Skip to main content

Main menu

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Peer reviewer login
  • Journal club
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Peer reviewer login
  • Journal club
  • Alerts
  • Subscriptions

Use of the terms “overdiagnosis” and “misdiagnosis” in the COPD literature: a rapid review

Elizabeth T. Thomas, Paul Glasziou, Claudia C. Dobler
Breathe 2019 15: e8-e19; DOI: 10.1183/20734735.0354-2018
Elizabeth T. Thomas
1Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
2Gold Coast University Hospital, Southport, Australia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Elizabeth T. Thomas
Paul Glasziou
1Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Claudia C. Dobler
1Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
2Gold Coast University Hospital, Southport, Australia
3Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Claudia C. Dobler
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Figures

  • Tables
  • Figure 1
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1

    Study flow diagram.

  • Figure 2
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 2

    Components of a COPD diagnosis.

Tables

  • Figures
  • Table 1

    Types of overdiagnosis and misdiagnosis

    1Physician COPD diagnosis despite normal spirometry
    The physician did not use spirometry to establish a diagnosis of COPD (and a normal spirometry was later found in the study)
    The physician “ignored” a normal spirometry result
    2Discordant results for COPD diagnosis based on different spirometry-based definitions for airflow obstruction (e.g. post-bronchodilator FEV1/FVC <0.7 or FEV1/FVC <LLN)
    3COPD diagnosis based on pre-bronchodilator spirometry results
    4Comorbidities (e.g. heart failure or asthma) that affect spirometry and have clinical features which overlap with COPD
    5Normalisation of abnormal (post-bronchodilator) spirometry at follow-up
  • Table 2

