Study Finds Suboptimal Adherence to GOLD Guidelines for COPD

An analysis of adoption of and adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD) in the primary care setting unearthed disappointing results, demonstrating suboptimal use of pulmonary function tests, no routine use of validated symptoms scales for diagnosis, and variation in pharmacotherapy.

The 2018 update to the GOLD guidelines requires 3 features for COPD diagnosis, including a postbronchodilator forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.70, to confirm persistent airflow limitation; relies mainly on “persistent” symptoms and exacerbation frequency to determine therapy specifics; and requires that every visit include education, training, and assessment.

“Despite the availability of well-established recommendations for diagnosis and management, COPD is often misdiagnosed and inappropriately treated in many patients, with approximately 50% of adults with COPD in the United States misdiagnosed or under diagnosed,” wrote the researchers.

Charts of 101 patients in 2 outpatient primary care offices in Corpus Christi, Texas, were reviewed over a 6-month period. The majority (79.21%) of patients were current or former smokers. Based on reviews of the charts, the researchers determined that out of 66 patients in clinic 1 and 35 in clinic 2, only 28.79% and 8.79%, respectively, underwent spirometry as part of their COPD examination.

Even more concerning, the researchers found that no patients in either clinic underwent a COPD assessment test or Modified Medical Research Center for dyspnea testing.

When looking at pulmonary function testing, which is integral to diagnosing COPD, less than one-third of patients had testing in clinic 1 and just 8.6% of patients in clinic 2 had testing.

“In patients who actually did have pulmonary function testing, a diagnosis of COPD could be substantiated in only 69%,” according to the authors, indicating that 31% of patients were incorrectly diagnosed with COPD.

Not only was there heterogeneity in pharmacotherapy, but according to the researchers, inhaler choices were inconsistent with updated GOLD guidelines for treatment. Less than half (42.42%) of patients across both clinics were given long-acting muscarinic antagonists to treat symptoms whereas 62% were given an inhaler regimen including inhaled corticosteroids.

Reported barriers to adherence to guidelines highlighted a lack of knowledge, with barriers including lack of clarity, unfamiliarity with recommendations, and lack of familiarity with the guidelines.

The researchers did note that the study was small and limited to 2 sites, indicating the need for analyses of much larger samples to see if these findings are reproduced. “However, the data do appear to be consistent with earlier trials in both the United States and internationally,” they wrote.

Reference

Surani S, Aiyer A, Eikermann S, et al. Adoption and adherence to chronic obstructive pulmonary disease GOLD guidelines in a primary care setting [published online April 4, 2019]. SAGE Open Med. doi: 10.1177/2050312119842221.