Under-diagnosis of Chronic Obstructive Pulmonary Disease: a Qualitative Study in Primary Care

Background: Chronic obstructive pulmonary disease (COPD) is under-diagnosed and diagnosis often occurs late thereby reducing opportunities to prevent deterioration. Investigation of causes has focused on the use of spirometry but the role of attitudes of doctors and patients has not been directly investigated.

Methods: A cross-sectional study of patients diagnosed with COPD and their general practitioners in two general practices in Tasmania who participated in semi-structured interviews and focus groups. Practice records were examined and patients underwent spirometry, quality of life and symptom assessment. Iterative content analysis identified themes that were compared with quantitative data.

Findings: For the 32 participating patients, mean recorded duration of COPD was 8.0 (SD 6.8) years and mean FEV(1)% predicted 38.4% (SD 19.8). Qualitative data were obtained from 14 (44%) of patients with COPD (5M/9F) and 16 general practitioners (GPs) (10M/6F). We identified three themes around the diagnosis of COPD in primary care: patients' labels, acquiring and communicating a diagnosis and consequences of delaying or withholding diagnosis. Doctors correctly recognised that patients were unfamiliar with COPD. They intentionally avoided early diagnosis as a result of nihilism and misperception of patients' attitudes. Patients often received the diagnosis from other sources and found delayed diagnosis frustrating.

Interpretation: Nihilistic attitudes to COPD may explain the disappointing results from promotion of spirometry in primary care. Education about COPD for doctors in primary care is needed and action to increase awareness and understanding of COPD in the community.