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ORIGINAL RESEARCH
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External validation of the PUMA COPD diagnostic

questionnaire in a general practice sample and the
PLATINO study population
This article was published in the following Dove Press journal:
International Journal of Chronic Obstructive Pulmonary Disease

Maria Victorina Lopez Varela1 Background: A seven-item prescreening questionnaire (gender, age, pack-years smoking,
Maria Montes de Oca2 dyspnea, sputum, cough, previous spirometry data) was developed for COPD detection in the
Fernando C Wehrmeister3 primary care setting (PUMA Study) of four Latin America countries.
Cecilia Rodriguez1 Objectives: To validate the PUMA prescreening COPD questionnaire externally in two
For personal use only.

different populations (primary care and general).

Larissa Ramirez4
Methods: The PUMA prescreening COPD questionnaire score was applied to subjects from
Ana Menezes3
the Hospital Maciel, Montevideo (primary care), case-finding program and the PLATINO
On behalf of the PLATINO team population (general) using PUMA study inclusion criteria. Post-bronchodilator FEV1/FVC
<0.70 and lower limit of normal (LLN) criteria were used to define COPD. Area under the
1
Department of Pulmonary, Universidad received operator curve (ROCAUC), sensitivity, specificity, predictive positive and negative
de la República, Montevideo, Uruguay;
2 values (PNV), number needed to treat (NNT), and best cut-points of the score were
Department of Pulmonary, Universidad
Central de Venezuela, Caracas, calculated.
Venezuela; 3Department of Pulmonary, Results: 974 individuals from Hospital Maciel and 2512 from the PLATINO population
Federal University of Pelotas, Pelotas,
Brazil; 4Department of Pulmonary,
were eligible, using post-bronchodilator FEV1/FVC <0.70, 45.1% and 18.7% had COPD,
AstraZeneca, San Jose, Costa Rica respectively, and using LLN 38.4% and 15.4% had COPD, respectively. From Hospital
Maciel (post-bronchodilator FEV1/FVC <0.70), the best cut-point of ≥6 had moderate
discriminatory power (ROCAUC 0.70), sensitivity 69.9%, specificity 62.1%, PNV 70.9%,
and NNT of 3. The discriminatory power was 0.73 (ROCAUC) in the PLATINO population
with three potential cut-points (Youden’s index): ≥3 (sensitivity 85.4%, specificity 46.9%),
≥4 (sensitivity 66.7%, specificity 66.5%), and ≥5 (sensitivity 51.5%, specificity 81.6%); the
PNV at each cut-point was 93.3%, 89.9%, and 88.0%, respectively. The NNT was 5 for
scores ≥3 and ≥4, and 4 for ≥5. The mean accuracy using the LLN for Hospital Maciel and
PLATINO was 0.67 and 0.70, respectively.
Conclusion: External validation of the PUMA prescreening questionnaire in two Latin
American populations (general and primary care) suggests moderate accuracy, similar to the
original study in which the questionnaire was developed.
Keywords: COPD, diagnostic questionnaire, primary care, validation, Latin America

Introduction
COPD is a common condition that leads to physical disability and represents a
Correspondence: Maria Victorina Lopez major health problem worldwide.
Varela Several studies have evaluated the prevalence of COPD underdiagnosis in different
Universidad de la República, Facultad de
Medicina, Hospital Maciel, Montevideo settings.1–4 Lamprecht et al evaluated the underdiagnosis of COPD using different
11200, Uruguay population-based studies and reported that approximately 81% of COPD cases remain
Tel +598 9 961 7256
Email victorina.lopezvarela@gmail.com undiagnosed and that there is considerable variation between the locations.2 In contrast,

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http://doi.org/10.2147/COPD.S206250
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 Lopez Varela et al Dovepress

