

the other two assessed the underdiag-

nosis of asthma and used an non-validated questionnai-

re as a diagnostic tool, without specialized clinical asses-

sment or spirometry.

10,22

In the five studies selected, overdiagnosis varied from

10.6

to 34%

and underdiagnosis from 6.5

to 19.2%.

COPD

Studies whose main focus was to assess the concordance

between the diagnosis by PHC physicians and specialists

were not encountered. The selected studies, which com-

pared the diagnosis by general practitioners and spiro-

metry results revealed mistakes in the diagnosis, charac-

terized by both under and overdiagnosis.

In the eight studies selected

23-31

overdiagnosis varied

from 28

to 40%

while underdiagnosis, from 25.7

81.4%.

A study conducted in Brazil assessed the concordance

between the diagnosis by PHC general practitioners and

spirometry according to the criteria established by the

GOLD initiative. 94 (66%) of the 142 (44.9%) of patients

undergoing spirometry had concordant diagnoses with

that of the general practitioners (Kappa = 0.55), with 9 ha-

ving a confirmed diagnoses and 85 without COPD. The

remainder (48; 34%) was discordant: 27 had COPD accor-

ding to the spirometry and were not diagnosed by the ge-

neral practitioners, and 21 were false positives. In this study,

the variables associated with the spirometric diagnosis of

COPD were: being male, having a rural origin, the presen-

ce of dyspnea and cough, being a current smoker, being

over 55 years, and exposure to smoke fromwood stoves.

Asthma and COPD

The studies encountered that evaluated asthma and COPD

in conjunction are heterogeneous in relation to the me-

thodologies employed. In the eight studies recovered,

32-39

the variation in the overdiagnosis of COPD was 36

86.1%,

while for asthma this was 38

to 74%.

The va-

riation in the underdiagnosis of COPD was 14

to 29%,

while for asthma this was 7

to 54%.

The majority used

an evaluation of the database followed by reassessment

of patients, with the exception of one study based on the

patient’s symptoms at a spontaneous visit to a primary

care unit.

For example, the Cadre study (

COPD and Asthma Diag-

nostic/management Reassessment

), conducted in the United

Kingdom involved more than a thousand GPs and inclu-

ded over 60 thousand patients who had been treated for

a respiratory condition and were reassessed using a stan-

dardized questionnaire applied by nurses, as well as spi-

rometry. An experienced GP then evaluated the question-

naire, spirometry results and made the diagnosis. This

new assessment showed incorrect diagnosis, with a 54%