Real-life GOLD 2011 implementation: the management of COPD lacks correct classification and adequate treatment

The 2021 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines and the outpatient management: Examining physician adherence and its effects on patient outcome

Background

Chronic obstructive pulmonary disease (COPD) is a common preventable illness that carries a large global economic and social burden. The global initiative for chronic obstructive lung disease (GOLD) guidelines has been utilized as a global strategy for the continued COPD diagnosis, assessment, and treatment. We aimed to determine if the adherence to the 2021 GOLD guideline directed management influenced outcomes.

Materials and Methods

Retrospective medical records review of adult patients with COPD, who received care in our office during the entire year of 2021. Patients managed as per the 2021 GOLD guidelines were compared with those who received usual care.

Results

Among 242 patients, 171 (70.7%) were GOLD management adherent (GA) and 71 (29.3%) were GOLD non-adherent (GNA). Certain comorbidities were associated with higher frequencies in the GA group, such as allergic rhinitis (63.2 vs. 18.3%; P < 0.001), coronary artery disease (55.9 vs. 38.0%; P = 0.011), GERD (63.2 vs. 32.4%; P < 0.001), anemia (38.6 vs. 19.7%; P = 0.004), malignancy (34.5 vs. 19.7%; P = 0.023), and immunodeficiency (12.3 vs. 1.4%; P = 0.007). There was no significant difference in the mortality between the GA and GNA groups (5.3 vs. 9.9%; P = 0.254). Although the frequency of number of exacerbations was greater in the GA group, the difference in the mean number of exacerbations was not statistically significant (0.39 ± 1.08 vs. 0.39 ± 1.14; P = 0.984).

Conclusion

We found no significant difference in the patient outcomes, such as number of exacerbations of COPD and mortality, when comparing the 2021 GOLD guideline adherent versus GOLD guideline non-adherent management of COPD.

Outpatient Management of Chronic Obstructive Pulmonary Disease: Physician Adherence to the 2017 Global Initiative for Chronic Obstructive Lung Disease Guidelines and its Effect on Patient Outcomes

Background

Chronic obstructive pulmonary disease (COPD) is a common and preventable illness that carries significant economic and social burden. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides a comprehensive review of the available literature for the diagnosis and management of COPD. Despite being considered the standard of care, adherence to the GOLD guidelines varies among practitioners. In addition, there is yet to be a clear correlation between misalignment with GOLD practicing guidelines and patient outcomes. We studied the outpatient management of COPD, with special attention paid to whether or not adherence to the 2017 GOLD guidelines affected patient outcomes.

Methods

This retrospective electronic medical record review study observed the outpatient management of patients with COPD, aged 18 year or older, who presented to the suburban primary care office. Patients who received treatment according to the GOLD guidelines were compared with the patients who did not. Categorical data were analyzed as frequencies with percentages. Frequencies were compared using Chi-square and Fisher's exact tests. A P value < 0.05 was used to determine statistical significance.

Results

A total of 158 patients were included in this study. Thirty-six percent of the patients were treated according to the GOLD guidelines. There was no significant difference in the mortality, exacerbations or hospitalizations between the patients who were treated according to the GOLD guidelines and those who were not. Comparing prescribing practices for those treated according to the GOLD guidelines versus those who were not, a significant difference in management occurred in regards to long acting beta agonist (P < 0.05) and inhaled corticosteroid therapy (P < 0.001). The differences in the use of other pharmacological and nonpharmacological agents were not significant.

Conclusions

Adherence to the 2017 GOLD guidelines had no statistically significant difference in patient outcomes. GOLD nonadherent patients received long-acting beta agonist and inhaled corticosteroid therapy at a significantly higher frequency compared to GOLD-adherent patients.

Inhaled corticosteroid use by exacerbations and eosinophils: a real-world COPD population

Background: Blood eosinophils may predict response to inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD) where ICS is recommended in patients at high risk of exacerbations. The proportion of patients who may benefit the most from ICS-based therapy was quantified in a real-world population. Materials and methods: European data from the Adelphi Real World Respiratory Disease Specific Programme™ 2017 survey were collected from consecutive COPD patients by participating physicians. Overall, 1,528 patients were assessable for Global Initiative for COPD (GOLD) 2017 status and were included in the analysis. Results: More GOLD D patients had elevated eosinophil counts compared with GOLD B. The proportions of GOLD D patients with a history of ≥2 exacerbations and eosinophil counts of ≥150, ≥300, and ≥400 cells/µL were 81.2%, 39.4%, and 24.6%, respectively. In total, 10.6% of the patients had ≥300 eosinophils/µL and a history of ≥2 exacerbations. ICS-based therapy was received by 41.5% of GOLD B and 68.0% of GOLD D patients. Conclusion: There was no apparent relation between ICS use and eosinophil blood count. There are differences in the distributions of patients with frequent exacerbations and/or high blood eosinophil counts and the use of ICS in COPD. These data may provide information for the implementation of future treatment recommendations.

