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      Categorization of COPD patients in Turkey via GOLD 2013 strategy document: ALPHABET study

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          To determine distribution of COPD assessment categories and physicians’ adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013 strategy in Turkish COPD patients.


          A total of 1,610 COPD patients (mean [standard deviation] age: 62.6 [9.9] years, 85.7% were males) were included in this multicenter, non-interventional, cross-sectional study. Patients were categorized via GOLD 2013 strategy document. Consistency between reported and re-classified GOLD categories, and measures used for symptom evaluation and exacerbation was analyzed.


          Overall, 41.1% of patients were assigned to GOLD A, while 13.2% were assigned to GOLD C categories. Long-acting beta-2 agonist + long-acting muscarinic antagonist + inhaled corticosteroid regimen was the most common treatment (62.0%). Over-treatment was noted in >70% of GOLD A, B, and C patients. A high consistency between measures of symptom evaluation (Kappa coefficient =0.993, P<0.0001) and a low-moderate consistency between exacerbation risk measures (Kappa coefficient =0.237, P<0.0001) were noted.


          Our findings revealed GOLD A as the most prevalent category in Turkish cohort of COPD patients. Group assignment was altered depending on the chosen measure for symptom and risk assessment. Physician non-adherence to treatment recommendations in GOLD 2013 document leading to over-treatment in patients assigned to GOLD A, B, and C categories was also detected.

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          Most cited references 17

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          GOLD 2011 disease severity classification in COPDGene: a prospective cohort study.

          The 2011 GOLD (Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease [COPD]) consensus report uses symptoms, exacerbation history, and forced expiratory volume (FEV1)% to categorise patients according to disease severity and guide treatment. We aimed to assess both the influence of symptom instrument choice on patient category assignment and prospective exacerbation risk by category. Patients were recruited from 21 centres in the USA, as part of the COPDGene study. Eligible patients were aged 45-80 years, had smoked for 10 pack-years or more, and had an FEV1/forced vital capacity (FVC) <0·7. Categories were defined with the modified Medical Research Council (mMRC) dyspnoea scale (score 0-1 vs ≥2) and the St George's Respiratory Questionnaire (SGRQ; ≥25 vs <25 as a surrogate for the COPD Assessment Test [CAT] ≥10 vs <10) in addition to COPD exacerbations in the previous year (<2 vs ≥ 2), and lung function (FEV1% predicted ≥50 vs <50). Statistical comparisons were done with k-sample permutation tests. This study cohort is registered with, number NCT00608764. 4484 patients with COPD were included in this analysis. Category assignment using the mMRC scale versus SGRQ were similar but not identical. On the basis of the mMRC scale, 1507 (33·6%) patients were assigned to category A, 919 (20·5%) to category B, 355 (7·9%) to category C, and 1703 (38·0%) to category D; on the basis of the SGRQ, 1317 (29·4%) patients were assigned to category A, 1109 (24·7%) to category B, 221 (4·9%) to category C, and 1837 (41·0%) to category D (κ coefficient for agreement, 0·77). Significant heterogeneity in prospective exacerbation rates (exacerbations/person-years) were seen, especially in the D subcategories, depending on the risk factor that determined category assignment (lung function only [0·89, 95% CI 0·78-1·00]), previous exacerbation history only [1·34, 1·0-1·6], or both [1·86, 1·6-2·1; p<0·0001]). The GOLD classification emphasises the importance of symptoms and exacerbation risk when assessing COPD severity. The choice of symptom measure influences category assignment. The relative number of patients with low symptoms and high risk for exacerbations (category C) is low. Differences in exacerbation rates for patients in the highest risk category D were seen depending on whether risk was based on lung function, exacerbation history, or both. National Heart, Lung, and Blood Institute, and the COPD Foundation through contributions from AstraZeneca, Boehringer Ingelheim, Novartis, and Sepracor. Copyright © 2013 Elsevier Ltd. All rights reserved.
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            Distribution and prognostic validity of the new Global Initiative for Chronic Obstructive Lung Disease grading classification.

            The new Global Initiative for Chronic Obstructive Lung Disease (GOLD) update includes airflow limitation, history of COPD exacerbations, and symptoms to classify and grade COPD severity. We aimed to determine their distribution in 11 well-defined COPD cohorts and their prognostic validity up to 10 years to predict time to death. Spirometry in all 11 cohorts was postbronchodilator. Survival analysis and C statistics were used to compare the two GOLD systems by varying time points. Of 3,633 patients, 1,064 (33.6%) were in new GOLD patient group A (low risk, less symptoms), 515 (16.3%) were B (low risk, more symptoms), 561 (17.7%) were C (high risk, less symptoms), and 1,023 (32.3%) were D (high risk, more symptoms). There was great heterogeneity of this distribution within the cohorts ( x (2) , P < .01). No differences were seen in the C statistics of old vs new GOLD grading to predict mortality at 1 year (0.635 vs 0.639, P = .53), at 3 years (0.637 vs 0.645, P = .21), or at 10 years (0.639 vs 0.642, P = .76). The new GOLD grading produces an uneven split of the COPD population, one third each in A and D patient groups, and its prognostic validity to predict time to death is no different than the old GOLD staging based in spirometry only.
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              The 2011 revision of the global strategy for the diagnosis, management and prevention of COPD (GOLD)--why and what?

              The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published a strategy for diagnosis and for management of chronic obstructive pulmonary disease (COPD) since 2001 and this has formed the basis for numerous national and regional guidelines. We describe the background for the 2011 revision of the GOLD document. The GOLD document is updated annually and revised every 5 years based on published research as well as an evaluation by an expert panel of how to best formulate and disseminate knowledge on COPD. The GOLD 2011 revision states that spirometry is required for making a clinical diagnosis of COPD. At the same time, the document has less emphasis on spirometric evaluation of disease severity and launches a combined assessment taking symptoms, spirometry and history of exacerbations into account. This is matched with initial treatment for COPD where smoking cessation, pulmonary rehabilitation and physical activity in general are given high priority followed by pharmacologic treatment guided by the novel assessment scheme. Comorbidities are often present in COPD and the GOLD 2011 revision gives some guidance in how to manage these as well as how to manage COPD in the presence of comorbidities. A more clinically oriented GOLD document will hopefully improve assessment and management of COPD. © 2012 Blackwell Publishing Ltd.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                13 November 2015
                : 10
                : 2485-2494
                [1 ]Department of Chest Diseases, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
                [2 ]Department of Chest Diseases, Safranbolu State Hospital, Karabuk, Turkey
                [3 ]Department of Chest Diseases, Ataturk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
                [4 ]Department of Chest Diseases, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
                [5 ]Department of Chest Diseases, Dr Suat Seren Chest Diseases and Thoracic Surgery Training and Research Hospital, Izmir, Turkey
                [6 ]Department of Chest Diseases, Cukurova Dr Askim Tufekci State Hospital, Adana, Turkey
                [7 ]Department of Chest Diseases, Ege University Faculty of Medicine, Izmir, Turkey
                [8 ]Department of Chest Diseases, Bingol State Hospital, Bingol, Turkey
                [9 ]Department of Chest Diseases, Akdeniz University, Faculty of Medicine, Antalya, Turkey
                [10 ]Department of Chest Diseases, Gazi University Faculty of Medicine, Ankara, Turkey
                [11 ]Medical Department, Novartis Pharmaceuticals, Istanbul, Turkey
                Author notes
                Correspondence: Hakan Gunen, Department of Chest Diseases, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Basibuyuk Mah., 34854 Maltepe, Istanbul, Turkey, Tel +90 532 621 1699, Email hgunen@
                © 2015 Gunen et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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