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      Distribution, Temporal Stability and Appropriateness of Therapy of Patients With COPD in the UK in Relation to GOLD 2019

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          Abstract

          Background

          The 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report made recommendations for the assessment, initial and subsequent treatment chronic obstructive pulmonary disease (COPD) based on biomarkers, including blood eosinophil counts.

          Methods

          We evaluated the distribution of UK COPD patients initiating maintenance therapy and established patients by GOLD group, the prevalence of comorbidities and appropriateness of therapy using electronic patient records from the Optimum Patient Care Research Database (OPCRD). Changes in effective GOLD group, therapy and exacerbation rates over the next 2 years were analysed.

          Findings

          11,409 established COPD patients and 699 starting therapy were studied. 44·3%, 25·7%, 13·8% & 16·2% of established COPD patients and 45·2%, 28·5%, 15·7% & 10·6% initiating therapy were in GOLD groups A, B, C & D respectively.

          The overall proportion in each GOLD group was similar after 2 years but there was substantial movement of patients between groups. Diabetes and cardiovascular disease were the most common comorbidities in all groups in both cohorts.

          LAMA monotherapy was the commonest initial therapy in all GOLD groups. In both cohorts there was over-treatment with escalation, de-escalation or switching in nearly 50% during follow-up.

          In both cohorts, exacerbation rates were highest in group D and appeared higher in over-treated patients.

          Interpretation

          Most patients are not at risk of exacerbations and co-morbidities are common. Many patients change effective GOLD group and therapy over time. Prescribing is not in accordance with guideline recommendations and many patients still appear over treated.

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          Most cited references21

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          Management of COPD in the UK primary-care setting: an analysis of real-life prescribing patterns

          Background Despite the availability of national and international guidelines, evidence suggests that chronic obstructive pulmonary disease (COPD) treatment is not always prescribed according to recommendations. This study evaluated the current management of patients with COPD using a large UK primary-care database. Methods This analysis used electronic patient records and patient-completed questionnaires from the Optimum Patient Care Research Database. Data on current management were analyzed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) group and presence or absence of a concomitant asthma diagnosis, in patients with a COPD diagnosis at ≥35 years of age and with spirometry results supportive of the COPD diagnosis. Results A total of 24,957 patients were analyzed, of whom 13,557 (54.3%) had moderate airflow limitation (GOLD Stage 2 COPD). The proportion of patients not receiving pharmacologic treatment for COPD was 17.0% in the total COPD population and 17.7% in the GOLD Stage 2 subset. Approximately 50% of patients in both cohorts were receiving inhaled corticosteroids (ICS), either in combination with a long-acting β2-agonist (LABA; 26.7% for both cohorts) or a LABA and a long-acting muscarinic antagonist (LAMA; 23.2% and 19.9%, respectively). ICS + LABA and ICS + LABA + LAMA were the most frequently used treatments in GOLD Groups A and B. Of patients without concomitant asthma, 53.7% of the total COPD population and 50.2% of the GOLD Stage 2 subset were receiving ICS. Of patients with GOLD Stage 2 COPD and no exacerbations in the previous year, 49% were prescribed ICS. A high proportion of GOLD Stage 2 COPD patients were symptomatic on their current management (36.6% with modified Medical Research Council score ≥2; 76.4% with COPD Assessment Test score ≥10). Conclusion COPD is not treated according to GOLD and National Institute for Health and Care Excellence recommendations in the UK primary-care setting. Some patients receive no treatment despite experiencing symptoms. Among those on treatment, most receive ICS irrespective of severity of airflow limitation, asthma diagnosis, and exacerbation history. Many patients on treatment continue to have symptoms.
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            Barriers to adherence to COPD guidelines among primary care providers.