Determinants of CAT (COPD Assessment Test) scores in a population of patients with COPD in central and Eastern Europe: The POPE study

BACKGROUND

The COPD Assessment Test (CAT) has been proposed to help guide therapy in chronic obstructive pulmonary disease (COPD). It is important to understand the distribution of scores in different COPD populations and their determinants.

METHODS

The POPE study is an international, observational cross-sectional study of COPD subjects in 11 Central and Eastern European countries aimed at characterizing COPD phenotypes. Here we report the analysis of CAT scores with the objective of identifying their determinants, evaluating symptom load and investigating the distribution of scores among the participating countries. Additionally, we investigated the discrepancies between the CAT and modified Medical Research Council (mMRC) scores when used to classify patients according to the GOLD strategy.

RESULTS

The study included 3452 patients (69.2% men, mean forced expiratory volume in 1 s (FEV1% predicted) 52.5%). The mean CAT score was 17.5 (SD = 7.8), ranging from 15.1 in Hungary to 21.2 in Bulgaria. Multiple linear regression analysis showed six variables significantly associated with CAT scores: depression, number of previous exacerbations, 6-min walking distance, FEV1(%), mMRC and country and explained 47.2% of the variance of CAT. According to either CAT or mMRC, up to 23.9% patients would be classified in different GOLD groups.

CONCLUSIONS

The CAT score may be predicted by factors related to COPD severity, depression and exercise capacity, with significant differences in the distribution of CAT scores in different countries. According to our results CAT >10 is not equivalent to mMRC >2 for assessing symptom burden.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT02119494.

Breathing Out Completely Before Inhalation: The Most Problematic Step in Application Technique in Patients With Non-Mild Chronic Obstructive Pulmonary Disease

Background: Patient adherence to an inhaled medication application technique (A-ApplT) represents a major health-care issue in patients with chronic obstructive pulmonary disease (COPD). However, there is a lack of studies evaluating this issue thoroughly. The aim of our study was to introduce a universal easy-to-use method of assessing the A-ApplT to chronic medication in moderate to very severe COPD individuals.

Methods: The Czech Multicenter Research Database of COPD (COPD CMRD), a large observational prospective study, was used as a source of clinical data. A-ApplT was evaluated using our Five Steps Assessment. This measure is based on dichotomous evaluation of each of five predefined consecutive application technique steps and can be used in all settings for all currently available inhalation systems in COPD subjects.

Results: A total of 546 participants (75.0% men; mean age 66.7 years; mean forced expiratory volume in 1s 44.7%) were available for analysis. This represents 69.6% of all patients recruited in the COPD CMRD. Less than one third of patients presented their application technique without any erroneous steps. The most problematic steps were breathing out completely in one breath immediately before inhalation (step No. 3), and the actual inhalation maneuver (step No. 4). The total number of errors was similar for dry powder inhalers and pressurized metered-dose inhalers.

Conclusion: Our novel instrument, Five Steps Assessment, is comfortable for use in routine clinical practice to explore A-ApplT. The A-ApplT in real-life patients with non-mild COPD was inadequate and patients should be repeatedly trained by properly (re-)educated medical staff.

Real-life evaluation of COPD treatment in a Bulgarian population: a 1-year prospective, observational, noninterventional study

Introduction

This was the first study designed to prospectively evaluate treatment patterns in chronic obstructive pulmonary disease (COPD) and the degree of adherence with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy recommendations in routine clinical practice in Bulgaria.

Methods

The study was conducted in an outpatient setting and enrolled patients of both genders, aged >40 years, who were diagnosed with COPD (as per GOLD 2013). Evaluations were performed at baseline and at 6- and 12-month visits.

