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The national COPD screening programme in China: rationale and design

Jieping Lei, Ke Huang, Jun Pan, Wei Li, Hongtao Niu, Xiaoxia Ren, Fen Dong, Yong Li, Baicun Li, Cunbo Jia, Ting Yang, Chen Wang on behalf of the China National Chronic Obstructive Pulmonary Disease Screening Program Investigators
ERJ Open Research 2023 9: 00597-2022; DOI: 10.1183/23120541.00597-2022
Jieping Lei
1Department of Clinical Research and Data Management, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
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Ke Huang
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
5Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
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Jun Pan
6General Office, China–Japan Friendship Hospital, Beijing, PR China
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Wei Li
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
5Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
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Hongtao Niu
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
5Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
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Xiaoxia Ren
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
5Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
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Fen Dong
1Department of Clinical Research and Data Management, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
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Yong Li
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
7Pulmonary Function Laboratory, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
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Baicun Li
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
8National Center for Respiratory Medicine Laboratories, China–Japan Friendship Hospital, Beijing, PR China
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Cunbo Jia
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
6General Office, China–Japan Friendship Hospital, Beijing, PR China
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Ting Yang
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
5Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
11These authors contributed equally
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  • For correspondence: zryyyangting@163.com
Chen Wang
2National Center for Respiratory Diseases, Beijing, PR China
3Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
4National Clinical Research Center for Respiratory Diseases, Beijing, PR China
5Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, PR China
9Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, PR China
10Department of Respiratory Medicine, Capital Medical University, Beijing, PR China
11These authors contributed equally
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Abstract

Background COPD is the most prevalent chronic respiratory disease in China. It is estimated that there is a large, as-yet undetected, high-risk population who will develop in COPD in future.

Methods and design In this context, a nationwide COPD screening programme was launched on 9 October 2021. This multistage sequential screening programme incorporates a previously validated questionnaire (i.e. COPD Screening Questionnaire) and pre- and post-bronchodilator spirometry to target the COPD high-risk population. The programme plans to recruit 800 000 participants (eligible age 35–75 years) from 160 districts or counties of 31 provinces, autonomous regions or municipalities across China. The filtered COPD high-risk population and early-detected COPD patients will receive integrated management and be followed-up for ≥1 year.

Discussion This is the first large-scale prospective study to determine the net benefit of mass screening for COPD in China. Whether the smoking cessation rate, morbidity, mortality and health status of individuals at high risk of COPD could be improved along with this systematic screening programme will be observed and validated. Moreover, the diagnostic accuracy, cost-effectiveness and superiority of the screening programme will also be assessed and discussed. The programme marks a remarkable achievement in the management of chronic respiratory disease in China.

Abstract

The national COPD screening programme is the first large-scale prospective study to determine the net benefit of mass screening for COPD in China. The programme aims for remarkable achievements in management of chronic respiratory disease in China. https://bit.ly/3Hi475g

Background

COPD is the most prevalent chronic respiratory disease in China. According to the China Pulmonary Health study, one of the largest cross-sectional surveys on chronic respiratory disease in China, the prevalence of spirometry-defined COPD in Chinese adults was 8.6%, accounting for 99.9 million people [1]. Of note, a previous pulmonary function test had been conducted in only 9.7% of the entire study population, in 12.0% of the confirmed COPD patients and in 55.8% of the people with a self-reported history of COPD [1]. Besides, only 2.6% of the confirmed COPD patients were aware of their respiratory condition [1]. Another nationwide survey also reported an overall low rate of 10.8% pulmonary function test implementation in primary healthcare in China [2]. These data indicated large unmet needs, both from the perspectives of demand and supply, in the prevention and management of COPD in China.

Beyond the large number of confirmed cases, it is believed that there exists a much larger population at high risk of COPD not yet diagnosed as COPD, but which has a high probability of developing COPD in the future. However, the definition of this population has not gained a global consensus; the terms Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 0 [3], pre-COPD [4] or early COPD [5] are sometimes used. In these cases, many research questions are unanswered, e.g. the precise definition of the pre-clinical stage of the disease, the prevalence and epidemiological characteristics of the high-risk population, the development and prognosis of the disease at an early stage, etc.

Meanwhile, the United States Preventive Services Task Force (USPSTF) [6, 7], the GOLD scientific committee [8, 9], the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society (ATS) and the European Respiratory Society (ERS) [10] have all recommended against mass screening for COPD in asymptomatic adults, since no net benefit has been proven; the optimal screening strategies for COPD are still controversial [11–13]. In this context, an active or opportunistic case-finding scheme is proposed [14]. The case-finding method refers to identifying COPD patients among the population who are exposed to high-risk factors (e.g. cigarette smoke) and present with significant respiratory symptoms (e.g. cough, sputum, dyspnoea, wheeze) that are relevant to COPD [15]. If the approach is employed as part of routine care for those who visit clinics for respiratory disease, it is opportunistic case-finding; if the approach is adopted in target population with self-reported risk factor exposure and/or chronic respiratory symptoms, it is active case-finding [15]. Many countries, for example Finland [16], Denmark [17, 18], the United Kingdom [19–21], Poland [22–24], India [25], Nepal, Peru and Uganda [26–28] have attempted to find suitable screening strategies to improve early management of COPD. In China, the design, implementation, cost and effectiveness of a feasible COPD screening scheme must be determined.