Casas et al evaluated a high-risk primary care population PUMA was a multicenter, multinational, cross-sectional, non-
from Latin America and found COPD underdiagnosis in interventional study conducted in the primary care setting of
77% of cases when using a definition of post-bronchodilator four Latin American countries: Argentina, Colombia,
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FEV1/FVC<0.70, and underdiagnosis in 73% of cases when Venezuela, and Uruguay. At-risk patients completed the inter-
using a lower limit of normal (LLN) for FEV1/FVC view and performed acceptable post-bronchodilator spirome-
definition.3 Underdiagnosis or non-diagnosis of COPD is try. The simple PUMA prescreening questionnaire assessed
important as these patients have significant limitations in risk factors and respiratory symptoms (gender, age, smoking
their level of physical activity, reduced quality of life, pack-years, dyspnea, sputum, cough, and previous spirometry
increased mortality and also contribute considerably to the data) to select high-risk patients for spirometry screening.14
burden of health care.5–8 Therefore, the approach of trying to The score could range from 0 to 9 (higher scores indicating
identify the underdiagnosis of COPD is essential in order to higher COPD risk) with 0–2 points assigned for each category.
reduce the burden of the disease, delay disease progression The points applied to each variable in the original PUMA
and improve health through smoking cessation support. questionnaire are described in detail elsewhere14 and a mod-
Primary care is an ideal setting for implementing ified version is shown in Table S1. The best cut-point of the
search strategies to detect COPD cases. However, general simple score according to Youden’s index to discriminate
practitioners (GPs) have to handle multiple diseases; there- between persons with and without COPD was ≥5 points and
fore, the availability of a simple tool to identify COPD the discriminatory power represented by the received operator
cases is extremely useful for these physicians. curve (ROC) was 0.76.14
For personal use only.

Different risk factors and symptom-based prescreening

questionnaires have been developed for the early detection External validation samples
of COPD. These questionnaires aid the selection of Patient data used for validation of the prescreening ques-
patients for spirometry screening to confirm definitively tionnaire were taken from the PLATINO population-based
the diagnosis of COPD. study15 and from the Hospital Maciel, Montevideo, pri-
Even though there are validated COPD prescreening mary care case-finding program; in both population sam-
questionnaires9–13 coming from developed countries they ples, those patients fulfilling the original PUMA study
may not be applicable in the primary care or general inclusion criteria (≥40 years, current or ex-smokers [≥10
population of developing countries such as those evaluated pack-years, ≥50 pipes/year or ≥50 cigars/year], and/or
in the present study. exposure to biomass smoke [wood or coal, for cooking
In an at-risk population visiting the primary care set- or heating; exposure ≥100 hr/year]) were selected.14 In the
ting in four Latin American countries, Lopez et al assessed Hospital Maciel sample, the criterion of exposure to bio-
the accuracy of a prescreening score developed to detect mass was not used because these data were not collected.
COPD (the PUMA study).14 The simple score had an For both the PLATINO population-based and the Hospital
accuracy of 76% for detecting COPD (using a definition Maciel samples, the study designs were reviewed and
of post-bronchodilator FEV1/FVC <0.70). To date, there approved, by the local Institutional Review Boards and
has not been an external evaluation of this prescreening Ethics committees, the studies were performed in accor-
questionnaire. dance with the Declaration of Helsinki, and all patients
The aim of this study was to validate externally the provided written informed consent prior to participating.
PUMA study prescreening COPD questionnaire in two
different populations from Latin America and to compare Hospital Maciel, Montevideo, sample
its performance with the findings from the original PUMA The Hospital Maciel, Montevideo, implemented a case-
study. finding COPD program from January 2010 to December
2015. The main objective of this program was to increase
the availability of spirometry and enhance COPD diagno-
Methods sis at the primary care level. The selection of patients for
Development of the PUMA questionnaire spirometry was based on GPs criteria for possible COPD.
in the original sample Each week, a respiratory technician from the pulmonary
The development of the seven-item COPD diagnostic PUMA function laboratory of the Hospital Maciel attended the
questionnaire has been described in detail elsewhere.14 Briefly, primary care centers to perform spirometry in those