Results

Of the 811 enrolled patients, 719 were assessed and completed the 12-month observation period. Overall, a substantial number of patients experienced moderate airflow limitation (~49% patients, GOLD 2 as per GOLD 2013; mean postbronchodilator forced expiratory volume in 1 second value was ~50% of the predicted value), belonged to GOLD group D (~51% patients), and had COPD assessment test score ≥10 or modified Medical Research Council score ≥2 (~79% patients), and ≤1 exacerbation in the past 1 year (~80% patients). Short-acting β2-agonists (~63% patients), inhaled corticosteroids/long-acting β2-agonist fixed-dose combination (~62% patients), and long-acting muscarinic antagonists (~59% patients) were the most frequently used medications at all visits, regardless of severity. High levels of deviation from GOLD recommendations were observed in GOLD groups A and B patients. The deviation comprised high use of inhaled corticosteroid-containing regimens in ~45% and 63% of patients in GOLD groups A and B, respectively. Only 25 (3%) of the 796 patients reported at least one adverse event.

Conclusion

The routine clinical practice for COPD in Bulgaria deviates from the GOLD recommendations largely in patients at a low risk (GOLD groups A and B), while the deviation was lesser in those at a higher risk (GOLD groups C and D).

Implementation of GOLD consensus report in real life: results from the Velletri-Lariano (VELA) cohort

BACKGROUND

COPD is one of the leading causes of morbidity and mortality. Pharmacotherapy improves quality of life and reduces exacerbations although low adherence with prescribed treatments may represent a barrier to optimal disease management. The first objective of this paper is to report the distribution of COPD patients according to GOLD categories, in a sample of patients from a cohort study in an area of the Latium region in Italy. The second objective is to evaluate the agreement between the distributions of severity obtained from the HCPs and the experts included in the study board (Board).

METHODS

COPD patients were given a card to collect demographic and clinical data at baseline. Information in those cards was independently evaluated by HCPs and Board to include each patient into one of the four GOLD categories.

RESULTS

In a sample of 187 stable COPD patients, 59% male, mean age 70 year, the distribution of GOLD categories according to the Board was: 6% A, 34% B, 2% C, and 58% D. A discrepancy in GOLD classification was observed between the study board and field-based HCPs, regarding more than 50% of the patients, with a clear trend to underestimate the frequency of patients in D level (21%) and to overestimate the frequency in C level (21%).

CONCLUSIONS

These results describe for the first time the distribution of COPD patients in an Italian cohort according to the GOLD categories, with the highest frequencies in levels B and D. The misclassification from HCPs may impact the therapeutic approach and the clinical outcomes.

A cross-sectional survey of current treatment and symptom burden of patients with COPD consulting for routine care according to GOLD 2014 classifications

Background

As part of the Respiratory Disease Specific Program (DSP) conducted to provide observations of clinical practice from a physician and matched patient viewpoint, this study aimed to establish how patients with COPD are treated according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification system and to quantify the symptom burden.

Methods

Data were obtained from the Respiratory DSP, a cross-sectional survey of patients with a diagnosis of COPD consulting for routine care in France, Germany, Italy, Spain, the UK, and the USA during the third quarter of 2013. Patients’ exacerbation risk and symptom data were used for classification into GOLD groups A−D based on GOLD 2014 criteria. Prescribing practices were stratified by physician type and time since patient diagnosis.

Results

A total of 903 physicians participated in the Respiratory DSP, with data from 1,641 patients included in this analysis. Most patients were classified into GOLD groups B (n=742; 45.2%) and D (n=704; 42.9%). Patients in groups A and D were most likely to be treated in line with GOLD recommendations (61.5% and 77.5%, respectively), compared with 40.1% for group B. Patients with a diagnosis within the past 12 months were more likely to be treated according to recommendations. Inhaled corticosteroids (ICSs) in combination with one or more long-acting bronchodilator were prescribed across all GOLD groups. Patterns of treatment were, in general, similar for patients treated by a primary care physician or a pulmonologist. COPD assessment test scores ≥10 indicating a high symptom burden were reported for >80% of patients.

Conclusion

This analysis confirmed a high symptom burden among patients with COPD and indicates some misalignment of prescribing with GOLD recommendations, particularly regarding the role of ICS/long-acting β₂-agonist (LABA) and ICS/LABA + long-acting muscarinic antagonist combinations across the different GOLD groups.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