In July 2020, the central government of China launched a national project and offered government funds for the purchase of portable spirometers for 50% of primary care institutions, and to provide primary care workers with professional training, aiming to improve their capabilities in the early detection and management of COPD [29]. A year later, in October 2021, the central government initiated another programme for national COPD screening, and authorised the National Center for Respiratory Diseases as the leading organisation [30]. The screening programme uses a previously validated questionnaire and a portable spirometer to target the COPD high-risk population, which is defined based on high-risk factor exposure, respiratory symptoms and pulmonary function. The screening is voluntary for residents, in an active case-finding framework. The programme has a multistage design, involving primary care institutes and superior specialised hospitals, with ultimate goals to facilitate early detection of COPD in a primary area, to prevent severe outcomes and to reduce the burden of the disease.

Materials and methods

Objectives

The major objectives of this national COPD screening programme are 1) to determine the prevalence and characteristics of population at high risk of COPD and those with underdiagnosed or misdiagnosed COPD; 2) to prospectively investigate whether smoking cessation rate, morbidity, mortality and health-related quality of life would be significantly improved with a systematic screening programme; and 3) to assess the cost-effectiveness, cost–utility and cost–benefit of the multistage screening scheme.

Design

This screening programme is cross-sectional at baseline; the filtered COPD high-risk population and confirmed COPD patients will be prospectively followed-up according to planned schedules.

Participants

Adults who are potentially at high risk of COPD with an age between 35 and 75 years are eligible to be recruited. Moreover, the participants should be residents who have lived in the survey area for >6 months in the past year. Participation in the screening programme is voluntary, but signed informed consent is required. The exclusion criteria are 1) experienced myocardial infarction, stroke or shock in the past 3 months; 2) experienced severe cardiac insufficiency, severe arrhythmia or unstable angina pectoris in the past 4 weeks; 3) experienced massive haemoptysis in the past 4 weeks; 4) received chest, abdominal or ophthalmic surgery in the past 3 months; 5) mental disorders (e.g. auditory hallucinations, visual hallucinations, seizures requiring medication, taking antipsychotics, etc.); 6) cognitive impairment (e.g. dementia, impairment of comprehension, etc.); 7) uncontrolled hypertension (i.e. systolic blood pressure >200 mmHg and/or diastolic blood pressure >100 mmHg); 8) heart rate >120 beats⋅min−1; 9) aortic aneurysm; 10) severe hyperthyroidism; 11) pregnant or lactating women; and 12) experienced respiratory infection (e.g. tuberculosis, influenza, etc.) in the past month.

It is hypothesied that the statistical significance level (α) is 0.05, the admissible error (δ) is 0.08, the screening sensitivity (P) is 0.80, and the specificity (P) is 0.70. The following formula is used to estimate the sample size [31]: Embedded Image The required numbers of samples with true positive and true negative screening results are 311 088 and 409 637, respectively. If accounting an attrition rate of 10%, ≥792 798 samples are needed.

Thus, this screening programme plans to recruit a total of 800 000 participants from 160 districts or counties (5000 for each site on average) in 31 provinces, autonomous regions or municipalities directly under the central government of China. The planned recruitment numbers are listed in table 1.

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TABLE 1

The distribution of participants across the country

Implementation

The national COPD screening programme was launched officially on 9 October 2021. This programme incorporates multistage sequential screening strategies, as follows.

Step 1

Firstly, the organisers broadly promote the COPD screening programme through multiple media (e.g. television, mobile phone, broadcast, internet, newspaper, etc.) in communities. The residents who are interested and are willing to participate in the programme are instructed to complete an online screening questionnaire via their mobile phones. The COPD Screening Questionnaire (COPD-SQ; supplementary table S1) is a previously validated questionnaire; a score of ≥16 indicates a higher probability of COPD [33]. The COPD-SQ has been recommended to be used in the primary care setting for COPD screening in China [34–36]. Those who have a COPD-SQ score <16 are considered non-COPD high-risk.

Step 2

The residents who have a COPD-SQ score ≥16 and meet the inclusion and exclusion criteria should make an appointment for an on-site screening within 3 months. They will be asked to sign a paper informed consent form and complete another detailed survey questionnaire (including demographic information, smoking status, physical activities and medical history on respiratory disease) and undergo anthropometry measurement (including height, weight, waist and hip circumferences, blood pressure, heart rate and pulse oxygen saturation).

Step 3

A pre-bronchodilator pulmonary function test via a spirometer is administrated to participants. The collected indices mainly include forced expiratory volume in 1 s (FEV1), FEV1 % predicted, forced vital capacity (FVC), FVC % pred, FEV1/FVC ratio, peak expiratory flow (PEF) and PEF % pred. Participants with COPD-SQ scores ≥16 and pre-bronchodilator FEV1/FVC ≥0.70 are categorised as COPD high-risk population I. This population will receive customised and integrated management, which includes in-time intervention; telephone follow-up and secondary intervention at month six; and face-to-face follow-up and intervention at month 12.

