Why Is Europe Neglecting Chronic Respiratory Disease?

The magnitude of chronic respiratory diseases (CRDs) across Europe has been overlooked, leading to under- and misdiagnosis, poor management, and inadequate funding, according to a new report.

Published by the World Health Organization (WHO) Europe and the European Respiratory Society, the report found that 81.7 million people in the region are living with a CRD — including chronic obstructive pulmonary disease (COPD), asthma, and other lung diseases — and 6.8 million are newly diagnosed each year.

CRDs are the sixth leading cause of death in the WHO European region, with almost 400,000 dying from a CRD every year, nearly 80% of which are caused by COPD. However, most of these deaths are driven by preventable risk factors, primarily tobacco use and indoor and outdoor air pollution. The region has one of the highest rates of tobacco use, with one fourth of its adults being smokers, and more than 90% breathing air that is polluted with dangerous levels of particulate matter.

Answering the Whys

So why are CRDs so vastly underdiagnosed in Europe? Why do healthcare professionals not have the skills and expertise to identify them, as stated in the report? And what resources are required to bridge this gap?

On a policy level, the report noted an important paradox: Earlier progress led to a decline in CRD mortality, but this consequently led to reduced research funding and weakened surveillance. Without understanding the true burden of disease, it is difficult to advocate for increased policy focus and additional funding.

“Unfortunately, due to complexity with their definitions and absence of unanimously agreed targets, CRD surveillance and monitoring systems are not well designed,” the report said. “Determining the real magnitude of the CRD burden is fundamental to identifying unmet needs at population level.”

“There has been a reduction in investment for CRD research compared with other noncommunicable diseases, where epidemiological studies have defined their global burden and priority actions; there are only a handful of population-based studies on CRDs,” the report continued.

Numerous health system and health worker challenges prevent the timely and correct diagnosis of CRDs. These include overlapping symptoms with other respiratory conditions and frequent comorbidities; limited healthcare provider knowledge and skills, especially at the primary healthcare level; inadequate access to diagnostic tools; lack of respiratory health specialists; and lack of awareness among patients, all of which can contribute to under- and misdiagnosis and thus delays in accessing treatment.

Respiratory Diseases Not so Glamorous

Philip Bardin, FRACP, PhD, professor and director of Lung and Sleep Medicine at Monash University and Medical Centre, Melbourne, Australia, and an international authority in the field of asthma and COPD, told Medscape Medical News that the impact of CRDs in the community has long been underappreciated.

“We compete in the health space with other chronic diseases that use shock and awe tactics such as: ‘You will have a stroke, a heart attack, or your foot will fall off’ to gain public attention and funding,” he said. “Historically, [there has been] poor advocacy by craft groups.”

Peter Burney, MD, professor of respiratory epidemiology and public health at the National Heart and Lung Institute at Imperial College London and honorary consultant physician at Royal Brompton Hospital, London, England, echoed Bardin’s thoughts.

“Respiratory diseases are not glamourous; there is little sympathy for the old and the poor, and even less if they have been smokers. Asthma research has always been better funded with publicity that focuses on childhood [exposure to] smoking. Governments ought to be spurred on by the high costs of COPD in [terms of] direct costs of hospitalization.”

He cited a 2015 study published in the journal Chest that reviewed population-based prevalence studies that measured lung function and looked for undiagnosed COPD.

Undiagnosed COPD was high in almost all locations studied, he said.

“London (UK) had a high prevalence of disease, but approximately 80% [of detected COPD cases were] undiagnosed. The why is complicated,” he said. “Firstly, COPD is a very recent invention, and chronic obstructive pulmonary disease may mean more to average Americans than others. We used to call it bronchitis or chronic obstructive bronchitis.”

The Primary Care Challenge

With a shortage of respiratory specialists, some countries are expanding the role of primary healthcare to include the identification of CRDs, joining many other countries that have for decades put primary providers on the front line of respiratory medicine.

But while spirometry is one of the essential tools for diagnosing and monitoring CRDs, it remains limited as it requires well-trained staff, reliable equipment, and standardized procedures.

“Spirometry is not commonly done in general practice, and it was more or less stopped during COVID. It is difficult to do well, and quality assurance is a problem,” Burney said. “If a practitioner is not using skills learned in medical school and in early training, the skill in interpreting spirometry results soon atrophies. In addition, primary care is feeling a bit put upon, and it is difficult in these circumstances to launch a whole new initiative.”

Promise in Education

Expanding education and using innovative technology appear to hold some promise in overcoming such challenges.

The report cited Spain, which has a new e-learning program, Spirometry Simplified, for primary healthcare providers to expand their knowledge. Also, Italy and Spain are testing tele-spirometry. Here, a technician remotely controls from within a hospital a computer with spirometer software that is connected to a primary care patient. The aim is to help overcome the issue of poor-quality spirometry use in primary care.

“Solutions need to come via patient participation and teamwork by doctors, nurses, and others to improve care. Waiting for governments and bureaucrats to solve problems will take us nowhere,” Bardin said. “Doing better what we’ve always done will get us what we’ve always had.”

Bardin and Burney reported having no relevant financial relationships.

Sophie Cousins, MIPH, is a global health journalist who has reported from more than 20 countries.