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 Dovepress Lopez Varela et al

patients identified by the GPs. Patients completed a short six points. In the PLATINO study, we had a power of
risk factor and respiratory symptoms questionnaire that 100% to estimate the parameters in any of the three
included questions on gender, smoking habits, respiratory major cut-off points (between a score of 3 and 5). All
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symptoms, and prior spirometric testing. Spirometry tests analyses were done using Stata 13.0 (StataCorp. 2013,
were performed using a portable, ultrasound Easy One Stata Statistical Software: Release 13, StataCorp LP,
spirometer (ndd Medical Technologies Inc., Zurich, College Station, TX, USA).
Switzerland) at baseline and 15 mins after inhalation of a
bronchodilator (400 μg salbutamol), according to the Results
American Thoracic Society criteria. A total of 1091 sub- A total of 974 eligible individuals completed interviews and
jects completed the questionnaire and spirometry. performed acceptable spirometry in the Hospital Maciel,
Montevideo sample and 2512 subjects from the PLATINO
PLATINO study sample baseline study (all sites) were eligible for the analysis. The
The PLATINO study was a population-based survey per- flow chart for the patients is shown in Figure 1. Of these,
formed in five Latin American cities; a total of 5314 439/974 (45.1%) subjects in the Hospital Maciel sample
subjects completed the interview and recorded spirometric and 450/2512 (18.7%) subjects from the PLATINO sample
measurements using a portable spirometer (Easy One spi- had COPD defined by post-bronchodilator FEV1/FVC
rometer, ndd Medical Technologies, Inc.) at baseline and <0.70 (Figure 2). Using the LLN criteria, 374/974 (38.4%)
15 mins after inhalation of salbutamol 200 μg, according subjects in the Hospital Maciel sample and 364/2512
For personal use only.

to the American Thoracic Society criteria of acceptability (15.4%) participants in the PLATINO study had COPD
and reproducibility. Complete details of the methodology, (Figure 2).
participation rates and patients’ characteristics of the Description of sample characteristics according to each
PLATINO study have been published elsewhere.16 Data population sample is shown in Table 1. In the Hospital
were collected on several factors potentially associated Maciel sample, there was a higher proportion of women
with COPD, including gender, smoking habits, exposure than men, nearly half of the subjects were ≥60 years of
to biomass smoke, respiratory symptoms, and prior spiro- age, 64% were heavy smokers (>30 pack-years), about
metric testing.16 Copies of the questionnaires are available 75% of subjects reported respiratory symptoms (dyspnea,
at the PLATINO website (http://www.platino-alat.org). cough, and phlegm) and previous spirometry had only
been performed in about 8% of subjects. In the
COPD definition PLATINO study, the proportion of men was slightly higher
Definition and severity stratification of COPD proposed by than women, around one-third of subjects were ≥60 years
GOLD was used: post-bronchodilator FEV1/FVC <0.70. of age, subjects smoked less (about 60% smoked <20
We also performed parallel analyses using the post- pack-years), dyspnea was the most common symptom
bronchodilator LLN for FEV1/FVC as a criterion to define (~47%), only about 25% of subjects reported cough and
COPD.16 phlegm, and previous spirometry had only been performed
in 13% of subjects.
Statistical analysis Description of COPD individuals’ characteristics from
The characteristics of the patient populations in the two population sample according to the post-bronchodilator
studies were described as absolute values and relative FEV1/FVC <0.70 and the LLN definitions are shown in
frequencies. The simple score was applied and then we Tables 2 and 3, respectively. Using the post-bronchodilator
calculated the area under the ROC and also the sensitivity, FEV1/FVC <0.70 definition, COPD patients in the
specificity, predictive positive value (PPV), predictive Hospital Maciel sample were more likely to be men,
negative value (PNV), and the number needed to treat approximately 60% were ≥60 years of age, heavy smokers
(NNT) for each point in the score. The Youden index (70% smoked >30 pack-years), with moderate to very
(the sum of sensitivity and specificity-1) was used to severe airway obstruction (GOLD ≥2) and respiratory
determine the best cut-point. We calculated the power of symptoms reported in >70% of patients (Table 2).
our analyses, considering the obtained results, using the Previous spirometry was recorded in only 11% of patients.
routine rocsize in Stata. For the study in Hospital Maciel, In the PLATINO sample, COPD subjects were more likely
our sample had a power of 99.8% for the cut-off score of to be men, ≥60 years of age (58%), there were fewer

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Hospital maciel sample PLATINO sample

Original sample Original sample

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N = 1,091 N = 5,571
Excluded
N = 177 Excluded
(pack-year<10 during N = 3,059
life)
Final sample Biomass exposure only;N=137
Pack-year in life only;N = 667
N = 974 Current smoker;N = 550
Any co-occurrence;N=1,705
Final sample

N = 2,512

Figure 1 The flow chart for the patients screening.