Step 4

For those participants who have a COPD-SQ score ≥16 and a pre-bronchodilator FEV1/FVC <0.70, a post-bronchodilator pulmonary function test is performed. Participants with COPD-SQ scores ≥16, pre-bronchodilator FEV1/FVC <0.70 and post-bronchodilator FEV1/FVC ≥0.70 are grouped as COPD high-risk population II. This population will also receive customised and integrated management, which includes in-time intervention; face-to-face follow-up and secondary intervention at month six; and face-to-face follow-up and intervention at month 12.

Step 5

Participants with COPD-SQ scores ≥16, pre-bronchodilator FEV1/FVC <0.70 and post-bronchodilator FEV1/FVC <0.70 will be suspected COPD patients. These suspected patients will be referred to a superior specialised hospital for definite diagnosis and further treatment.

Step 6

Participants having a verified post-bronchodilator FEV1/FVC <0.70 in the superior hospital are confirmed COPD patients after excluding other obstructive lung diseases, according to the diagnostic criteria of COPD in the GOLD 2021 report [37]. Otherwise, if the participant has a post-bronchodilator FEV1/FVC ≥0.70 in the superior hospital, he or she belongs to COPD high-risk population II. The confirmed COPD patients will receive more intensive management, which includes: in-time intervention; telephone follow-up at month one; telephone follow-up and secondary intervention at month three; and face-to-face follow-up and intervention at month 12. If the participants are diagnosed with other respiratory diseases, they will be referred for specialised treatment in the superior hospital.

A clear definition of the study population is presented in supplementary table S2. The baseline survey and follow-up investigation plans and contents for respective target populations are described in supplementary tables S3 and S4. The in-time and secondary intervention measures are listed in supplementary table S5. The integrated management measures include health education, lifestyle guidance, symptom monitoring, suggestions on smoking cessation, vaccination, physical activity, etc. Implementation of the entire programme is illustrated in figure 1.

FIGURE 1
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FIGURE 1

Workflow of the systematic COPD screening programme. This is a multistage sequential screening scheme, incorporating a previously validated questionnaire (i.e. COPD Screening Questionnaire (COPD-SQ)) and pre- and/or post-bronchodilator spirometry tests to target the COPD high-risk population. The filtered COPD high-risk population and early-detected COPD patients will then receive customised and integrated management measures. BD: bronchodilator; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; PCCM: pulmonary and critical care medicine.

Ethics and registration

The project protocol, informed consent and questionnaires have been approved by the institutional review board at the China–Japan Friendship Hospital (Beijing, PR China; approval number 2021-145-K103). The programme has been registered at the ClinicalTrials.gov with identifier NCT05480176. All participants are required to provide written informed consent.

Project and data management

This national COPD screening programme is led by the National Center for Respiratory Diseases, and is managed by the centres for disease control and prevention (CDCs) and/or tertiary hospitals at the province level. This screening programme has a four-level structured management team, responsible for the project and data quality. The structure and responsibilities of the management team are presented in figure 2.

FIGURE 2
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FIGURE 2

Settings of the four-level quality controls. This COPD screening programme has four-level (i.e. national, provincial, district (for urban area) or county (for rural area), and local) management teams, taking distinct responsibilities for project and data management. QC: quality control.

The central management office, within the National Center for Respiratory Diseases, oversees the entire programme. The national quality control team consists of senior respiratory physicians, senior pulmonary function technicians, professional epidemiologists and managers from the information technology department. Their responsibilities include developing the national quality control scheme, organising and offering professional training, auditing all the quality control and training work, issuing a project newsletter each month and executing regular online and on-site monitoring.

The provincial quality control team consists of senior respiratory physicians and senior pulmonary function technicians who are responsible for developing the provincial quality control scheme, organising and offering professional training and executing regular online and on-site monitoring.

The district (for urban area) or county (for rural area) quality control team mainly include respiratory physicians and pulmonary function technicians. They are in charge of developing the district or county and local quality control schemes, organising and offering professional training and executing regular online and on-site monitoring.

At a local level, the quality control team consists of medical staff from the participating centres. They are responsible for auditing the local screening work and dealing with local quality control issues.

Comprehensive and professional training, e.g. calibration of the spirometer, technical standard operating procedure, quality control of the spirometry test, interpretation of the test data, diagnosis and management of COPD, etc., are offered to local medical staff when the programme is initiated. The medical staff will obtain credentials when completing the training. Then the trained and certified technicians are capable of performing quality pulmonary function tests.

The pre- and post-bronchodilator spirometry manoeuvres are conducted in a seated position, and the participant is required to wear a nose clip and a disposable mouthpiece. Regarding the post-bronchodilator test, a short-term bronchodilator (salbutamol 400 μg) is administered by inhalation through a 500-mL spacer, then the spirometry is performed 20 min later. For each participant, three acceptable and repeatable tests are preferred; if not qualified, the test could be performed consecutively up to eight times. The spirometry data will be centrally reviewed and adjudicated. In addition, a daily calibration check for the spirometer using a 3-L syringe is required. The grading criteria used for quality assessment of FEV1 (flow) and FVC (volume) are consistent with the ATS/ERS [38, 39] and Chinese [40] guidelines (supplementary table S6).

