Chronic obstructive pulmonary disease (COPD) has a significant impact on morbidity and mortality. Considering the number of patients registered in the mainland Portugal primary healthcare (PHC) units, there has been a 152% increase in COPD diagnoses between 2011 and 2019, totalizing 137,774 registered patients in December 2019.¹

PHC is the primary contact of patients with COPD and plays a critical role in their treatment and improving their quality of life. ² PHC are essential for prevention, early diagnosis, follow-up, and, whenever necessary, referral of difficult-to-control COPD cases. ^2-3 The evaluation of COPD patients’ follow-up on PHC is made by a set of relevant indicators to be recorded and monitored as they set opportunities to improve patient care.

The coronavirus disease 2019 (COVID-19) pandemic has brought challenges and difficulties that impact the healthcare system. Routine management and diagnosis of COPD have entirely changed in many settings, reducing regular face-to-face consultations to severe situations and limiting spirometry and pulmonary rehabilitation. ^1,4

Aiming to reflect on the COVID-19 pandemic impact on COPD management at PHC, we analyzed the publicly available COPD indicators of the BI-CSP platform (a solution for clinical and health governance in primary healthcare, available at https://bicsp.min-saude.pt/), considering monthly data between Dec/2018 and Feb/2020 (pre-pandemic), between Mar/2020 and Jun/2021 (pandemic) and between Jul/2021 and Sep/2022 (post-general population vaccination against COVID-19). The National values of the following indicators were analyzed: proportion of patients with COPD with FEV1 evaluation in three years (BI-CSP indicator 2013.049.01); incidence of COPD (BI-CSP indicator MORB.241.01); proportion of elderly or chronic disease with flu vaccine (BI-CSP indicator 2013.030.01); proportion of COPD patients >6 months with flu vaccine (BI-CSP indicator 2021.439.01); and proportion of COPD patients aged 40 years or older with a COPD surveillance consultation registered in the last year (BI-CSP indicator 2021.436.01).

Figure 1 presents the PHC COPD indicators in the three periods and data from the Directorate General for Health (DGS) concerning COVID-19 incident cases between March 2020 and March 2022.

*Resulting from the reprocessing of year-end data in February (BI-CSP). 

Before the pandemic, there was a growing trend in the proportion of PHC patients with COPD, which reversed after the beginning of the pandemic and remained until the end of 2020. A fast increase is observed during 2021, with a new significant decrease in early 2022, coincident with the new pandemic peak. This indicator was stabilizing to values slightly lower than before the COVID-19 pandemic in September 2022.

To some extent, the evolution of these indicators overlaps the pandemic waves, the infection control measures and lockdowns, and the vaccination periods. The variable diagnostic opportunities due to whether or not patients attended their consult caused by fear of seeking medical assistance or by consultations reductions, patients seeking assistance only in acute episodes and reduced prevalence of seasonal respiratory viruses, may explain the decrease in the number of incident COPD cases, similar to other countries.

The eligibility of COPD patients for priority COVID-19 vaccination may have driven an increase in the codification of this condition in PHC. However, the proportion of patients with COPD and FEV1 in the previous three years has decreased, possibly due to the difficulty in conducting spirometry. During the pandemic, the international recommendations were to restrict pulmonary function testing to selected cases only, limiting the number of regular pulmonary function tests and new diagnoses. ⁵ The COPD and FEV1 indicators have been increasing after the last most significant peak of cases in Jan-Feb/2022 but in September 2022 were not yet reaching pre-pandemic values.

Since Sep/2021, an indicator concerning the proportion of COPD patients aged 40 years or older with a COPD surveillance consultation registered in the last year is available. In Sep/2021, 47.1% of PHC patients had a registry of at least one surveillance consultation. One year later, in Sep/2022, although an increase of 8.8% was seen, only half of PHC patients (51.3%) had a registry, showing that still much is yet to be done.

The COVID-19 pandemic brought opportunities to reorganize and contemplate specific actions on lung diseases other than COVID-19. Given the disease characteristics, this pandemic led to an increased interest in respiratory illnesses, including COPD. ⁶ This increased awareness may influence some PHC indicators, namely, the flu vaccination coverage that showed a greater adherence in the last pandemic period (Figure 1b). Data for COPD patients have only been available since September 2020. Still, if it follows the curve of older patients, flu coverage is expected to grow and remain higher than observed before the pandemic. Accordingly, we can assume that the pandemic positively affected awareness among groups at higher risk, namely COPD patients.

The analysis of the COPD indicators of the BI-CSP platform allowed us to confirm the significant impact of the COVID-19 pandemic on COPD management at PHC. The restrictions of patients’ visits and difficulty in conducting spirometry limited diagnostic opportunities; on the other hand, the pandemic increased population awareness of vaccination and respiratory diseases. Beyond the primary objective of this analysis, these results lead us to identify the needs and barriers to COPD management in PHC. There is a need to identify and monitor COPD patients, and there must be available, equitable, accessible resources to achieve this goal. Although the BI-CSP platform allows for more detailed information for registered PHC professionals, this analysis was restricted by access to public data.

There are scarce data on the National prevalence of COPD in Portugal. Considering the 2013 study from Barbara et al. restricted to the Lisbon area, where 14.2% of the population aged ≥40 years old presented COPD, ⁷ we can assume that the 2022 prevalence of 2.28% among PHC registered patients aged ≥40 years old observed in the BI-CSP platform is highly underestimated. ⁸ There is undoubtedly a need to identify, follow, and manage Portuguese COPD patients. The availability of management data, contractualized indicators as existing in diabetes or hypertension, a COPD-specific computer system allowing patient surveillance, a structured, scheduled consultation not dependent on exacerbations occurrence, on-time access to spirometry, improvement COPD awareness and knowledge are some of the measures that we believe that would enhance PHC COPD management and health outcomes.