50% Table 1 Description of sample characteristics for the Hospital

45.1%
Maciel, Montevideo, and the PLATINO study samples
40% 38.4%
For personal use only.

Characteristics Hospital Maciel, PLATINO study

Patients (%)

30% Montevideo

20% 18.7% n (%) [N=974] n (%) [N=2512]

15.4%
Sex
10%
Female 531 (54.5) 1225 (48.8)
0% Male 443 (45.5) 1287 (51.2)
Hospital Maciel PLATINO
FEV1/FVC <0.70 LLN Age (complete years)

40–49 141 (14.5) 972 (39.1)

Figure 2 Prevalence of COPD according to different criteria (post-bronchodilator
FEV1/FVC <0.70 and post-bronchodilator LLN for FEV1/FVC) using the Hospital 50–59 349 (35.8) 755 (60.4)
Maciel, Montevideo, sample and the PLATINO study baseline population. 60+ 484 (49.7) 758 (30.5)
Abbreviation: LLN, lower limit of normal.
Pack-years smoked during life

<20 214 (22.0) 1479 (59.2)

smokers (41% smoked <20 pack-years), with mild to
20–30 139 (14.3) 401 (16.1)
moderate airway obstruction (GOLD 1–2) (Table 2). >30 621 (63.7) 617 (24.7)
Dyspnea was the most common symptom (50%), while
Dyspnea
less than half reported cough and phlegm (~35%).
Previous spirometry was recorded in only 22% of patients No 220 (22.6) 1315 (52.9)
Yes 754 (77.4) 1171 (47.1)
(Table 2). Similar results were found in both population
samples for COPD defined using the post-bronchodilator Chronic phlegm
LLN FEV1/FVC definition (Table 3). No 343 (35.2) 1914 (76.2)
The area under the curve (AUCs) of the PUMA simple Yes 631 (64.8) 597 (23.8)
score with COPD as the outcome are shown in Figure 3A
Chronic cough
and B using the post-bronchodilator FEV1/FVC <0.70 and
No 225 (23.1) 1866 (74.3)
post-bronchodilator LLN FEV1/FVC definitions, respec-
Yes 749 (76.9) 645 (25.7)
tively. Sensitivity, specificity, PPV, PNV, and NNT for
each cut-point of the PUMA simple score are shown in Previous spirometry performed during life

Table 4. The mean accuracy (AUCs) of the PUMA simple No 892 (91.6) 2178 (86.8)
score for detecting COPD using post-bronchodilator Yes 82 (8.4) 333 (13.2)

FEV1/FVC <0.70 definition for the Hospital Maciel and Note: Maximum missing values for PLATINO are for variable age (n=27).

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Table 2 Description of sample characteristics for the Hospital Table 3 Description of sample characteristics for the Hospital
Maciel, Montevideo, and the PLATINO study samples in indivi- Maciel, Montevideo, and the PLATINO study samples in indivi-
duals with COPD defined using the post-bronchodilator FEV1/ duals with COPD defined using the post-bronchodilator LLN
FVC <0.70 definition FEV1/FVC definition
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Variable Hospital Maciel, Montevideo PLATINO study Variable Hospital Maciel, Montevideo PLATINO study

n (%) [N=439] n (%) [N=450] n (%) [N=374] n (%) [N=364]

Sex Sex

Female 191 (43.5) 166 (36.9) Female 169 (45.2) 132 (36.3)
Male 248 (56.5) 284 (63.1) Male 205 (54.8) 232 (63.7)

Age (complete years) Age (complete years)

40–49 35 (8.0) 67 (14.9) 40–49 36 (9.6) 84 (23.1)

50–59 138 (31.4) 122 (27.1) 50–59 134 (35.8) 106 (29.1)
60+ 266 (60.6) 261 (58.0) 60+ 204 (54.6) 174 (47.8)

Pack-years smoked during life Pack years smoked during life

<20 67 (15.3) 185 (41.1) <20 55 (14.7) 147 (40.4)

20–30 62 (14.1) 84 (18.7) 20–30 52 (13.9) 70 (19.2)
>30 310 (70.6) 181 (40.2) >30 267 (71.4) 147 (40.4)
For personal use only.

