Diagnostic Momentum in COPD: A Literature Review of How Repeated Empirical Treatment May Delay Objective Diagnosis in Primary Care

This narrative literature review proposes and develops the concept of diagnostic momentum as an underexamined contributor to delayed COPD (chronic obstructive pulmonary disease) diagnosis in primary care, distinct from — and operating at a different point in the patient journey than — structural access barriers such as spirometer availability, staffing, and cost. Drawing on cognitive science literature on anchoring and confirmation bias, diagnostic error research, and studies on spirometry underuse, the review argues that once a clinician anchors on a presumptive diagnosis (such as acute bronchitis or asthma) during an initial encounter, that impression tends to be carried forward and reinforced across subsequent visits through repeated empirical treatment, delaying the point at which objective spirometry-based diagnosis is ordered — even in settings where testing capacity exists. The review situates this hypothesis specifically within Ghana and the broader sub-Saharan African context, where COPD prevalence is rising due to household air pollution and other exposures, and where spirometry access is concentrated in teaching and tertiary-care hospitals. This setting is proposed as a novel and empirically tractable context for testing whether diagnostic momentum operates as an independent, additive contributor to diagnostic delay once structural access is controlled for. The paper closes with a concrete empirical research agenda for testing this hypothesis directly.