Study Finds Pulmonologists and PCPs Prescribe Differing Treatments for Patients With COPD

A study published in the International Journal of Chronic Obstructive Pulmonary Disease found differing methods in the treatment of chronic obstructive pulmonary disease (COPD) between pulmonologists and primary care physicians (PCPs). The study aimed to understand the current use of COPD maintenance medication in the United States.

The study used secondary data from a survey—the Respiratory Disease Specific Programme—of patients with COPD and their physicians in the United States. The surveys were completed between July and December 2019. Each physician completed a patient survey. Patients were asked to complete a COPD Assessment Test (CAT) questionnaire and provide their CAT score on the date of the survey.

PCPs and pulmonologists were required to manage 3 or more patients with COPD per month and be actively involved in the management of patients with COPD. All patients were aged 18 years or older with a diagnosis of COPD. Patients with an asthma diagnosis or currently enrolled in a clinical study were excluded.

Patients were grouped according to physician type that provided data in the survey. Physicians were asked if they referred to guidelines when treating patients with COPD and, if so, which ones they referred to.

There were 92 PCPs and 79 pulmonologists who completed the survey, who provided records for 408 and 392 patients, respectively; 451 patients completed the voluntary patient self-completion questionnaire.

The mean age of the patients was 66.4 years, 45% of the patients were female, and 87% were current or former smokers. Patients were reported to have moderate COPD (49.4%) and 19.3% had severe/very severe COPD; 40.9% and 42.3% of patients taking an inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) only or a long-acting muscarinic antagonist (LAMA) only, respectively, were reported as having mild disease.

A lower proportion of patients were prescribed ICS/LABA only when consulting a pulmonologist vs a PCP (21.7% vs 31.4%). Pulmonologists more frequently prescribed their patients LAMA/LABA only (16% vs 12%), single-inhaler ICS/LAMA/LABA triple therapy (14.0% vs 7.1%), and ICS/LABA + LAMA triple therapy (13.7% vs 15.6%). Prescriptions of LAMA monotherapy were similar between PCPs and pulmonologists.

Most patients (58.8%) who were currently consulting a PCP had their current COPD regimen initiated by a PCP; 31.9% of patients consulting a PCP had their regimen initiated by a pulmonologist. There were 87.2% of patients currently consulting a pulmonologist who had their current regimen initiated by a pulmonologist and 8.2% who had their treatment initiated by a PCP.

A randomly assigned subset of 43 PCPs and 32 pulmonologists were presented with 4 patient profiles and asked to provide treatment choices based on severity of the COPD profile. The researchers found that pulmonologists treated each patient differently across the patient profiles and PCPs most frequently selected ICS/LABA for each of the profiles.

The study found that 79.1% of PCPs and 71.9% of pulmonologists referred to guidelines before making treatment decisions; those who reported referring to guidelines stated they most frequently consulted the GOLD guidelines (PCPs, 79.4%; pulmonologists, 91.3%).

There were some limitations to this study. Patient and physician participation was based on willingness to participate and pragmatic geographical considerations, which may have influenced the sample. Exclusion of patients with asthma also limits the generalizability of the findings. Spirometry testing was not used, and it is possible that some patients had an incorrect diagnosis. Missing data on the clinical history of COPD and treatment history limit the conclusions that can be drawn.

The researchers concluded that pulmonologists were more likely to prescribe dual bronchodilation and triple therapy than PCPs and that PCPs were more likely to prescribe ICS/LABA regardless of patient symptom presentation.

“Physician education and improved understanding of patient types that benefit from each treatment pathway could help optimize patient care in COPD, particularly in the primary care setting,” the authors wrote.

Reference

Mannino D, Siddall J, Small M, Haq A, Stiegler M, Bogart M. Treatment patterns for chronic obstructive pulmonary disease (COPD) in the United States: results from an observational cross-sectional physician and patient survey. Int J Chron Obstruc Pulmon Dis. 2022;17:749-761. doi:10.2147/COPD.s340794