Global Initiative For Chronic Obstructive Lung Disease Recommendations Research Articles

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Guidelines Reviewed.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report is an essential resource for all clinicians who strive to provide optimal care to patients with chronic obstructive lung disease (COPD). The annual report of GOLD makes few revisions and updates besides including data from the preceding year. At an interval, GOLD comes up with a significant modification in its guidelines, which is generally a major overhaul of the pre-existing guidelines. According to the latest 2023 updates, published in November 2022, there have been significant advancements made in the field of COPD. These include the development of more precise definitions for COPD and its exacerbations, the introduction of a new set of parameters to measure exacerbation severity, and updating the COPD assessment tool. Additionally, revisions have been made to the initial and follow-up treatment guidelines. The report also simplifies the treatment algorithm and sheds light on new findings that suggest the use of pharmacological triple therapy can reduce mortality rates. Furthermore, the report includes discussions on inhaler device selection and adherence to COPD medications. These improvements demonstrate a continued effort to enhance COPD treatment and management. Although there are some areas that could benefit from more detailed guidance and explanation, such as the proper utilization of blood eosinophil counts for treatment decisions, and the establishment of treatment protocols post-hospitalization, the latest modifications to the GOLD recommendations will undoubtedly aid healthcare providers in addressing any gaps in patient care. We aim to highlight key changes in the GOLD 2023 report and present a viewpoint about their potential implications in a real-world clinical scenario.

Corticosteroid and antibiotic use in hospitalized patients in Lebanon with acute exacerbation of chronic obstructive pulmonary disease

BackgroundChronic obstructive pulmonary disease (COPD) is currently one of the leading causes of death worldwide, with 90% of these deaths reported in low- and middle-income countries. In Lebanon, the prevalence of COPD is 9.7%. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends the use of antibiotics and corticosteroids in inpatients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The studies examining the level of conformity with the GOLD recommendations are rare, which increases the need for the current study.MethodsA 3-month cross-sectional study was done. Patients included were those diagnosed with acute exacerbations of COPD and admitted to one of the selected hospitals in Beirut, of various nationalities and sexes, aged 18 to 89. Data were selected from patient files admitted between January 2020 and June 2022 using a data collection sheet. The SPSS version 24 statistics software was used to conduct statistical analysis.ResultsA total of 260 patients were recruited, with 86.7% receiving systemic corticosteroids, 24.3% respecting dose, and 81.8% respecting the appropriate duration of corticosteroid intake. 80% exhibited pulmonary indications for receiving antibiotics, and 56.53% had the necessary cardinal symptoms. Around 74.5% of patients use antibiotics for the recommended time of 5 to 7 days. Age (p value = 0.006), gender (p value = 0.049), alcohol consumption (p value = 0.018), and use of psychiatric medications (p value = 0.049) are correlated with the conformity index of corticosteroid administration. A correlation was observed between the duration of use of antibiotics with cardinal symptoms (p value = 0.003), CRP-value (p value = 0.007), and type of hospital (p value = 0.00).ConclusionThis investigation revealed a need for correction in a deviation from the guidelines, shed light on existing clinical procedures, and emphasized the growing concern about the uncontrollable rate of antibiotic use and inadequate corticosteroid dosing.

Adherence to the GOLD Guidelines in Primary Care: Data from the Swiss COPD Cohort.

(1) Introduction: Chronic obstructive pulmonary disease (COPD) and its associated morbidity and mortality are a global burden on both affected patients and healthcare systems. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) issues guidelines with the aim of improving COPD management. Previous studies reported significant variability in adherence to these recommendations. The objective of this study was to evaluate Swiss primary practitioners' adherence to the GOLD guidelines for the pharmacological treatment of stable COPD. (2) Methods: We studied patients who were included in the Swiss COPD cohort study, an ongoing prospective study in a primary care setting, between 2015 and 2022. The key inclusion criteria are age ≥ 40 years, FEV1/FVC ratio < 70%, and a smoking history of at least 20 pack-years. Adherence to the GOLD guidelines was assessed per visit and over time. (3) Results: The data of 225 COPD patients (mean age 67 ± 9 years, 64% male) and their respective 1163 visits were analyzed. In 65% of visits (726/1121), treatment was prescribed according to the GOLD guidelines. Non-adherence was most common in GOLD groups A and B (64% and 33%) and mainly consisted of over-treatment (two long-acting bronchodilators in group A (98/195, 50%) and ICS in groups A (21/195, 11%) and B (198/808, 25%)). In group D, the prescriptions conformed with the guidelines in 99% of cases (109/108). Guideline adherence was associated with high symptom load (COPD Assessment Test) (OR 1.04, p = 0.002), high number of exacerbations (OR = 2.07, p < 0.001), asthma overlap (OR 3.36, p = 0.049), and diabetes mellitus (OR 2.82, p = 0.045). (4) Conclusion: These results confirm a conflict between the GOLD recommendations and primary practice, mainly concerning over-treatment in GOLD groups A and B. Patients with high symptom load, high exacerbation risk, asthma overlap, and diabetes mellitus are more likely to be treated in conformity with the guidelines. Further research is needed to uncover the reasons for the discrepancies and to design strategies for improvement.

