Israel Medical Association Journal

Background: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends a ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) of less than 70% (FEV1/FVC < 0.7) after bronchodilators as the criteria for obstruction. However, because the FEV1/FVC ratio decreases with age, using a fixed ratio may lead to overdiagnosis of obstruction in the geriatric population. Using the lower limit of normal (LLN) as threshold for obstruction has been suggested.

Objectives: To determine the rate of overdiagnosis using the GOLD criteria compared to LLN in patients aged 60 and older. To find a better threshold with a minimal rate of over- and underdiagnosis.

Methods: The study population included adults aged 60 years and older who performed pulmonary function test (PFT) at Shaare Zedek Medical Center between 2014 and 2019 with results of FEV1/FVC < 0.7.

Results: We included 430 patients aged 60 years and older, 273 males (63.5%) and 157 females (36.5%). Mean age was 72 ± 8 years. Overdiagnosis was found in 35.6% of patients (95% confidence interval 31.1–40.3%) by using the GOLD criteria compared to the LLN. Overdiagnosis was reduced to 6.4% with the 0.65 threshold. The ideal point of the FEV1/FVC ratio where overdiagnosis and underdiagnosis were at their lowest rates was 0.638.

Conclusions: Use of the GOLD criteria for airflow obstruction may be associated with an overdiagnosis of more than 35% in patients older than 60 years. Lowering the FEV1/FVC ratio to < 0.65 might be more accurate in this population.

Too much healthcare is prevalent, wasteful, and harmful. It consists of two separate phenomena: overdiagnosis and overuse. Overdiagnosis is the labeling of a person with a disease or abnormal condition that would not have caused the person harm if left undiscovered. Individuals derive no clinical benefit from overdiagnosis, although they may experience physical, psychological, or financial harm. It has been found that 15–30%, 20–50%, 0–67%, and 50–90% of people with screen detected breast, prostate, lung, and thyroid cancer, respectively, are overdiagnosed. Since many screening tests have trade-off between benefit and harm, a shared decision-making approach is essential. Incidental findings are very common and may also cause overdiagnosis. Overdiagnosis is recognizable in populations and not at the individual level. However, overuse is recognizable at the level of the individual practitioner. Choosing Wisely, an intervention directed at reducing low value care, now faces the challenge of developing interventions that go beyond recommendations. While some of the drivers of overdiagnosis and overuse are similar, different and parallel strategies are needed in order to reduce them. This is one of the major challenges to our health care system.