Dyspnea Dyspnea

No 81 (18.5) 222 (49.9) No 70 (18.7) 185 (51.3)

Yes 358 (81.5) 223 (50.1) Yes 304 (81.3) 176 (48.7)

Chronic phlegm Chronic phlegm

No 111 (25.3) 298 (66.2) No 89 (23.8) 226 (62.1)

Yes 328 (74.7) 152 (33.8) Yes 285 (76.2) 138 (37.9)

Chronic cough Chronic cough

No 76 (17.3) 280 (62.2) No 60 (16.0) 220 (60.4)

Yes 363 (82.7) 170 (37.8) Yes 314 (84.0) 144 (39.6)

Previous spirometry performed during life Previous spirometry performed during life

No 390 (88.8) 351 (78.0) No 333 (89.0) 280 (76.9)

Yes 49 (11.2) 99 (22.0) Yes 41 (11.0) 84 (23.1)

GOLD 2007 classification

I 83 (18.9) 247 (54.9)

Hospital Maciel sample has a 70.9% chance of not having
II 236 (53.7) 171 (38.0)
III 100 (22.8) 25 (5.6) COPD (Table 4). In the PLATINO sample, a subject hav-
IV 20 (4.6) 7 (1.56) ing a score of <5 has an 88.0% chance of not having
COPD (Table 4). Similar results were observed with the
LLN definition (Table 4).
PLATINO samples was 0.70 and 0.73 (Figure 3A), respec-
tively. Using the LLN definition for the Hospital Maciel
and PLATINO samples, the mean accuracy was 0.67 and Discussion
0.70, respectively (Figure 3B). The best cut-point accord- In the present study, the validity of the recently developed
ing to Youden’s index (sensitivity + specificity −1) for the PUMA COPD prescreening questionnaire was evaluated
PUMA simple score was ≥6 in the Hospital Maciel sample in two different patient samples: 974 at-risk patients from
and between 3 and 5 in the PLATINO sample, for both the Hospital Maciel primary care COPD case-finding pro-
definitions. Using the post-bronchodilator FEV1/FVC gram, and 2512 subjects from the PLATINO population-
<0.70 definition, a subject having a score of <6 in the based study. The discriminative capacity of the PUMA

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1.00
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0.75
Sensitivity
0.500.25
0.00

0.00 0.25 0.50 0.75 1.00

1-Specificity
Hosp maciel ROC area: 0.7042 PLATINO ROC area: 0.7336
PUMA ROC area: 0.7634 Reference
For personal use only.

B
1.00
0.75
Sensitivity
0.500.25
0.00

0.00 0.25 0.50 0.75 1.00

1-Specificity
Hosp maciel ROC area: 0.6671 PLATINO ROC area: 0.7011
PUMA ROC area: 0.7304 Reference

Figure 3 Area under the ROC for score (1 point for each category variable) with COPD as outcome using: (A) post-bronchodilator FEV1/FVC <0.70 and (B) post-
bronchodilator LLN for FEV1/FVC as definitions for the Hospital Maciel, Montevideo, the PLATINO study, and the original PUMA study baseline populations as samples.
Abbreviations: LLN, lower limit of normal; ROC, received operator curve.

questionnaire in both populations was similar to that found discriminative capacity of the questionnaire was lower at
in the original study: using the COPD definition of post- 0.67 and 0.70, respectively.
bronchodilator FEV1/FVC <0.70, the ROCAUC was 0.70 There are three externally validated prescreening ques-
and 0.73 for the Hospital Maciel and the PLATINO tionnaires that assess risk factors and respiratory symp-
samples, respectively; using the LLN definition, the toms to select high-risk patients for spirometry screening:

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Table 4 Sensitivity, specificity, PPV, PNV for each cut-point of proposed score (1 point for each category variable) using Hospital
Maciel, Montevideo, and PLATINO study samples
Score Sensitivity Specificity PPV PNV NNT
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% (95% CI) % (95% CI) % (95% CI) % (95% CI)