The national quality control team should review (online) ≥5% of spirometry test results regularly for each province, autonomous region or municipality; the provincial quality control team should review ≥10% of test results regularly for each district or county; and the district or county quality control team should check at least a third of test results each month for the region. The provincial quality control team should examine the first five test reports and assign appropriate grades for each participating centre. If the test qualified rate is <60%, the pulmonary function technicians should undergo a second round of training. Continuous education and technical support are available for the participating centres throughout the programme.

All data and original pulmonary function reports are entered and uploaded to a password-protected, electronic data collection system. Any missing value, outlier and illogical information will be sent to the local participating centres to be checked and amended.

Research questions and planned analyses

To achieve the study aims, this national COPD screening programme will address the following questions.

  1. The prevalence and characteristics of population at high-risk of COPD, and those with underdiagnosed or misdiagnosed COPD;

  2. the predictors of positive screening;

  3. the most appropriate definition of COPD high-risk population;

  4. the improvement of smoking cessation rate, morbidity, mortality and health-related quality of life alongside the screening programme;

  5. the variation of respiratory condition alongside the screening programme;

  6. the impact factors that are correlated with development of the disease;

  7. the cost-effectiveness, cost–benefit and cost–utility of this multistage screening scheme;

  8. the generalisability of this systematic COPD screening programme.

This national COPD screening programme could provide us with a platform for multiple studies and analyses. In short, descriptive analyses will be used to summarise the epidemiological and clinical characteristics of the study population. Sensitivity, specificity, positive predictive values, negative predictive values and the area under the receiver operating characteristic curve, along with 95% confidence intervals, will be used to examine and compare the diagnostic and discriminative accuracy of different definitions and screening approaches in the target population. Health technology assessment and health economic measurement will be employed to determine the cost-effectiveness, cost–utility and cost–benefit of current systematic screening strategies. Linear, logistic, Cox or other appropriate regression models will be adopted to assess the disease outcomes and corresponding impact factors. Due to the exploratory nature of the programme, the planned analyses are not limited to the aforementioned methods. The exact analysis methods could be decided when the analyses are conducted.

Discussion

This is an attempt to implement a nationwide COPD screening programme in a developing country, based on a continuously increasing disease burden and a potential large population of underdiagnosed or misdiagnosed COPD patients in China [1, 41]. This programme is an advance in COPD management (especially in the primary area) from the perspective of public health; however, the clinical and economic benefits of mass screening for COPD still have to be evaluated.

Strengths

There are multiple strengths to this national screening programme. First, currently there is a paucity of evidence that screening questionnaires and/or spirometry could improve smoking cessation rates, vaccination rates and COPD-related health outcomes (e.g. morbidity, mortality, health-related quality of life, etc.) [15, 42, 43]. To our knowledge, this is the first large-scale prospective study to determine and validate whether smoking cessation rate, morbidity, mortality and health status of individuals at high risk of COPD could be improved under a systematic screening and management scheme. Second, this programme attempts to target the population at high risk of COPD who could gain more benefit from systematic screening approaches combining questionnaires and pre- and post-bronchodilator spirometry. In other words, screening the symptomatic population with risk factor exposure and with suspected airway limitation might be the most cost-effective way, especially in countries or regions with limited resources. Third, this is not solely a disease screening programme, but also incorporates scheduled follow-ups and integrated management measures to respective populations (i.e. non-COPD high-risk population, COPD high-risk population I, COPD high-risk population II, suspected COPD patients and confirmed COPD patients), searching for the optimal management mode for screening-detected and early COPD patients. Fourth, in contrast to pure research projects, this is a central government-funded, National Center for Respiratory Diseases-led, multiple-agency (e.g. government sectors, CDCs, primary care institutions, specialised hospitals, etc.) programme, which could guarantee the implementation efficiency and quality control of the whole programme. Lastly, and importantly, this is real-world practice of population medicine in management of COPD in China, to maximise the long-term public health, societal and economic welfare of the entire population [44].

Limitations

There are several limitations to this programme. First, it was originally designed and initiated as a public health project, rather than a research study. Thus, the survey items are not as sophisticated as a typical case report form in observational or interventional clinical trials. However, supplementary studies could be embedded in the established platform. Second, false positive and false negative detections are inevitable in a large-scale screening programme. These issues and relevant impacts should be discussed in all aspects of those involved, e.g. patients, physicians, households, government agencies, etc. Third, performing quality spirometry in a primary area and the management of such a volume of data are real challenges. Continuous input in the form of professional training and rigorous quality control are very necessary throughout the implementation of the programme.

Further considerations

While the USPSTF, GOLD, and other scientific committees or societies recommend against screening asymptomatic adults for COPD, active case-finding (i.e. using screening questionnaires and spirometry without a bronchodilator) among target populations who have risk factor exposure and present with COPD-related symptoms is suggested; more relevant research is encouraged [7, 10, 37]. Screening questionnaires (with or without a measurement of PEF) [33, 45–50], innovative handheld spirometers [51, 52] and optimal multistage screening strategies [18, 20, 28, 53] have been explored worldwide. Country- or region-specific active case-finding approaches should be developed due to resource constrains and varied population characteristics. COPD screening should be compared with screening for malignant tumours, cardiovascular diseases and diabetes mellitus, to demonstrate its noninferiority to the other diseases.