    Use of the terms “overdiagnosis” and “misdiagnosis” in the included studies

    First author, year [ref.]Population detailsTerms usedReason for classification as overdiagnosisEstimated prevalence of overdiagnosis/misdiagnosis
    van Dijk, 2015 [30]Population study (n=4882) with sample aged ≥40 years (mean±sd age 57±11 years), including former and current smokers; symptomatic; 4% had known chronic bronchitisOverdiagnosis, misdiagnosisDiscordant results between 1) post-bronchodilator FEV1/FVC <0.7 but ≥LLN; and 2) FEV1/FVC <0.7 + FEV1 <80% predictedPrevalence of spirometric airflow limitation was 17% by fixed ratio and 11% by LLN
    Patients who had airflow limitation meeting fixed ratio but not LLN were more likely to have cardiovascular disease (odds ratio 1.52)
    Llordés, 2015 [10]Smokers aged ≥45 years (n=1738), some with symptoms (21–46% depending on symptom); 10.5% pre-existing COPD diagnosisOverdiagnosisNormalisation of spirometry after 4 weeks of treatment
    COPD diagnosis despite no evidence of airflow obstruction on spirometry (defined as post-bronchodilator FEV1/FVC <0.7)
    Discordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN
    In subjects with a new diagnosis of COPD by fixed ratio, 16% presented normal spirometry after 4 weeks of treatment
    15.6% of people with physician-diagnosed COPD did not fulfil the spirometric criteria for COPD
    Prevalence of COPD using LLN was 15.5% compared to 24.3% using fixed ratio
    Spero, 2017 [15]Patients admitted to a community teaching hospital (n=6018); aged ≥18 years (mean±sd age 69.5±12.8 years); admitted for respiratory complaints with COPD as a principal or leading diagnosis and had spirometry performed during hospitalisationMisdiagnosis, overdiagnosisCOPD diagnosis despite no evidence of airflow obstruction on spirometry, defined as post-bronchodilator FEV1/FVC <0.7 (no spirometry had been performed before the study)
    Discordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN
    30.8% of cases of patients with a primary diagnosis of COPD had normal pulmonary function tests (COPD diagnosis refuted)
    Significant correlation between presence of hypertension, obstructive sleep apnoea, coronary artery disease, congestive heart failure and misdiagnosis of COPD
    10.7% of spirometry studies diagnosed as airflow obstruction by GOLD criteria would have been considered normal by LLN criteria (these patients were more likely never-smokers and asymptomatic)
    Lamprecht, 2011 [25]General population sample (n=1258), some with symptoms consistent with COPD; aged >40 years; 5.6% had a previous physician diagnosis of COPD, emphysema or chronic bronchitisOverdiagnosisDiscordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN6.4% of the study population had discordant obstructive cases (FEV1/FVC <0.7 and ≥LLN)
    Discordant cases had similar profiles to those with restrictive disease and these subjects more often had diagnosis of heart disease than those with normal function
    Schermer, 2008 [26]Symptomatic adults (n=14 056) referred for spirometry by their GP for suspected COPD; mean±sd age 53.0±21.4 years; 69% current/former smokersOverdiagnosisDiscordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN
    Only pre-bronchodilator spirometry result
    Age yearsFixed ratio overdiagnosis
    31–408.9%
    41–5015.5%
    51–6023.9%
    61–7033.2%
    71–8038.7%
    ≥8142.7%
    25.3% of obstructive pattern diagnosed by pre-bronchodilator spirometry was not classified as COPD on post-bronchodilator spirometry
    García-Rio, 2011 [27]General population sample (n=3802) aged 40–80 years, including smokers, some with symptoms consistent with COPDOverdiagnosisDiscordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN4.6% of subjects aged 40–80 years had overdiagnosed COPD
    Wang, 2013 [28]Population study (n=1382); sample aged 56–84 years (mean±sd age 67.7±13.3 years); never-smokers; asymptomatic; no previous diagnosis of asthma, COPD or heart diseaseOverdiagnosisDiscordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN9.5% of asymptomatic population were diagnosed with COPD using the fixed criterion compared with 4.3% using the LLN (using spirometric reference values that were specifically derived for the study population in Jinan, China)
    Fisher, 2016 [14]Members of the 1921 birth cohort from North-East England recruited around their 85th birthday (n=845); >50% former smokers; symptomatic; 16.6% had previous diagnosis of COPD; median number of comorbid diseases was 5Overdiagnosis, misdiagnosisCOPD diagnosis despite no evidence of airflow obstruction on spirometry, defined as either 1) post-bronchodilator FEV1/FVC <0.7, 2) FEV1/FVC <LLN, or 3) Global Lung Function Initiative criteria
    Discordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN
    75.6% of those with physician-diagnosed COPD met the GOLD criteria for spirometry; however, using the LLN only 41.1% had airflow obstruction
