Thorax 2000;55:562-565 ( July )

Underdiagnosis of asthma: is the doctor or the patient to blame? The DIMCA project

C P van Schayck^{a b}, F M M A van der Heijden^a, G van den Boom^a, P R S Tirimanna^a, C L A van Herwaarden^c

^a Department of General Practice and Social Medicine, University of Nijmegen, Nijmegen, The Netherlands, ^b Department of General Practice, University of Maastricht, 6200 MD Maastricht, The Netherlands, ^c Department of Pulmonary Diseases, University Lung Centre Dekkerswald, Groesbeek, The Netherlands

Correspondence to: Professor Dr C P van Schayck email: onno.vanschayck{at}HAG.unimaas.nl

Received 16 September 1999; Returned to authors 25 November 1999; Revised version received 7 March 2000; Accepted for publication 21 March 2000

BACKGROUNDIt is important to diagnose asthma at an early stage as early treatment may improve the prognosis in the long term. However, many patients do not present at an early stage of the condition so the physician may have difficulty with the diagnosis. A study was therefore undertaken to compare the proportion of patients who underpresented their respiratory symptoms with the proportion of underdiagnosed cases of asthma by the general practitioner (GP). A secondary aim was to investigate whether bad perception of dyspnoea by the patient was a determining factor in the underpresentation of asthma symptoms to the GP.
METHODSA random sample of 1155 adult subjects from the general population in the eastern part of the Netherlands was screened for respiratory symptoms and lung function and the results were compared with the numbers of asthma related consultations registered in the medical files of the GP. In subjects with reduced lung function the ability to perceive dyspnoea was investigated during a histamine provocation test in subjects who did and did not report their symptoms to their GP.
RESULTSOf the random sample of 1155 subjects 86 (7%) had objective airflow obstruction (forced expiratory volume in one second (FEV₁) below the reference value corrected for age, length, and sex minus 1.64SD on two occasions) and had symptoms suggestive of asthma. Of these 86 subjects only 29 (34%) consulted the GP, which indicates underpresentation by 66% of patients. Of all subjects with objective airflow obstruction who presented to their GP with respiratory symptoms, 23 (79%) were recorded in the medical files as having asthma, indicating underdiagnosis by the GP in 21% of cases. Of the subjects with objective airflow obstruction who visited the GP with respiratory symptoms 6% had bad perception of dyspnoea compared with 26% of those who did not present to the GP in spite of airflow obstruction (² = 3.02, p = 0.08).
CONCLUSIONSUnderpresentation to GPs of respiratory symptoms by asthmatic patients contributes significantly to the problem of underdiagnosis of asthma. Underdiagnosis by the GP seems to play a smaller role. Furthermore, there are indications that underpresentation of symptoms by the patient is at least partly explained by a worse perception of dyspnoea.


Keywords: asthma; underdiagnosis; underpresentation; general practice

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© 2000 by Thorax
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