            Despite efforts to disseminate guidelines for managing chronic obstructive pulmonary disease (COPD), adherence to COPD guidelines remains suboptimal. Barriers to adhering to guidelines remain poorly understood. Clinicians from two general medicine practices in New York City were surveyed to identify barriers to implementing seven recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Barriers assessed included unfamiliarity, disagreement, low perceived benefit, low self-efficacy, and time constraints. Exact conditional regression was used to identify barriers independently associated with non-adherence. The survey was completed by 154 clinicians. Adherence was lowest to referring patients with a forced expiratory volume in 1 s (FEV(1)) <80% predicted to pulmonary rehabilitation (5%); using FEV(1) to guide management (12%); and ordering pulmonary function tests (PFTs) in smokers (17%). Adherence was intermediate to prescribing inhaled corticosteroids when FEV(1) <50% predicted (41%) and long-acting bronchodilators when FEV(1) <80% predicted (54%). Adherence was highest for influenza vaccination (90%) and smoking cessation counseling (91%). In unadjusted analyses, low familiarity with the guidelines, low self-efficacy, and time constraints were significantly associated with non-adherence to ≥2 recommendations. In adjusted analyses, low self-efficacy was associated with less adherence to prescribing inhaled corticosteroids (OR: 0.28; 95% CI: 0.10, 0.74) and time constraints were associated with less adherence to ordering PFTs in smokers (OR: 0.31; 95% CI: 0.08, 0.99). Poor familiarity with recommendations, low self-efficacy, and time constraints are important barriers to adherence to COPD guidelines. This information can be used to develop tailored interventions to improve guideline adherence. Copyright © 2011 Elsevier Ltd. All rights reserved.
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              How far is real life from COPD therapy guidelines? An Italian observational study.

              According to the GOLD international guidelines, the treatment of chronic obstructive pulmonary disease (COPD) should be proportional to the severity of airflow obstruction graded according to FEV(1)% predicted. Regular treatment with long-acting bronchodilators should be prescribed for symptomatic patients with FEV(1) < 80%. Inhaled corticosteroids should be added in patients with FEV(1) < 50% predicted and frequent exacerbations. To investigate whether pulmonologists follow the GOLD guidelines when prescribing treatment for COPD. A multicenter, cross-sectional, observational study was carried out in 49 Pulmonary Units evenly distributed throughout the country. For each patient the demographic, clinical data and the current therapies were registered in an electronic database. 4094 patients (mean age: 70.9 ± 9.4; males 72.4%, female 27.6%) were enrolled. Disease severity was classified as: mild (745), moderate (1722), severe (923), very severe (704). Irrespective of disease severity, inhaled corticosteroids alone or in combination with long-acting bronchodilators were used in 15.2% and 66.8% of patients, respectively. The appropriateness of the pharmacological treatment of the COPD patients was defined in accordance with the GOLD recommendations. The treatment was appropriate in 37.9% of patients and inappropriate in 62.1%, p < 0.0001. The inappropriateness was due to under-prescription in 7.2% and to over-prescription in 54.9% of patients. The presence and the number of exacerbations represented an important trigger for over-prescription at stages I and II. This study shows that there is a poor relationship between the recommendations of the GOLD international guidelines and current clinical practice, and that exacerbations may play a role in over-prescription. Copyright © 2012 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Journal
                EClinicalMedicine
                EClinicalMedicine
                EClinicalMedicine
                Elsevier
                2589-5370
                24 July 2019
                September 2019
                24 July 2019
                : 14
                : 32-41
                Affiliations
                [a ]University of Exeter Medical School, Exeter, UK
                [b ]Observational and Pragmatic Research Institute Pte Ltd (OPRI), Singapore
                Author notes
                [* ]Corresponding author at: University of Exeter Medical School, Exeter, UK. d.halpin@ 123456nhs.net
                Article
                S2589-5370(19)30117-8
                10.1016/j.eclinm.2019.07.003
                6833455
                31709400
                6b2f6b97-7877-4d15-ba80-fcba314407e9
                © 2019 Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 1 May 2019
                : 10 June 2019
                : 16 July 2019
                Categories
                Research Paper

                copd,gold,clinical practice,pharmacotherapy,comorbidities
                copd, gold, clinical practice, pharmacotherapy, comorbidities

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