Post-bronchodilator FEV1/FVC <0.70 definition as outcome

Hospital Maciel, Montevideo

≥1 – – – – –
≥2 99.3 (98.0; 99.9) 0.9 (0.3; 2.2) 45.1 (42.0; 48.3) 62.5 (24.5; 91.5) 13
≥3 97.5 (95.6; 98.7) 6.9 (4.9; 9.4) 46.2 (43.0; 49.5) 77.1 (62.7; 88.0) 4
≥4 95.2 (92.8; 97.0) 18.9 (15.6; 22.5) 49.1 (45.7; 52.5) 82.8 (74.9; 89.0) 3
≥5 85.4 (81.8; 88.6) 37.6 (33.5; 41.8) 52.9 (49.1; 56.6) 75.8 (70.2; 80.9) 3
≥6 69.0 (64.5; 73.3) 62.1 (57.8; 66.2) 59.9 (55.5; 64.2) 70.9 (66.6; 75.0) 3
≥7 44.6 (39.9; 49.4) 82.6 (79.1; 85.7) 67.8 (62.1; 73.2) 64.5 (60.8; 68.1) 3
≥8 21.2 (17.5; 25.3) 94.0 (91.7; 95.9) 74.4 (65.8; 81.8) 59.2 (55.9; 62.6) 3
≥9 2.3 (1.1; 4.2) 100.0 (99.3; 100.0) 100.0 (69.2; 100.0) 55.5 (52.3; 58.7) 2

PLATINO study

≥1 98.4 (96.8; 99.4) 7.3 (6.2; 8.6) 19.6 (18.0; 21.3) 95.3 (90.6; 98.1) 7
For personal use only.

≥2 93.0 (90.3; 95.2) 25.2 (23.2; 27.2) 22.2 (20.4; 24.2) 94.0 (91.6; 95.9) 6
≥3 85.4 (81.8; 88.5) 46.9 (44.7; 49.2) 27.0 (24.7; 29.4) 93.3 (91.6; 94.8) 5
≥4 66.7 (63.1; 72.0) 66.5 (64.4; 68.6) 31.7 (28.8; 34.8) 89.9 (88.3; 91.5) 5
≥5 51.5 (46.7; 56.2) 81.6 (79.8; 83.3) 39.1 (35.1; 43.2) 88.0 (86.4; 89.4) 4
≥6 31.5 (27.2; 36.0) 91.3 (89.9; 92.5) 45.3 (39.7; 51.0) 85.3 (83.7; 86.8) 3
≥7 13.5 (10.4; 17.0) 97.6 (96.8; 98.2) 56.1 (46.1; 65.7) 83.1 (81.5; 84.6) 3
≥8 6.3 (4.2; 9.0) 99.6 (99.2; 99.8) 77.8 (60.8; 89.9) 82.2 (80.6; 83.7) 2
≥9 1.4 (0.5; 2.9) 99.9 (99.7; 100.0) 85.7 (42.1; 99.6) 81.5 (79.9; 83.1) 1

Post-bronchodilator LLN FEV1/FVC definition as outcome

Hospital Maciel-Montevideo

≥1 – – – – –
≥2 98.9 (97.3; 99.7) 0.7 (0.2; 1.7) 38.3 (35.2; 41.5) 50.0 (15.7; 84.3) –
≥3 96.8 (94.5; 98.3) 6.0 (4.2; 8.2) 39.1 (35.9; 42.3) 75.0 (60.4; 86.4) 7
≥4 94.4 (91.5; 96.5) 16.8 (13.9; 20.1) 41.4 (38.1; 44.8) 82.8 (74.9; 89.0) 4
≥5 83.2 (79.0; 86.8) 33.7 (29.9; 37.6) 43.9 (40.2; 47.6) 76.2 (70.6; 81.2) 5
≥6 68.4 (63.5; 73.1) 58.3 (54.3; 62.3) 50.6 (46.1; 55.0) 74.8 (70.6; 78.7) 4
≥7 43.9 (38.8; 49.0) 79.1 (75.7; 82.3) 56.7 (50.8; 62.5) 69.3 (65.7; 72.8) 4
≥8 21.1 (17.1; 25.6) 92.3 (89.9; 94.3) 63.2 (54.1; 71.6) 65.3 (61.9; 68.5) 4
≥9 2.1 (0.9; 4.2) 99.7 (98.8; 100.0) 80.0 (44.4; 97.5) 62.0 (58.9; 65.1) 2