A review of national guidelines for management of COPD in Europe

The quality of care can be improved by the development and implementation of evidence-based treatment guidelines. Different national guidelines for chronic obstructive pulmonary disease (COPD) exist in Europe and relevant differences may exist among them.This was an evaluation of COPD treatment guidelines published in Europe and Russia in the past 7 years. Each guideline was reviewed in detail and information about the most important aspects of patient diagnosis, risk stratification and pharmacotherapy was extracted following a standardised process. Guidelines were available from the Czech Republic, England and Wales, Finland, France, Germany, Italy, Poland, Portugal, Russia, Spain and Sweden. The treatment goals, criteria for COPD diagnosis, consideration of comorbidities in treatment selection and support for use of long-acting bronchodilators, were similar across treatment guidelines. There were differences in measures used for stratification of disease severity, consideration of patient phenotypes, criteria for the use of inhaled corticosteroids and recommendations for other medications (e.g. theophylline and mucolytics) in addition to bronchodilators.There is generally good agreement on treatment goals, criteria for diagnosis of COPD and use of long-acting bronchodilators as the cornerstone of treatment among guidelines for COPD management in Europe and Russia. However, there are differences in the definitions of patient subgroups and other recommended treatments.

Diagnosing COPD: advances in training and practice - a systematic review

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung syndrome, caused by long-term inhalation of noxious gases and particles, which leads to gradual airflow limitation. All health care professionals who care for COPD patients should have full access to high-quality spirometry testing, as postbronchodilator spirometry constitutes the principal method of COPD diagnosis. One out of four smokers 45 years or older presenting respiratory symptoms in primary care, have non-fully reversible airflow limitation compatible with COPD and are mostly without a known diagnosis. Approximately 50.0%-98.3% of patients are undiagnosed worldwide. The majority of undiagnosed COPD patients are isolated at home, are in nursing or senior-assisted living facilities, or are present in oncology and cardiology clinics as patients with lung cancers and coronary artery disease. At this time, the prevalence and mortality of COPD subjects is increasing, rapidly among women who are more susceptible to risk factors. Since effective management strategies are currently available for all phenotypes of COPD, correctly performed and well-interpreted postbronchodilator spirometry is still an essential component of all approaches used. Simple educational training can substantially improve physicians' knowledge relating to COPD diagnosis. Similarly, a physician inhaler education program can improve attitudes toward inhaler teaching and facilitate its implementation in routine clinical practices. Spirometry combined with inhaled technique education improves the ability of predominantly nonrespiratory physicians to correctly diagnose COPD, to adequately assess its severity, and to increase the percentage of correct COPD treatment used in a real-life setting.

Applying the wisdom of stepping down inhaled corticosteroids in patients with COPD: a proposed algorithm for clinical practice

Current guidelines for the management of chronic obstructive pulmonary disease (COPD) recommend limiting the use of inhaled corticosteroids (ICS) to patients with more severe disease and/or increased exacerbation risk. However, there are discrepancies between guidelines and real-life practice, as ICS are being overprescribed. In light of the increasing concerns about the clinical benefit and long-term risks associated with ICS use, therapy needs to be carefully weighed on a case-by-case basis, including in patients already on ICS. Several studies sought out to determine the effects of withdrawing ICS in patients with COPD. Early studies have deterred clinicians from reducing ICS in patients with COPD as they reported that an abrupt withdrawal of ICS precipitates exacerbations, and results in a deterioration in lung function and symptoms. However, these studies were fraught with numerous methodological limitations. Recently, two randomized controlled trials and a real-life prospective study revealed that ICS can be safely withdrawn in certain patients. Of these, the WISDOM (Withdrawal of Inhaled Steroids During Optimized Bronchodilator Management) trial was the largest and first to examine stepwise withdrawal of ICS in patients with COPD receiving maintenance therapy of long-acting bronchodilators (ie, tiotropium and salmeterol). Even with therapy being in line with the current guidelines, the findings of the WISDOM trial indicate that not all patients benefit from including ICS in their treatment regimen. Indeed, only certain COPD phenotypes seem to benefit from ICS therapy, and validated markers that predict ICS response are urgently warranted in clinical practice. Furthermore, we are now better equipped with a larger armamentarium of novel and more effective long-acting β2-agonist/long-acting muscarinic antagonist combinations that can be considered by clinicians to optimize bronchodilation and allow for safer ICS withdrawal. In addition to providing a review of the aforementioned, this perspective article proposes an algorithm for the stepwise withdrawal of ICS in real-life clinical practice.

Factors associated with the prescription of inhaled corticosteroids in GOLD group A and B patients with COPD - subgroup analysis of the Taiwan obstructive lung disease cohort

Background and objective

The overprescription of inhaled corticosteroids (ICS) in the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A and B patients with chronic obstructive pulmonary disease (COPD) is not uncommon in clinical practice. The aim of this study was to explore the factors associated with the use of ICS in these patients.

