Intended for healthcare professionals

Analysis Too Much Medicine

Chronic obstructive pulmonary disease: missed diagnosis versus misdiagnosis

BMJ 2015; 351 doi: (Published 01 July 2015) Cite this as: BMJ 2015;351:h3021
  1. Martin R Miller, professor of medicine1,
  2. Mark L Levy, general practitioner2
  1. 1Institute of Occupational and Environmental Medicine, University of Birmingham, Birmingham B15 2TT, UK
  2. 2Harrow Clinical Commissioning Group, London, UK
  1. Correspondence to: M R Miller m.r.miller{at}
  • Accepted 31 March 2015

Summary box

  • Clinical context—The prevalence and mortality of chronic obstructive pulmonary disease (COPD) is increasing globally

  • Diagnostic change—A new diagnostic threshold for airflow obstruction (FEV1/FVC <0.7) was introduced in 2001 (GOLD). This contrasts with internationally agreed criteria using statistically defined lower limits of normal (LLN) for different populations

  • Rationale for change—The new diagnostic criterion was simple so could be easily implemented in non-specialist settings

  • Leap of faith—Treatment of people identified by GOLD criteria would reduce morbidity and mortality

  • Increase in disease—The new definition estimates COPD prevalence at 22% in those aged over 40 years in England and Wales compared with 13% using LLN criteria

  • Evidence of misdiagnosis and missed diagnosis—Up to 13% of people thought to have COPD on GOLD criteria have been found to be misdiagnosed

  • Harms from misdiagnosis and missed diagnosis—Cardiovascular mortality is unexpectedly high among mildly breathless patients with GOLD diagnosed COPD

  • Limitations—Few studies have compared patient outcomes with GOLD and other criteria for diagnosing COPD

  • Conclusions—COPD management programmes and guidelines should adopt LLN criteria for defining airflow obstruction to avoid overdiagnosis in elderly people and missed diagnosis in younger patients

By 2004 chronic obstructive pulmonary disease (COPD) was claimed to be the fourth most important cause of death worldwide,1 and its global prevalence and mortality are on the increase.2 Smoking accounts for about 75% of cases,3 but environmental exposures to tobacco smoke and other pollutants such as biomass fuels and occupational exposures may account for the remaining cases.4 5 6 COPD is a progressive disease, and in the later stages patients have frequent admissions to hospital, with over a third being readmitted in 30 days, contributing to an annual cost of £800m (€1bn; $1.24bn) in the UK.7 In the UK concern has …

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