Pneumocafé project: an inquiry on current COPD diagnosis and management among General Practitioners in Italy through a novel tool for professional education

Adherence to COPD management guidelines in general practice? A review of the literature

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive illness that is mostly managed in the general practice setting. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines are the international gold standard, and it is important to understand how these are being applied in general practice.

AIMS

This review aimed to assess the current level of adherence to international best practice guidelines among general practitioners in relation to COPD.

METHODS

PubMed and EMBASE searches (from 2012 to 2016) were performed and used the search terms guidelines, COPD, general practitioners, and primary care. Papers were excluded if they were not primary sources, were published before 2012, or did not pertain to a general practice setting.

RESULTS

After applying set inclusion and exclusion criteria, 11 studies were retrieved. These papers were grouped under three categories: diagnosis, pharmacological, and non-pharmacological management, based on the GOLD guidelines.

CONCLUSIONS

Current studies show significant variability in adherence to the GOLD guidelines. Barriers identified include lack of clarity, unfamiliarity with recommendations, and lack of familiarity with the guidelines. If general practice is expected to manage COPD and other chronic diseases, health service investment is needed to provide appropriate focused guidelines, to support their dissemination and resources to implement them in practice.

Most Italians attending a congress on health of elderly people do not know and do not recognize respiratory diseases

Background

The present study reports the results of a survey jointly carried out by three Italian respiratory scientific associations (AIMAR, AIPO, SIMeR) together with an important Federation of elderly patients (FederAnziani) during the National Conference of Italian Court for Health Right held in Rimini from November 29^th to December 1^st, 2013. The survey, based on a spirometric examination preceded by a questionnaire on respiratory health, was conducted on elderly people coming from all Italian regions to attend the Conference.

Methods

Nine hundred forty-nine subjects (574 females and 375 males), mean age 66.2 ± 10.1 years, were interviewed and performed spirometric examination. There were 137 smokers (14.4 %). Mean value of Body Mass Index (BMI) was significantly higher in males (27.6 ± 6.6) than in females (26.3 ± 4.3).

Results

17.1 % (N = 143) of the studied subjects reported to be suffering from respiratory disease and the prevalent illnesses were asthma (31.5 %) and COPD/emphysema (24.5 %), but only 3.3 % of the whole surveyed group was able to identify COPD as a pulmonary disease, however without knowing its characteristics, while these were known by 0.5 % of the interviewed subjects only.

A high number of subjects, 22 % of whom were smokers, declared chronic sputum production. 10.2 % of the study group showed an obstructive defect at spirometry when the criterium of lower limit of the normal (LLN) was considered, whereas it was 12.4 % if the fixed limit of 0.70 was chosen. 64 % of the obstructed people thought they did not have any respiratory disease.

Conclusions

The results of this survey, able to spread the knowledge of respiratory diseases and spirometry in a wide sample of subjects for the most part scarcely aware of them, emphasize the need for a greater divulgation of respiratory issues among the general population.

Treatment patterns in COPD patients newly diagnosed in primary care. A population-based study

INTRODUCTION

Treatment for COPD is tailored based on clinical characteristics and severity. However, prescription patterns in COPD patients newly diagnosed in primary care may differ from guideline recommendations.

METHOD

We performed an epidemiological study with data obtained from the Information System for the Development in Research in Primary Care (SIDIAP), a population database that contains information of 5.8 million inhabitants (80% of the population of Catalonia). Patients newly diagnosed with COPD from 2007 to 2012 were identified and information about the initial treatment patterns was collected. The initial treatment was also described by phenotype and severity.

RESULTS

During the study period 41,492 patients were newly diagnosed with COPD. Patients were classified as non exacerbators (28,552 patients, 69%), asthma-COPD overlap syndrome (ACOS) (2152 patients, 5.2%) and frequent exacerbators (10,888 patients, 27.6%). Among the patients in whom FEV1 was available, 13.9% were GOLD stage 1, 55.2% stage 2, 26% stage 3 and 4.8% stage 4. Globally, the most frequently prescribed treatment patterns were short-acting bronchodilators (SABD) in monotherapy (17.7%), long-acting β-2 agonists (LABA) + inhaled corticosteroids (ICS) (17.3%) and triple therapy (12.2%). The frequency of patients treated with a SABD increased from 15.9% to 19.5% during the study period, while the number of untreated patients decreased from 24.4% to 15.1%. Up to 45.2% of patients were initially treated with ICS, which were frequently prescribed in the ACOS (69.2%) and in the exacerbator phenotype patients (52.4%) while ICS use has decreased from 43.8% in 2007 to 35.8% in 2012 in non exacerbator patients. Up to 13.6% and 14.8% of GOLD 4 patients received no treatment or only SABD after diagnosis.

CONCLUSIONS

Initial treatment patterns in newly diagnosed COPD patients often do no comply with guidelines. The use of ICS is excessive but has decreased mainly in non exacerbator patients. Many COPD patients still remain untreated after diagnosis, although this has decreased. Some GOLD 4 patients are still receiving SABD or no treatment at all after diagnosis.

Standards of suitability for the management of chronic obstructive respiratory diseases

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) ranks third as cause of mortality and disability-adjusted life years (DALY) worldwide and also in Italy it imposes a huge health, social and economic load. Early symptoms of COPD are often disregarded by patients and physicians, spirometry is underutilized, and the diagnosis is delayed till the disease has reached a distinct severity level. Despite the availability of various guidelines, the behavior of health workers involved in the management of COPD is still rather unlike. These considerations are the reason why in October 2013 AIMAR (Interdisciplinary Scientific Association for Research in Lung Disease) devised and organized a "Third Consensus Conference", aimed at pointing out the standards of suitability for COPD management. In this context three important topics of discussion were identified: early and more widespread diagnosis, management of acute and subacute phases, long-term assistance to chronic patients.

METHODS

The procedure recommended by the Italian Health Superior Institute (ISS) for Consensus Conferences organization was applied. The Conference was structured in three sessions, each dealing with one of the above mentioned topics and including a short update of the subject-matter and presentation, discussion and voting of some statements with a choice ranging from total agreement to total disagreement or no knowledge. The results of voting were eventually recorded in the document, reviewed by an independent jury, that forms the substance of this paper.

RESULTS

The essential role of spirometry, the need for distinguish between different COPD phenotypes, and the obligatoriness to base on the blood gas analysis findings the long-term oxygen therapy, were largely agreed, as well as the need for interventions aimed at decreasing the rate of acute exacerbations. More specific topics like the use of noninvasive ventilation, recognizing the factors affecting outcome and mortality, the choice of pharmacological and non pharmacological treatments in COPD patients led to lively discussing, but they did not always reach the total agreement, probably because of insufficient familiarity with these problems and of diversities in organization and instruments availability. The chronic respiratory assistance was treated with particular regard to smoking cessation, whose implementation is still insufficient. Many doubts rose due to uncertainty, lack of ability and standardization of procedures, insufficient institutional support, and difficulties to realize a network for assistance to chronic patients.

CONCLUSIONS

The results of this Third Consensus Conference revealed some certainties and many doubts and diversities of view also on topics whose importance is well demonstrated in scientific literature. Thus, there is still a long distance to cover before reaching a suitable standardization of COPD management and such situation urges the need for improving not only the health professional's operativeness but also the organizational support by competent institutions. In this context some initiatives organized by AIMAR in cooperation with other respiratory scientific societies and patients' associations are going on.