    44.5% of the healthy reference group who were asymptomatic met the GOLD cut-off for COPD
    24.4% of those with physician-diagnosed COPD did not satisfy spirometric criteria for COPD using GOLD criteria
    Steinacher, 2012 [29]Consecutive patients of an outpatient heart failure clinic (n=89); median age 67.0 years; 55% former/current smokers; 12.4% with self-reported COPD; majority New York Heart Association class II heart failureOverdiagnosis, misdiagnosisCOPD diagnosis despite no evidence of airflow obstruction on spirometry, defined as post-bronchodilator FEV1/FVC <0.7
    Discordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN
    Heart failure affects spirometry interpretation; clinical symptoms overlapping with those of COPD
    Among participants who did not demonstrate airflow obstruction on spirometry, 6% had a previous diagnosis of COPD; these 6% were identified as false positives by the GOLD criteria
    Application of the GOLD criteria led to a significantly higher rate of COPD in the heart failure population (43.8%) compared to using the LLN (24.7%)
    12.3% patients who presented an FEV1/FVC >0.7 had an FVC <LLN and had measured FVC experimentally substituted by 80% of predicted FVC, to detect airway obstruction that was possibly masked by heart failure-related restriction; this led to a decline in FEV1/FVC to <0.7 in eight cases and <LLN in seven cases
    Minasian, 2013 [17]Patients with stable chronic heart failure (n=187); sample aged ≥18 years (mean±sd 69±10 years); 83% former or current smokers; 82% reported dyspnoeaOverdiagnosisDiscordant results for COPD diagnosis based on post-bronchodilator FEV1/FVC <0.7 but ≥LLN
    COPD diagnosis despite no evidence of airflow obstruction on spirometry, defined as post-bronchodilator FEV1/FVC <0.7 or <LLN
    Clinical symptoms and risk factor profile of heart failure overlapping with those of true COPD
    COPD prevalence varied according to the definition, with 19.8% according to the LLN definition compared to 32.1% using GOLD definition after 3 months of follow-up
    32% of patients with history of obstructive lung disease did not have GOLD COPD, and 50% did not meet LLN COPD according to spirometry
    74% of patients with misclassified COPD (discordant spirometry) had respiratory symptoms and a smoking history and 64% of non-COPD (with heart failure) also had respiratory symptoms and smoking history
    Zwar, 2011 [19]Patients (n=445) aged 40–80 years (mean age 65 years), who from GP practice records were considered to have a diagnosis of COPD, emphysema or chronic bronchitis; 30.5% current smokersMisdiagnosisCOPD diagnosis despite normal spirometry (pre- and post-bronchodilator FEV1/FVC >0.7, FVC and FEV1 >80% of predicted values) or restriction (pre- and post- FEV1/FVC >0.7, FVC and FEV1 <80% of predicted values) or asthmaOf all patients with known COPD, 42.2% had post-bronchodilator showing asthma only, normal spirometry or other spirometric diagnoses such as restriction
    Starren, 2012 [21]Patients referred for spirometry by GPs with definite COPD (n=1156); mean±sd age 61.3±15.6 years; 65% smokersMisdiagnosisCOPD diagnosis despite normal spirometry (pre- and post-bronchodilator FEV1/FVC >0.7, FVC and FEV1 >80% of predicted values) or restriction (pre- and post- FEV1/FVC >0.7, FVC and FEV1 <80% of predicted values) or asthma19.4% of patients with definite COPD according to physicians did not demonstrate COPD on spirometry (2% had asthma, 4% had restriction and 13% had no airway obstruction)
    Spyratos, 2016 [11]Population study (n=3200) including current and former smokers aged >40 years (mean±sd age 60.5±13.4 years); 8.6% had previously physician-diagnosed COPDOverdiagnosisCOPD diagnosis despite normal spirometry (pre- and post-bronchodilator FEV1/FVC >0.7, FVC and FEV1 >80% of predicted values) or restriction (pre- and post- FEV1/FVC >0.7, FVC and FEV1 <80% of predicted values)9.6% of group diagnosed with COPD had been overdiagnosed
    Hill, 2010 [12]Patients aged ≥40 years with a smoking history of ≥20 pack-years recruited from primary care practices (n=382); 11% had self-reported pre-existing COPDOverdiagnosisCOPD diagnosis despite no evidence of airflow obstruction on spirometry, defined as post-bronchodilator FEV1/FVC <0.7 and FEV1 <80% predicted29.6% with diagnosis of COPD had been overdiagnosed (11.8% of total study population who had medical records reviewed)
    Gershon, 2018 [13]Random population-based sample of adults aged >40 years (n=1403), including symptomatic subjects with smoking history; 8.8% with physician diagnosis of COPDOverdiagnosisCOPD diagnosis despite no evidence of airflow obstruction on spirometry, defined as post-bronchodilator FEV1/FVC <0.7Of all participants included in analysis, 5.1% had overdiagnosed COPD