Moreover, a combination of lung cancer and COPD screening using low-dose computed tomography (CT) is recommended in the GOLD 2022 report [37]. The benefit of annual low-dose CT screening in aged current or former smokers even with normal pulmonary function or with mild-to-moderate COPD has been reported in the United States [54]. Furthermore, combined screening for early lung cancer, COPD and cardiovascular disease has been initiated [55–57]. One-off low-dose CT screening has been demonstrated to be significantly associated with reduced lung cancer mortality and all-cause mortality in a large population in China [58]; thus a comparison between low-dose CT and the current active case-finding method is possible.

Conclusions

The COPD screening programme will mark a remarkable achievement in management of chronic respiratory disease in China. The diagnostic accuracy, cost-effectiveness and superiority of current systematic screening approaches will be assessed and discussed in future.

Supplementary material

Supplementary Material

Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

Table S1 00597-2022.supplementary_table_S1

Table S2 00597-2022.supplementary_table_S2

Table S3 00597-2022.supplementary_table_S3

Table S4 00597-2022.supplementay_table_S4

Table S5 00597-2022.supplementary_table_S5

Table S6 00597-2022.supplementary_table_S6

Acknowledgements

We deeply appreciate the continuous support in all aspects contributed to this programme, including the national and local health commissions and other related government agencies, the participating primary care institutions and their medical staff, the involved specialised hospitals and the multidisciplinary experts working for project and data management, as well as all participants.

Footnotes

  • Provenance: Submitted article, peer reviewed.

  • Support statement: The work with this manuscript is supported by the Chinese Academy of Medical Science Innovation Fund for Medical Sciences (number 2021-I2M-1-049) and the Major Program of National Natural Science Foundation of China (number 82090011). The funder has no role in design and implementation of the programme, data collection, data analysis or preparation of the manuscript. Funding information for this article has been deposited with the Crossref Funder Registry.

  • Author contributions: J. Lei conceptualised and wrote the first draft, and critically revised the manuscript. K. Huang, J. Pan, W. Li, H. Niu, X. Ren, F. Dong, Y. Li, B. Li and C. Jia were involved in implementation and management of the programme and revision of the manuscript. T. Yang and C. Wang designed the programme, supervised the work, had full access to all of the data and took responsibility for the integrity of the work as a whole, from inception to the published article. All authors have read and approved the final manuscript to be published.

  • Ethics statement: The project protocol, informed consent and questionnaires have been approved by the institutional review board at the China–Japan Friendship Hospital (approval number 2021-145-K103). All participants are required to provide written informed consent.

  • Data availability statement: The raw data supporting the conclusions of this article can be made available from the corresponding authors on reasonable request.

  • Conflict of interest: The programme is conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

  • Received November 7, 2022.
  • Accepted January 25, 2023.
  • Copyright ©The authors 2023
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References

