The majority of patients with chronic obstructive pulmonary disease (COPD) are cared for by primary care providers (PCPs). While some studies suggest that certain patients who are treated by pulmonary specialists may experience improved outcomes, the role of PCPs in the diagnosis and treatment of patients with COPD remains critical.

PCPs play a central role in all aspects of COPD, in terms of both diagnosis and long-term management. We know that there may often be a long lag between the onset of COPD and its diagnosis, mainly because many of the symptoms are nonspecific. Unless someone suspects that a patient has COPD, the diagnosis is often not made, and these individuals with nonspecific symptoms are most often being seen in the primary care setting.

Even after a diagnosis of COPD is made, approximately 90% of patients receive their care from PCPs. In a large study from Canada that evaluated nearly 900,000 individuals with COPD, more than 82% of people with COPD saw other specialists for the management of comorbidities, but only approximately 11% saw a pulmonologist. Moreover, only 30% of high-risk patients who had been hospitalized with COPD-related symptoms were being treated by a pulmonologist. These data underscore that, for most patients with COPD, the PCP is the primary decision maker. They are most often responsible for the diagnosis, initial treatment selection, and ongoing management.

If patients are seen by a pulmonologist, does it change outcomes? The data are mixed. Some studies have shown improved outcomes in those seeing a specialist, some have not. However, there are data to suggest that pulmonologists are more likely to use practices that are aligned with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidance, including using spirometry to confirm diagnosis and prescribing medications that are concordant with the guidelines.

While there is no official US guidance on when a patient should be referred to a pulmonologist, the National Institute for Health and Care Excellence (NICE) from the United Kingdom recommends that the following patients may benefit from seeing a specialist: those with frequent exacerbations, those with lung hyperinflation who are under consideration for lung volume reduction procedures, those who may need oxygen therapy or chronic noninvasive ventilation therapy, and those with hemoptysis or other comorbidities such as bronchiectasis.

There are some barriers to providing optimal COPD management in the primary care setting. Limited access to spirometry equipment, difficulty interpreting spirometry results, and time constraints when caring for patients with multiple comorbidities are all clinical challenges. This is especially important because confirming the diagnosis via spirometry and clarifying any overlap with other diseases such as coronary artery disease and congestive heart failure are key for appropriate treatment.

Given their central role, PCPs are uniquely positioned to improve treatment overall for patients with COPD. The continuity of care and frequent patient contact they provide can help support treatment adherence. PCPs can also optimize outcomes by implementing regular assessments of inhaler technique and secondary prevention interventions such as smoking cessation, simplifying treatment regimens when possible, addressing cost and insurance barriers, and reinforcing patient education.