PLATINO study

≥1 97.8 (95.7; 99.0) 7.1 (6.0; 8.3) 16.1 (14.6; 17.8) 94.6 (89.6; 97.6) 9
≥2 90.3 (86.8; 93.2) 24.3 (22.4; 26.2) 17.9 (16.2; 19.7) 93.2 (90.7; 95.2) 9
≥3 82.0 (77.6; 85.8) 45.3 (43.1; 47.5) 21.5 (19.4; 23.8) 93.2 (91.4; 94.7) 7
≥4 64.3 (59.1; 69.2) 64.7 (62.6; 66.9) 25.0 (22.2; 27.9) 90.8 (89.2; 92.3) 6
≥5 49.0 (43.8; 54.3) 80.1 (78.3; 81.9) 31.1 (27.3; 35.1) 89.6 (88.1; 91.0) 5
≥6 30.7 (26.0; 35.8) 90.3 (88.9; 91.6) 36.8 (61.3; 42.5) 87.7 (86.2; 89.1) 4
≥7 14.1 (10.7; 18.2) 97.3 (96.5; 98.0) 49.0 (39.1; 59.0) 86.1 (84.6; 87.5) 3
≥8 7.2 (4.8; 10.4) 99.6 (99.2; 99.8) 76.5 (58.8; 89.3) 85.4 (83.9; 86.9) 2
≥9 1.7 (0.6; 3.6) 99.9 (99.7; 100.0) 85.7 (42.1; 99.6) 84.8 (83.2; 86.2) 1
Abbreviations: PPV, predictive positive value; PNV, predictive negative value.

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the COPD Diagnostic Questionnaire (CDQ),9 the Lung The PUMA questionnaire assigns scores to gender,
Function Questionnaire (LFQ),10,11 and the COPD age, smoking history (pack-years), dyspnea, sputum,
Population Screener (COPD-PS).12 The predictive accu- cough and data from prior spirometry. The best cut-point
of ≥5 had a moderate discriminatory power ROCAUC of
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racy of these questionnaires in external validation studies

was measured against post-bronchodilator FEV1/FVC 0.76 with a sensitivity and specificity of 74% and 65%,
<0.70 and ranged from 57% to 72%.13 respectively.14 A subject with a score of <5 has a 91%
The CDQ is a symptom- and risk factor-based COPD (PNV) chance of not having COPD. The use of the PUMA
prescreening questionnaire that was performed in a pri- score to identify patients with and without COPD has not
mary care-based US and UK.9 Possible scores range from been validated in other populations.
0 to 38 (higher scores associated with higher COPD risk). The present study evaluated the discriminatory capa-
Two cut-points (16.5 and 19.5) have been proposed to city of the PUMA questionnaire score in individuals from
select patients for spirometry screening based on two different settings (primary care and general popula-
ROCAUC curves from the original development study.9,17 tion) using the original PUMA study inclusion criteria.
The CDQ has been externally validated in five studies The results from the Hospital Maciel, Montevideo (pri-
focused primarily on European and Australian primary mary care sample), showed that the best cut-point of ≥6
care populations.18–22 Most of the validation studies had a moderate discriminatory power ROCAUC of 0.70, a
reported that a CDQ score of >16.5 had a sensitivity sensitivity of 69.9%, a specificity of 62.1%, a PNV of
70.9% and a NNT of 3 (one person diagnosed with
ranging from 80% to 91% and a specificity ranging
For personal use only.

COPD for every three persons assessed spirometrically).