Methods

The Taiwan obstructive lung disease (TOLD) study was a retrospective, observational nationwide survey of COPD patients conducted at 12 hospitals (n=1,096) in Taiwan. Multivariate logistic regression models were used to explore the predictors of ICS prescription in GOLD group A and B patients.

Results

Among the group A (n=179) and group B (n=398) patients, 198 (34.3%) were prescribed ICS (30.2% in group A and 36.2% in group B, respectively). The wheezing phenotype was present in 28.5% of group A and 34.2% of group B patients. Wheezing was the most significant factor for an ICS prescription in group A (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.14–4.75; P=0.020), group B (OR, 1.93; 95% CI, 1.24–2.99; P=0.004), and overall (OR, 2.04; 95% CI, 1.40–2.96; P<0.001). The COPD assessment test score was also associated with an ICS prescription in group B (OR, 1.04; 95% CI, 1.00–1.07; P=0.038).

Conclusion

About one-third of the GOLD group A and B patients with COPD in Taiwan are prescribed ICS. Our findings suggest that wheezing and COPD assessment test score are related to the prescription of ICS in these patients.

Is asymptomatic peripheral arterial disease associated with walking endurance in patients with COPD?

Objective

Symptomatic peripheral arterial disease (PAD) is associated with impaired walking endurance in patients with chronic obstructive pulmonary disease (COPD). However, it is unknown whether asymptomatic PAD is associated with impaired walking endurance in patients with COPD.

Methods

This prospective cross-sectional study enrolled 200 COPD patients (mean age: 70.9 years) who volunteered to perform ankle-brachial index (ABI) and 6-minute walk test (6MWT) consecutively. Demographic data, lung function, dyspnea scales, and cardiovascular risk factors were recorded. The ABI was used to detect PAD (ABI <0.90). All patients were free of PAD symptoms at enrollment.

Results

Of the 200 COPD patients, 17 (8.5%) were diagnosed with asymptomatic PAD. The COPD patients without asymptomatic PAD did not walk significantly further on the 6MWT than the COPD patients with asymptomatic PAD (439±86 m vs 408±74 m, P=0.159). The strongest correlation with the distance walked on the 6MWT was Medical Research Council dyspnea scale (r²=−0.667, P<0.001), followed by oxygen-cost diagram (r²=0.582, P<0.001) and forced expiratory volume in 1 second (r²=0.532, P<0.001). In multivariate linear regression analysis, only age, forced expiratory volume in 1 second, and baseline pulse oximetry were independently correlated with the distance covered on the 6MWT (P<0.05). However, body mass index, baseline heart rate, and ABI were not correlated with the distance covered on the 6MWT.

Conclusion

Asymptomatic PAD is not associated with walking endurance in patients with COPD. Therefore, it is important to detect and treat asymptomatic PAD early so that COPD patients do not progress to become exercise intolerant. Limited by the small sample size and predominantly male (99%) population in the study, further large-scale prospective studies are needed to verify the results.

The reasons for triple therapy in stable COPD patients in Japanese clinical practice

Background

Triple combination therapy involving long-acting muscarinic antagonists long-acting β₂ agonists, and inhaled corticosteroids has recently become an option for maintenance treatment of COPD. Some add-on clinical trials have reported the benefits of these combinations. However, the process to step up to triple therapy varies for individual cases.

Methods

Keio University and affiliated hospitals conducted an observational COPD cohort study, recruiting patients diagnosed as having COPD by pulmonary physicians and those referred for investigation of possible COPD. Their prescription history and clinical course were retrospectively analyzed based on the physicians’ medical records and patient questionnaires. This study was registered with UMIN (UMIN000003470, April 10, 2010).

Results

A total of 95 of the 445 COPD patients (21%) were treated with inhaled corticosteroids/long-acting β₂ agonists/long-acting muscarinic antagonists as maintenance therapy, including 12 in COPD Grade I, 31 in Grade II, 38 in Grade III, and 14 in Grade IV, based on the Global Initiative for Chronic Obstructive Lung Disease spirometric grading. For more than half of the patients on triple therapy, the treatment had been intensified due to unsatisfactory improvement of symptoms, and 32% were treated with triple therapy due to comorbid asthma. In contrast, there were COPD patients whose therapy was maintained after starting with triple therapy because of their serious conditions or concurrent exacerbation at diagnosis (8%).

Conclusion

Triple therapy was often prescribed in the real-life management of COPD, even in patients whose airflow limitation was not severe. To better control symptoms was the major reason for choosing triple therapy, regardless of the severity of COPD, in Japan.