  1. ↵
    1. Wang C,
    2. Xu J,
    3. Yang L, et al.
    Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study. Lancet 2018; 391: 1706–1717. doi:10.1016/S0140-6736(18)30841-9
    OpenUrlCrossRefPubMed
  2. ↵
    1. Peng B,
    2. Zhang XJ,
    3. Jiang XT, et al.
    The availability of essential medicines and diagnostic devices for chronic obstructive pulmonary disease in primary care (in Chinese). Chin Gen Prac 2022; 25: 771–781.
    OpenUrl
  3. ↵
    1. Pauwels RA,
    2. Buist AS,
    3. Calverley PM, et al.
    Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001; 163: 1256–1276. doi:10.1164/ajrccm.163.5.2101039
    OpenUrlCrossRefPubMed
  4. ↵
    1. Han MK,
    2. Agusti A,
    3. Celli BR, et al.
    From GOLD 0 to pre-COPD. Am J Respir Crit Care Med 2021; 203: 414–423. doi:10.1164/rccm.202008-3328PP
    OpenUrlPubMed
  5. ↵
    1. Martinez FJ,
    2. Han MK,
    3. Allinson JP, et al.
    At the root: defining and halting progression of early chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2018; 197: 1540–1551. doi:10.1164/rccm.201710-2028PP
    OpenUrlPubMed
  6. ↵
    1. Siu AL,
    2. Bibbins-Domingo K,
    3. Grossman DC, et al.
    Screening for chronic obstructive pulmonary disease: US Preventive Services Task Force recommendation statement. JAMA 2016; 315: 1372–1377. doi:10.1001/jama.2016.2638
    OpenUrlCrossRefPubMed
  7. ↵
    1. Mangione CM,
    2. Barry MJ,
    3. Nicholson WK, et al.
    Screening for chronic obstructive pulmonary disease: US Preventive Services Task Force reaffirmation recommendation statement. JAMA 2022; 327: 1806–1811. doi:10.1001/jama.2022.5692
    OpenUrl
  8. ↵
    1. Press VG,
    2. Cifu AS,
    3. White SR
    . Screening for chronic obstructive pulmonary disease. JAMA 2017; 318: 1702–1703. doi:10.1001/jama.2017.15782
    OpenUrl
  9. ↵
    1. Venkatesan P
    . GOLD report: 2022 update. Lancet Respir Med 2022; 10: e20. doi:10.1016/S2213-2600(21)00561-0
    OpenUrl
  10. ↵
    1. Qaseem A,
    2. Wilt TJ,
    3. Weinberger SE, et al.
    Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med 2011; 155: 179–191. doi:10.7326/0003-4819-155-3-201108020-00008
    OpenUrlCrossRefPubMed
  11. ↵
    1. Soriano JB,
    2. Zielinski J,
    3. Price D
    . Screening for and early detection of chronic obstructive pulmonary disease. Lancet 2009; 374: 721–732. doi:10.1016/S0140-6736(09)61290-3
    OpenUrlCrossRefPubMed
    1. van der Molen T,
    2. Schokker S
    . Primary prevention of chronic obstructive pulmonary disease in primary care. Proc Am Thorac Soc 2009; 6: 704–706. doi:10.1513/pats.200907-062DP
    OpenUrl
  12. ↵
    1. Martinez FJ,
    2. O'Connor GT
    . Screening, case-finding, and outcomes for adults with unrecognized COPD. JAMA 2016; 315: 1343–1344. doi:10.1001/jama.2016.3274
    OpenUrlPubMed
  13. ↵
    1. Labaki WW,
    2. Han MK
    . Improving detection of early chronic obstructive pulmonary disease. Ann Am Thorac Soc 2018; 15: Suppl. 4, S243–S248. doi:10.1513/AnnalsATS.201808-529MG
    OpenUrl
  14. ↵
    1. Lin JS,
    2. Webber EM,
    3. Thomas RG
    . Screening for Chronic Obstructive Pulmonary Disease: A Targeted Evidence Update for the US Preventive Services Task Force. Rockville, Agency for Healthcare Research and Quality (US), 2022.
  15. ↵
    1. Pietinalho A,
    2. Kinnula VL,
    3. Sovijärvi AR, et al.
    Chronic bronchitis and chronic obstructive pulmonary disease. The Finnish Action Programme, interim report. Respir Med 2007; 101: 1419–1425. doi:10.1016/j.rmed.2007.01.022
    OpenUrlCrossRefPubMed
  16. ↵
    1. Lyngsø AM,
    2. Backer V,
    3. Gottlieb V, et al.
    Early detection of COPD in primary care – the Copenhagen COPD Screening Project. BMC Public Health 2010; 10: 524. doi:10.1186/1471-2458-10-524
    OpenUrlCrossRefPubMed
  17. ↵
    1. Lyngsø AM,
    2. Gottlieb V,
    3. Backer V, et al.
    Early detection of COPD in primary care: the Copenhagen COPD screening project. COPD 2013; 10: 208–215. doi:10.3109/15412555.2012.714426
    OpenUrlCrossRef
  18. ↵
    1. Jordan RE,
    2. Adab P,
    3. Jowett S, et al.
    TargetCOPD: a pragmatic randomised controlled trial of targeted case finding for COPD versus routine practice in primary care: protocol. BMC Pulm Med 2014; 14: 157. doi:10.1186/1471-2466-14-157
    OpenUrl
  19. ↵
    1. Jordan RE,
    2. Adab P,
    3. Sitch A, et al.
    Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial. Lancet Respir Med 2016; 4: 720–730. doi:10.1016/S2213-2600(16)30149-7
    OpenUrl
  20. ↵
    1. Haroon S,
    2. Adab P,
    3. Dickens AP, et al.
    Impact of COPD case finding on clinical care: a prospective analysis of the TargetCOPD trial. BMJ Open 2020; 10: e038286. doi:10.1136/bmjopen-2020-038286
    OpenUrlPubMed
  21. ↵
    1. Zieliñski J,
    2. Bednarek M
    . Early detection of COPD in a high-risk population using spirometric screening. Chest 2001; 119: 731–736. doi:10.1378/chest.119.3.731
    OpenUrlCrossRefPubMed
    1. Zielinski J,
    2. Bednarek M,
    3. Górecka D, et al.
