Chest
Volume 119, Issue 6, June 2001, Pages 1691-1695
Journal home page for Chest

Clinical Investigations
COPD
Gender Bias in the Diagnosis of COPD

https://doi.org/10.1378/chest.119.6.1691Get rights and content

Background

COPD is thought to be more prevalent among men than women, a finding usually attributed to higher smoking rates and more frequent occupational exposures of significance for men. However, smoking prevalence has increased among women and there is evidence that women may be more susceptible to the adverse pulmonary function effects of smoking than men. There may also be underdiagnosis and misdiagnosis of COPD in both sexes because objective measures of lung function are underused.

Objectives

We undertook the present study to determine if there is gender bias in the diagnosis of COPD, such that women are less likely than men to receive a diagnosis of COPD. We also attempted to determine if underuse of lung function measurements was a factor in any bias detected.

Methods

We surveyed a random sample of 192 primary-care physicians (96 American and 96 Canadian; 154 men and 38 women) using a hypothetical case presentation and a structured interview. The case of cough and dyspnea in a smoker was presented in six versions differing only in the age and sex of the patient. After presentation of the history and physical findings, physicians were asked to state the most probable diagnosis and to choose the diagnostic studies needed. Physicians were then presented with spirometric findings of moderate or severe obstruction without significant bronchodilator response, and the questions repeated. Finally, the negative outcome of an oral steroid trial was described.

Results

Initially, COPD was given as the most probable diagnosis significantly more often for men than women (58% vs 42%; p < 0.05). The likelihood of a COPD diagnosis increased significantly and initial differences between sexes decreased as objective information was provided. After spirometry, COPD diagnosis rates for men and women were 74% vs 66% (p = not significant); after the steroid trial 85% vs 79% (p = not significant). Only 22% of physicians would have requested spirometry after the initial presentation.

Conclusions

In North America, primary-care physicians underdiagnose COPD, particularly in women. Spirometry reduces the risk of underdiagnosis and gender bias but is underused.

Section snippets

Study Design

We devised one hypothetical case summary to present to primary-care physicians for their review and man agement. The summary described a middle-aged former smoker (of approximately 40 pack-years consumption) who presented with morning cough persisting for 4 years and worsening intermittently following viral respiratory tract infections. For 3 years, the patient had been troubled by breathlessness on moderate exertion. On physical examination, the only abnormal finding was the presence of

Physicians Surveyed

We surveyed a random sample of 192 primary-care physicians (96 American and 96 Canadian; 154 men and 38 women). In the United States, interviews were conducted in the following geographic areas (major urban center and surrounding nonurban region): Chicago, San Francisco, Seattle, Houston, Denver, Long Island, and Atlanta. In Canada, interviews were conducted in the following geographic areas (major urban center and surrounding nonurban region): Toronto, Montreal, Vancouver, Calgary, Winnipeg,

Discussion

Our data show that many primary-care physicians in North America are reluctant to consider the diagnosis of COPD, even when confronted by a middle-aged former smoker with chronic cough, dyspnea, and wheezes on physical examination. Moreover, they are less likely to make the diagnosis of COPD in women than in men, a diagnostic bias that is eliminated by the presentation of compatible spirometric data. Regrettably, only a minority of primary-care physicians would consider requesting spirometry in

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The authors received a research grant-in-aid from Boehringer Ingelheim Canada Ltd and Boehringer Ingelheim Pharmaceuticals Inc.

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