Study Finds Inconsistencies With GOLD Guidelines Regarding Diagnosis, Treatment of COPD

The prevalence of chronic obstructive pulmonary disease (COPD) underdiagnosis, false diagnosis, and treatment in the primary care setting is high and often inconsistent with Global Initiative for the Chronic Obstructive Lung Disease (GOLD) guidelines.

A study found that more than half of patients with chronic obstructive pulmonary disease (COPD) were underdiagnosed, more than half of patients with COPD who were correctly diagnosed were overtreated, and most patients with COPD taking inhaled drugs were falsely diagnosed when examined against Global Initiative for the Chronic Obstructive Lung Disease (GOLD) guidelines.

Underdiagnosis of COPD is a prevalent issue worldwide, estimated at 50% to 80% of cases, and can be attributed to underuse of spirometry, certain patient characteristics, and mild obstruction. Overdiagnosis and misdiagnosis have been attributed to the spirometric threshold for defining COPD, errors regarding spirometry technique, errors made in primary care, differential diagnoses, and patients’ demographic characteristics.

Although pharmacological therapy is an effective intervention for management of COPD, it is not always administered in adherence to GOLD guidelines in everyday clinical practice. In Greece, the location of study, there are no national guidelines in place for COPD diagnosis or treatment.

The observational study enrolled 5226 participants from 5 primary care centers in northern Greece who were 40 years or older and were current or former smokers; 564 (10.8%) of them had respiratory symptoms and spirometry that confirmed the diagnosis of COPD. The participants were clustered into 5 groups of interest: those with a previous correct COPD diagnosis and correct treatment, previous correct diagnosis COPD but overtreatment, previous correct diagnosis COPD but undertreatment, a previous false diagnosis of COPD, and previously not diagnosed with COPD.

Study results were published in the European Journal of General Practice.

Findings showed:

  • Of 564 participants who had confirmed diagnosis of COPD guidelines, 300 (53.2%) were underdiagnosed.
  • Of 264 patients with a previous correct COPD diagnosis, 164 (62%) were already treated with 1 or 2 inhaled long-acting bronchodilators plus inhaled corticosteroids; taking into account COPD severity, 86.2% of them should have been treated only with long-acting bronchodilators (GOLD A + B).
  • Based on GOLD 2020 guidelines, investigators found that 117 participants (44.3%) were treated adequately, 8 (3%) were undertreated, and 139 (52.7%) were overtreated.
  • Of 725 participants who had a previous medical diagnosis and treatment of COPD, 462 (63.6%) were falsely diagnosed and prescribed inhaled drugs for COPD in the primary care setting.

Study results indicated that more than 50% of patients with COPD were underdiagnosed, more than 50% of patients with a previous correct diagnosis of COPD were overtreated, and most patients on treatment with inhaled drugs in the primary care setting are subjects with respiratory symptoms who are falsely diagnosed and treated as patients with COPD.

Correct interpretation of spirometry results can substantially reduce numbers of false diagnosis cases of COPD and the consequences associated with them, like the intake of unnecessary drugs and missed detection of other diseases. More frequent use of spirometry in primary care settings and adequate reporting of relevant symptoms to physicians can reduce the prevalence of underdiagnosis of COPD, the authors wrote.

Comprehensive training of general practitioners in Greece about COPD diagnosis, including risk factors, symptoms, and spirometric criteria, as well as the implementation of national guidelines on diagnosis and treatment of COPD are needed to decrease cases of overdiagnosis, misdiagnosis, underdiagnosis, and inappropriate treatment methods, the study authors concluded.


Spyratos D, Chloros D, Michalopoulou D, Tsiouprou I, Christoglou K, Sichletidis L. Underdiagnosis, false diagnosis and treatment of COPD in a selected population in Northern Greece. Eur J Gen Pract. 2021;27(1):97-102. doi:10.1080/13814788.2021.1912729