    Increasing COPD awareness. Eur Respir J 2006; 27: 833–852. doi:10.1183/09031936.06.00025905
    OpenUrlFREE Full Text
  22. ↵
    1. Bednarek M,
    2. Maciejewski J,
    3. Wozniak M, et al.
    Prevalence, severity and underdiagnosis of COPD in the primary care setting. Thorax 2008; 63: 402–407. doi:10.1136/thx.2007.085456
    OpenUrlAbstract/FREE Full Text
  23. ↵
    1. Jarhyan P,
    2. Hutchinson A,
    3. Khatkar R, et al.
    Diagnostic accuracy of a two-stage sequential screening strategy implemented by community health workers (CHWs) to identify individuals with COPD in rural India. Int J Chron Obstruct Pulmon Dis 2021; 16: 1183–1192. doi:10.2147/COPD.S293577
    OpenUrl
  24. ↵
    1. Siddharthan T,
    2. Pollard SL,
    3. Quaderi SA, et al.
    Effectiveness-implementation of COPD case finding and self-management action plans in low- and middle-income countries: global excellence in COPD outcomes (GECo) study protocol. Trials 2018; 19: 571. doi:10.1186/s13063-018-2909-8
    OpenUrlPubMed
    1. Mohan S,
    2. Cárdenas MK,
    3. Ricciardi F, et al.
    Cost-accuracy analysis of chronic obstructive pulmonary disease screening in low- and middle-income countries. Am J Respir Crit Care Med 2022; 206: 353–356. doi:10.1164/rccm.202201-0071LE
    OpenUrl
  25. ↵
    1. Siddharthan T,
    2. Pollard SL,
    3. Quaderi SA, et al.
    Discriminative accuracy of chronic obstructive pulmonary disease screening instruments in 3 low- and middle-income country settings. JAMA 2022; 327: 151–160. doi:10.1001/jama.2021.23065
    OpenUrl
  26. ↵
    1. Summary of the Work on Deepening Reform of the Medical and Health Care System in 2020 (in Chinese)
    1. National Health Commission of the People's Republic of China
    . Summary of the Work on Deepening Reform of the Medical and Health Care System in 2020 (in Chinese). 2021. www.nhc.gov.cn/tigs/ygjb/202107/d4bfd518075d4aff9fa3dcd362071b4b.shtml. Date last accessed: 10 September 2022.
  27. ↵
    1. National Center for Respiratory Diseases.The Initiation of the National COPD Screening Program (in Chinese)
    . 2021. www.cn-healthcare.com/article/20211019/content-561470.html. Date last accessed: 28 June 2022.
  28. ↵
    1. Tan HZ,
    2. Zhan SY,
    3. Luan RS, et al.
    Modern Epidemiology. 3rd Edn. Beijing, People's Medical Publishing House, 2019.
    1. National Bureau of Statistics
    . The Seventh National Population Census Data of China (2020). 2021. http://www.stats.gov.cn/tjsj/pcsj/rkpc/7rp/zk/indexch.htm. Date last accessed: 1 January 2023.
  29. ↵
    1. Zhou YM,
    2. Chen SY,
    3. Tian J, et al.
    Development and validation of a chronic obstructive pulmonary disease screening questionnaire in China. Int J Tuberc Lung Dis 2013; 17: 1645–1651. doi:10.5588/ijtld.12.0995
    OpenUrlPubMed
  30. ↵
    1. Writing Committee of the Expert Consensus
    . Chinese Association of Chest Physicians, Primary Health Care Working Committee. Expert consensus on chronic obstructive pulmonary disease screening at county level in China (2020). Natl Med J China 2021; 101: 989–994.
    OpenUrl
    1. Chinese Thoracic Society, Chronic Obstructive Pulmonary Disease Academic Group; Chinese Association of Chest Physicians, Chronic Obstructive Pulmonary Disease Working Committee
    . Guidelines for the diagnosis and treatment of chronic obstructive pulmonary disease (revised in 2021) (in Chinese). Chin J Tuberc Respir Dis 2021; 44: 170–205.
    OpenUrl
  31. ↵
    1. Expert Group of the Practice Guidelines
    . Practice guidelines on clinical diagnosis and treatment of chronic obstructive pulmonary disease (in Chinese). Int J Respir 2022; 42: 401–409.
    OpenUrl
  32. ↵
    1. Global Initiative for Chronic Obstructive Lung Disease
    . Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2021). 2021. www.goldcopd.org. Date last accessed: 15 June 2022.
  33. ↵
    1. Miller MR,
    2. Hankinson J,
    3. Brusasco V, et al.
    Standardisation of spirometry. Eur Respir J 2005; 26: 319–338. doi:10.1183/09031936.05.00034805
    OpenUrlAbstract/FREE Full Text
  34. ↵
    1. Graham BL,
    2. Steenbruggen I,
    3. Miller MR, et al.
    Standardization of spirometry 2019 update. An official American Thoracic Society and European Respiratory Society Technical statement. Am J Respir Crit Care Med 2019; 200: e70–e88. doi:10.1164/rccm.201908-1590ST
    OpenUrlCrossRefPubMed
  35. ↵
    1. Chinese Thoracic Society, Lung Function Group
    . Guidelines on Lung Function Test (Part II): the Spirometry (in Chinese). Chinese J Tuberculosis Respir Dis 2014; 37: 481–486.
    OpenUrl
  36. ↵
    1. Fang L,
    2. Gao P,
    3. Bao H, et al.
    Chronic obstructive pulmonary disease in China: a nationwide prevalence study. Lancet Respir Med 2018; 6: 421–430. doi:10.1016/S2213-2600(18)30103-6
    OpenUrl
  37. ↵
    1. Guirguis-Blake JM,
    2. Senger CA,
    3. Webber EM, et al.
    Screening for chronic obstructive pulmonary disease: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2016; 315: 1378–1393. doi:10.1001/jama.2016.2654
    OpenUrlCrossRefPubMed
  38. ↵
    1. Choi N,
    2. Jang S,