    Stafyla, 2018 [16]Subjects (n=186) aged >40 years (mean±sd age 62.3±12.6 years) recruited from primary healthcare settings; all current or former smokers; 82.3% had respiratory symptoms, 10.2% with known COPDOverdiagnosis, misdiagnosisCOPD diagnosis despite no evidence of airflow obstruction on spirometry, defined as post-bronchodilator FEV1/FVC <0.7 (no spirometry had been performed before the study)61.4% of non-COPD subjects according to spirometry had been misdiagnosed with COPD
    Roberts, 2009 [18]Patients referred for spirometry with clinical diagnosis of COPD to assess severity or suspected diagnosis for diagnostic confirmation (n=503); mean±sd age 63.8±11.3 years, including symptomatic smokers; 64.8% had received prior diagnosis of COPDMisdiagnosisCOPD diagnosis despite normal spirometry (pre- and post-bronchodilator FEV1/FVC >0.7, FVC and FEV1 >80% of predicted values) or restriction (pre- and post- FEV1/FVC >0.7, FVC and FEV1 <80% of predicted values)37.7% of patients that had a clinical diagnosis of COPD had spirometry results incompatible with a diagnosis of COPD
    Lacasse, 2012 [20]Patients discharged from acute care hospitals with a principal diagnosis of COPD (n=1221); mean±sd age 73.1±12.2 years; 81.9% smokersMisdiagnosisCOPD diagnosis despite normal spirometry (post-bronchodilator FEV1/FVC >0.7)15.2% of patients discharged with COPD as their principal diagnosis were confirmed to not have COPD according to a review of their medical records and spirometry by two pulmonologists
    Walters, 2011 [22]Patients in general practice with either a recorded diagnosis of COPD and/or record of current treatment with the specific COPD therapy tiotropium (n=341); mean±sd age 62.3±8.6 years; 39% current smokers; symptomaticMisdiagnosisCOPD diagnosis despite normal spirometry (pre- and post-bronchodilator FEV1/FVC >0.7, FVC and FEV1 >80% of predicted values, FVC >80% of predicted values) or restriction (pre- and post- FEV1/FVC >0.7, FVC and FEV1 <80% of predicted values)31% of patients did not meet the criteria for COPD; of these, three patterns were found on spirometry: 56% had normal lung function, 7% had mild airflow limitation (FEV1 <80% of predicted), and 37% had restrictive lung function
    Queiroz, 2012 [23]Patients recruited from selected primary healthcare centres with no acute respiratory symptoms (n=200); sample aged ≥40 years (mean±sd age 65.0±10.4 years); minimum of 20 pack-years’ smoking history or biomass fuel exposure; majority were symptomaticMisdiagnosis, overdiagnosisCOPD diagnosis despite normal spirometry (post-bronchodilator FEV1/FVC >0.7)14.6% of individuals who did not meet the diagnostic criteria for COPD reported a previous diagnosis of COPD
    Heffler, 2018 [24]Consecutive patients referred by GPs for spirometry (n=300); mean±sd age 58.5±18.9 years, including current or former smokers; majority had symptoms; 25% physician diagnosis of COPDMisdiagnosis, overdiagnosisCOPD diagnosis despite normal spirometry (post-bronchodilator FEV1/FVC >0.7)86.7% of those with previous doctor-diagnosis of COPD had non-concordant spirometric patterns
    Bellia, 2003 [31]Asthmatic subjects from pulmonary or geriatric institutions (n=128); mean±sd age 73.1±6.3 years; most symptomaticMisdiagnosisClinical features of asthma overlapping with those of COPD19.5% of newly diagnosed asthmatics had received a prior wrong diagnosis of COPD and/or emphysema
PreviousNext
Back to top
Vol 15 Issue 1 Table of Contents
Breathe: 15 (1)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Use of the terms “overdiagnosis” and “misdiagnosis” in the COPD literature: a rapid review
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Use of the terms “overdiagnosis” and “misdiagnosis” in the COPD literature: a rapid review
Elizabeth T. Thomas, Paul Glasziou, Claudia C. Dobler
Breathe Mar 2019, 15 (1) e8-e19; DOI: 10.1183/20734735.0354-2018

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Use of the terms “overdiagnosis” and “misdiagnosis” in the COPD literature: a rapid review
Elizabeth T. Thomas, Paul Glasziou, Claudia C. Dobler
Breathe Mar 2019, 15 (1) e8-e19; DOI: 10.1183/20734735.0354-2018
Reddit logo Technorati logo Twitter logo Connotea logo Facebook logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Abstract
    • Background
    • Literature review
    • Definitions of overdiagnosis
    • Discussion
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Subjects

  • COPD and smoking
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Management of difficult-to-treat asthma in adolescence and young adults
  • Respiratory complications of obesity
  • Diagnosis and management of PH in infants with BPD
Show more Reviews

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About Breathe

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Intructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN: 1810-6838
Online ISSN: 2073-4735

Copyright © 2023 by the European Respiratory Society