between 24% and 49% for identifying those subjects
When the questionnaire was applied to the general popula-
who were subsequently found positive for COPD by spiro-
tion sample from the PLATINO study the discriminatory
metry testing.13 The use of a higher cut-point of 19.5
power was slightly better with a ROCAUC of 0.73 and with
reduced sensitivity and PNV, but increased specificity
three potential cut-points according to the Youden’s index:
and PPV. The discriminative ability of the CDQ to identify
≥3 (sensitivity 85.4%, specificity 46.9%), ≥4 (sensitivity
patients with and without COPD ranges from 0.65 to 0.72
66.7%, specificity 66.5%), and ≥5 (sensitivity 51.5%, spe-
(ROCAUC).
cificity 81.6%); the chances for not having COPD (PNV)
The LFQ and the COPD-PS include risk factors and
at each cut-point were 93.3%, 89.9% and 88.0%, respec-
respiratory symptoms.10–12 Scores range from 5 to 25,
tively. The NNT was 5 for scores ≥3 and ≥4, and it was 4
with lower scores associated with an increased risk of
for a score ≥5.
COPD. A threshold of ≤18 has been proposed as the cut-
This validation study, unlike the external validations of
point for the risk of COPD that justifies using spirometry
other questionnaires (CDQ, LFQ and COPD-PS)18–24 found
to confirm the diagnosis. This questionnaire was validated a discriminatory capacity that was similar to that reported in
in a multicenter primary care study in 1288 smokers of at the original PUMA study, both in the primary care and in
least 10 pack-years of exposure.23 The study reported a the general population samples. The results also show a
high unacceptable spirometry rate (31%), as well as an performance of the PUMA score in this external validation
estimated sensitivity of 88% and specificity of 25%. in a similar range to the other prescreening COPD ques-
The COPD-PS assigns scores to age, history of smok- tionnaires (CDQ accuracy 0.65–0.73; LFQ accuracy 0.65;
ing, dyspnea, sputum production and functional limitations and COPD-PS accuracy 0.57–0.70).18–24
related to dyspnea. The score can range from 0 to 10.12 A This study has both strengths and limitations that need to
threshold of ≥5 has been proposed as a cut-point for the be mentioned. The two populations used to validate the
risk of COPD that justifies evaluation with spirometry. PUMA prescreening COPD questionnaire used the same
This questionnaire was validated in a Japanese population inclusion criteria of the original study, with the exception of
study (n=2357) and reported a sensitivity of 67% and biomass in the Hospital Maciel sample. A particular strength
specificity of 73% for a score ≥4, and 35% and 79%, of the study is that both the primary care and general popula-
respectively, for a score ≥5.24 The discriminative ability tion samples are large, and using two different population
(ROCAUC) of the COPD-PS questionnaire to identify samples increases the spectrum of validity of the PUMA
patients with and without COPD was 0.70 (score ≥4) and score. In addition to the lack of information on biomass in
0.57 (score ≥5).24 Hospital Maciel, other limitations are that the study

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 Dovepress Lopez Varela et al

validation samples included patients with and without Disclosure

respiratory symptoms, and this may underestimate the ability Larissa Ramirez is a full-time employee of AstraZeneca
of the PUMA score to detect cases of COPD as defined by the Latin America. Ana Menezes has been paid for her work
International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ by 193.93.192.81 on 17-Oct-2019

GOLD document screening criteria (risk factors plus respira- as a statistician for the study.
tory symptoms).16 This limitation also applies to the other The Hospital Maciel, Montevideo, data of this paper were
prescreening COPD questionnaire studies that looked to presented at the European Respiratory Society 2017 Congress
detect spirometrically defined COPD in patients with risk as a poster presentation with interim findings. The poster’s
factors but who were not necessarily symptomatic. Given the abstract was published in the European Respiratory Journal
controversy of detecting asymptomatic airflow obstruction, 2017; 50 (Suppl 61): PA1198. DOI: 10.1183/1393003. The
this could be considered as an advantage of the prescreening authors report no other conflicts of interest in this work.
COPD questionnaire in that asymptomatic patients would be
less likely to score above the validated cut-points. Further
research is needed to determine if the PUMA score performs
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Author contributions Chron Obstruct Pulm Dis. 2010;5:1–10.
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agree to be accountable for all aspects of the work. Respirology. 2016;21(7):1227–1234. doi:10.1111/resp.12834

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Supplementary material

Table S1 Points applied for each variable in the PUMA

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questionnaire

Variable Score

Sex Female 0
Male 1

Age (years) 40–49 0

50–59 1
60+ 2

Smoking history (pack-years) <20 0

20–30 1
>30 2

Dyspnea No 0
For personal use only.

Yes 1

Chronic phlegm No 0
Yes 1

Chronic cough No 0
Yes 1

Spirometry history performed during life No 0

Yes 1

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