Impact of adherence to GOLD guidelines on symptom prevalence, lung function decline and exacerbation rate in a Swiss COPD cohort
PRINCIPLES: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines aim to optimise chronic obstructive pulmonary disease (COPD) diagnosis and treatment.
However, little is known about the extent to which general practitioners’ (GP) adherence to GOLD guidelines improves patient outcomes.
METHODS: In this questionnaire-based study, COPD patients were screened and enrolled; exacerbation history was recorded, and demographic, spirometric and management data were collected for 12 months. Spirometry was performed at least every 6 months according to American Thoracic Society guidelines. Based on these data, patients were grouped into GOLD COPD severity classifications. Data were expressed as the difference between baseline and month 12.
RESULTS: Among 139 GPs, 454 patients were analysed regarding baseline and 12 month data. There was no significant change in distribution of GOLD COPD severity grades, lung function or guideline adherence. Chronic cough and sputum production were significantly reduced (p <0.001; p <0.020), as was exacerbation rate (p = 0.041). Factors associated with exacerbations were male sex, asthma and cerebrovascular insult as a co-morbidity. Exacerbation rate was significantly reduced in patients treated with combination therapy (long-acting β2-agonist (LABA)+ inhaled corticosteroids (ICS); p = 0.0178) and long-acting anticholinergics (LAAC; p = 0.0011). Patients treated per guidelines had no advantage in lung function, estimation of symptom prevalence or, most importantly, exacerbation rate.
CONCLUSIONS: While there was no improvement in adherence to GOLD guidelines, disease severity was not affected detrimentally, suggesting that guideline adherence does not seem to impact symptom prevalence, exacerbation rate or lung function decline after one year of follow up.
- GOLD. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. http://www.goldcopd.com. 2010:1–91.
- Brandli O, Schindler C, Kunzli N, Keller R, Perruchoud AP. Lung function in healthy never smoking adults: reference values and lower limits of normal of a Swiss population. Thorax. 1996;51(3):277–83.
- Miravitlles M. Guidelines versus clinical practice in the treatment of chronic obstructive pulmonary disease. Eur Respir J. 2002;20(1):243–4.
- Bailey R, Weingarten S, Lewis M, Mohsenifar Z. Impact of clinical pathways and practice guidelines on the management of acute exacerbations of bronchial asthma. Chest. 1998;113(1):28–33.
- Roche N, Lepage T, Bourcereau J, Terrioux P. Guidelines versus clinical practice in the treatment of chronic obstructive pulmonary disease. Eur Respir J. 2001;18(6):903–8.
- Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics. 2002;110(2 Pt 1):315–22.
- Pauwels RA. National and international guidelines for COPD: the need for evidence. Chest. 2000;117(2 Suppl):20S–2S.
- Jochmann A, Neubauer F, Miedinger D, Schafroth S, Tamm M, Leuppi JD. General practitioner’s adherence to the COPD GOLD guidelines: baseline data of the Swiss COPD Cohort Study. Swiss Med Wkly. 2010 Apr 21.
- Statistik Bf. N. Anzahl und Dichte der berufstätigen Ärzte und Zahnärzte. Available from: <http://www.bfs.admin.ch/bfs/portal/de/index/themen/14/03/03/key/01.html>2007.
- Pauwels RA, Buist AS, Ma P, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute and World Health Organization Global Initiative for Chronic Obstructive Lung Disease (GOLD): executive summary. Respir Care. 2001;46(8):798–825.
- Standardization of Spirometry, 1994 Update. American Thoracic Society. Am J Respir Crit Care Med. 1995;152(3):1107–36.
- Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532–55.
- Chen C-hH, Wolfgang; Unwin, Antony, eds. Handbook of data visualization. Springer Handbooks of Computational Statistics. Springer. 2008.
- Ripley. WNVaBD. Modern Applied Statistics with S-PLUS (Third Edition) Springer, New York. 1999:(xi) + 501 pages.
- Team RDC. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria 2008.
- Vogelmeier C, Hederer B, Glaab T, Schmidt H, Rutten-van Molken MP, Beeh KM, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med. 2011;364(12):1093–103.
- Mularski RA, Asch SM, Shrank WH, Kerr EA, Setodji CM, Adams JL, et al. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest. 2006;130(6):1844–50.
- Fritsch K, Jacot ML, Klarer A, Wick F, Bruggmann P, Krause M, et al. Adherence to the Swiss guidelines for management of COPD: experience of a Swiss teaching hospital. Swiss Med Wkly. 2005;135(7-8):116–21.
- Tashkin DP, Celli B, Senn S, Burkhart D, Kesten S, Menjoge S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. 2008;359(15):1543–54.
- Blinderman CD, Homel P, Billings JA, Tennstedt S, Portenoy RK. Symptom distress and quality of life in patients with advanced chronic obstructive pulmonary disease. J Pain Symptom Manage. 2009;38(1):115–23.
- Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356(8):775–89.
- Burge PS, Calverley PM, Jones PW, Spencer S, Anderson JA, Maslen TK. Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease: the ISOLDE trial. BMJ. 2000;320(7245):1297–303.
- Bourbeau J, Sebaldt RJ, Day A, Bouchard J, Kaplan A, Hernandez P, et al. Practice patterns in the management of chronic obstructive pulmonary disease in primary practice: the CAGE study. Can Respir J. 2008;15(1):13–9.
- Halpin DM, Gray J, Edwards SJ, Morais J, Singh D. Budesonide/formoterol vs. salmeterol/fluticasone in COPD: a systematic review and adjusted indirect comparison of pneumonia in randomised controlled trials. Int J Clin Pract. 2011;65(7):764–74.
- Moncelly L, Maurer C, Roche N, Zureik M, Chavaillon JM, Quieffin J, et al. Acute COPD exacerbations in women: EABPCO-CPHG study by the College of general hospital pneumologists. Rev Pneumol Clin. 2010;66(2):107–19.
- Faganello MM, Tanni SE, Sanchez FF, Pelegrino NR, Lucheta PA, Godoy I. BODE index and GOLD staging as predictors of 1-year exacerbation risk in chronic obstructive pulmonary disease. Am J Med Sci. 2010;339(1):10–4.
- Leuppi JD, Miedinger D, Chhajed PN, Buess C, Schafroth S, Bucher HC, et al. Quality of Spirometry in Primary Care for Case Finding of Airway Obstruction in Smokers. Respiration. 2009 Sep 26.
- Miedinger D, Linz A, Praehauser C, Chhajed PN, Buess C, Schafroth Torok S, et al. Patient-reported respiratory symptoms and pre-bronchodilator airflow limitation among smokers in Switzerland. Prim Care Respir J. 2010;19(2):163–9.
- Chavez PC, Shokar NK. Diagnosis and management of chronic obstructive pulmonary disease (COPD) in a primary care clinic. COPD. 2009;6(6):446–51.
- Wedzicha JA, Calverley PM, Seemungal TA, Hagan G, Ansari Z, Stockley RA. The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide. Am J Respir Crit Care Med. 2008;177(1):19–26.