    3. Yoo KH, et al.
    The effectiveness and harms of screening for chronic obstructive pulmonary disease: an updated systematic review and meta-analysis. J Korean Med Sci 2022; 37: e117. doi:10.3346/jkms.2022.37.e117
    OpenUrl
  39. ↵
    1. Wang C,
    2. Chen S,
    3. Shan G, et al.
    Strengthening population medicine to promote public health. Chin Med J 2022; 135: 1135–1137. doi:10.1097/CM9.0000000000002221
    OpenUrl
  40. ↵
    1. Price DB,
    2. Tinkelman DG,
    3. Nordyke RJ, et al.
    Scoring system and clinical application of COPD diagnostic questionnaires. Chest 2006; 129: 1531–1539. doi:10.1378/chest.129.6.1531
    OpenUrlCrossRefPubMed
    1. Martinez FJ,
    2. Raczek AE,
    3. Seifer FD, et al.
    Development and initial validation of a self-scored COPD Population Screener Questionnaire (COPD-PS). COPD 2008; 5: 85–95. doi:10.1080/15412550801940721
    OpenUrlCrossRefPubMed
    1. Hanania NA,
    2. Mannino DM,
    3. Yawn BP, et al.
    Predicting risk of airflow obstruction in primary care: validation of the lung function questionnaire (LFQ). Respir Med 2010; 104: 1160–1170. doi:10.1016/j.rmed.2010.02.009
    OpenUrlCrossRefPubMed
    1. Martinez FJ,
    2. Mannino D,
    3. Leidy NK, et al.
    A new approach for identifying patients with undiagnosed chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2017; 195: 748–756. doi:10.1164/rccm.201603-0622OC
    OpenUrlPubMed
    1. Weiss G,
    2. Steinacher I,
    3. Lamprecht B, et al.
    Development and validation of the Salzburg COPD-screening questionnaire (SCSQ): a questionnaire development and validation study. NPJ Prim Care Respir Med 2017; 27: 4. doi:10.1038/s41533-016-0005-7
    OpenUrl
  41. ↵
    1. Siddharthan T,
    2. Wosu AC,
    3. Pollard SL, et al.
    A novel case-finding instrument for chronic obstructive pulmonary disease in low- and middle-income country settings. Int J Chron Obstruct Pulmon Dis 2020; 15: 2769–2777. doi:10.2147/COPD.S268076
    OpenUrlPubMed
  42. ↵
    1. Kjeldgaard P,
    2. Lykkegaard J,
    3. Spillemose H, et al.
    Multicenter study of the COPD-6 screening device: feasible for early detection of chronic obstructive pulmonary disease in primary care? Int J Chron Obstruct Pulmon Dis 2017; 12: 2323–2331. doi:10.2147/COPD.S136244
    OpenUrl
  43. ↵
    1. Frith P,
    2. Crockett A,
    3. Beilby J, et al.
    Simplified COPD screening: validation of the PiKo-6® in primary care. Prim Care Respir J 2011; 20: 190–198. doi:10.4104/pcrj.2011.00040
    OpenUrlCrossRefPubMed
  44. ↵
    1. Pan Z,
    2. Dickens AP,
    3. Chi C, et al.
    Accuracy and cost-effectiveness of different screening strategies for identifying undiagnosed COPD among primary care patients (≥40 years) in China: a cross-sectional screening test accuracy study: findings from the Breathe Well group. BMJ Open 2021; 11: e051811. doi:10.1136/bmjopen-2021-051811
    OpenUrlAbstract/FREE Full Text
  45. ↵
    1. Young RP,
    2. Hopkins RJ
    . Chronic obstructive pulmonary disease (COPD) and lung cancer screening. Transl Lung Cancer Res 2018; 7: 347–360. doi:10.21037/tlcr.2018.05.04
    OpenUrlPubMed
  46. ↵
    1. Heuvelmans MA,
    2. Vonder M,
    3. Rook M, et al.
    Screening for early lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease (the big-3) using low-dose chest computed tomography: current evidence and technical considerations. J Thorac Imaging 2019; 34: 160–169. doi:10.1097/RTI.0000000000000379
    OpenUrlPubMed
    1. Xia C,
    2. Rook M,
    3. Pelgrim GJ, et al.
    Early imaging biomarkers of lung cancer, COPD and coronary artery disease in the general population: rationale and design of the ImaLife (Imaging in Lifelines) Study. Eur J Epidemiol 2020; 35: 75–86. doi:10.1007/s10654-019-00519-0
    OpenUrlCrossRef
  47. ↵
    1. Du Y,
    2. Li Q,
    3. Sidorenkov G, et al.
    Computed tomography screening for early lung cancer, COPD and cardiovascular disease in Shanghai: rationale and design of a population-based comparative study. Acad Radiol 2021; 28: 36–45. doi:10.1016/j.acra.2020.01.020
    OpenUrlPubMed
  48. ↵
    1. Li N,
    2. Tan F,
    3. Chen W, et al.
    One-off low-dose CT for lung cancer screening in China: a multicentre, population-based, prospective cohort study. Lancet Respir Med 2022; 10: 378–391. doi:10.1016/S2213-2600(21)00560-9
    OpenUrl
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The national COPD screening programme in China: rationale and design
Jieping Lei, Ke Huang, Jun Pan, Wei Li, Hongtao Niu, Xiaoxia Ren, Fen Dong, Yong Li, Baicun Li, Cunbo Jia, Ting Yang, Chen Wang
ERJ Open Research Mar 2023, 9 (2) 00597-2022; DOI: 10.1183/23120541.00597-2022

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The national COPD screening programme in China: rationale and design
Jieping Lei, Ke Huang, Jun Pan, Wei Li, Hongtao Niu, Xiaoxia Ren, Fen Dong, Yong Li, Baicun Li, Cunbo Jia, Ting Yang, Chen Wang
ERJ Open Research Mar 2023, 9 (2) 00597-2022; DOI: 10.1183/23120541.00597-2022
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