Clinical factors linked to the type of respiratory medication in COPD: results from the COSYCONET cohort.

The use of maintenance medication in patients with chronic obstructive pulmonary disease (COPD) in real life is known to deviate from recommendations in guidelines, which are largely based on randomized controlled trials and selected populations. We used the COSYCONET (COPD and Systemic Consequences - Comorbidities Network) cohort to analyze factors linked to the use of COPD drugs under non-interventional circumstances. COSYCONET is an ongoing, multi-center, non-interventional cohort of patients with COPD. Patients with COPD of Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 0-4 participating in visits 1-5 were included. Data covered the period from 2010 to 2018. Generalized linear models were used to examine the relation of COPD characteristics to different types of respiratory medication. A total of 1043 patients were included. The duration of observation was 4.5 years. Use of respiratory medication depended on GOLD grades 0-4 and groups A-D. Long-acting muscarinic antagonist therapy increased over time, and was associated with low carbon monoxide (CO) diffusing capacity, while inhaled corticosteroid (ICS) use decreased. Active smoking was associated with less maintenance therapy in general, and female sex with less ICS use. From the eight items of the COPD Assessment Test, only hill and stair climbing were consistently linked to treatment. Using data from a large, close to real-life observational cohort, we identified factors linked to the use of various types of respiratory COPD medication. Overall, use was consistent with GOLD recommendations. Beyond this, we identified other correlates of medication use that may help us to understand and improve therapy decisions in clinical practice. ClinicalTrials.gov NCT01245933.

Cost-consequence analysis of COPD treatment according to NICE and GOLD recommendations compared with current clinical practice in the UK.

ObjectivesThe objective of this study was to model the clinical and economic impact of adapting current clinical practice in the management of patients with chronic obstructive pulmonary disease (COPD) to treatment according to national and international guideline recommendations.DesignTreatment mapping was undertaken to hypothetically redistribute patients from current clinical practice, representing actual prescribing patterns in the UK, to an alternative recommendation-based treatment scenario, representing prescribing in accordance with either National Institute for Health and Care Excellence (NICE) guidance [NG115] or Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 strategy.SettingPrimary care practices in the UK (1-year time horizon).ParticipantsAdults with COPD undergoing long-acting inhaler maintenance therapy in the UK (N=1 067,531).InterventionsInhaler maintenance therapy.Outcome measuresCosts and clinical outcomes (type of treatment, rates of moderate and/or severe exacerbations, and mild-to-moderate and/or severe pneumonia events) were modelled for the two alternative pathways.ResultsCompared with current clinical practice, treating patients according to NICE guidance resulted in an estimated annual reduction in expenditure of £46.9 million, and an estimated annual reduction in expenditure of over £43.7 million when patients were treated according to GOLD 2020 strategy. Total cost savings of up to 8% annually could be achieved by treatment of patients according to either of these recommendations. Cost savings arose from a reduction in the rates of pneumonia, with an associated decrease in costs associated with antibiotic use and hospitalisation. Savings were achieved overall despite a small increase in the rate of exacerbations due to the redistribution of certain patients currently undergoing triple inhaled therapy to therapies not containing inhaled corticosteroids.ConclusionRedistribution of patients with COPD from current clinical practice to treatment according to published recommendations would provide substantial cost savings over the first year.

Implications of using the GLI-2012, GOLD and Australian COPD-X recommendations in assessing the severity of airflow limitation on spirometry among an Indigenous population with COPD: an Indigenous Australians perspective study

BackgroundAssessment of airflow limitation (AFL) is crucial in the clinical evaluation of patients with chronic obstructive pulmonary disease (COPD). However, in the absence of normative reference values among adult Australian...

ANNUAL EXPENDITURES AMONG PATIENTS WITH COPD INITIATING TIOTROPIUM/OLODATEROL VS TRIPLE THERAPY

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: In 2018, 16.4 million U.S. adults reported a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with annual healthcare costs projected to reach $49 billion by 2020. Up to 70% of COPD-related healthcare expenditures are attributable to acute COPD exacerbations. The 2018 Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends long-acting muscarinic antagonists/beta2-agonists (LAMA+LABA) as next-in-line therapy for symptomatic COPD patients on mono-maintenance therapy. The addition of inhaled corticosteroids and escalation to Triple Therapy [TT] should be reserved for those experiencing further exacerbations and after risk/benefit (e.g., pneumonia) assessment. However, evidence reveals TT is over-prescribed in discordance with GOLD recommendations. The purpose of this study is to compare COPD-related plan paid costs among matched cohorts of TIO+OLO (a fixed-dose LAMA+LABA inhaler) vs. TT initiators in a U.S. Medicare Advantage population: a) naïve to maintenance treatment and b) stratified by baseline exacerbation history (proxy for COPD severity): no=0 exacerbation; single=1 moderate exacerbation; multiple/severe=≥2 moderate or ≥1 severe exacerbation(s). METHODS: This retrospective, observational post-hoc analysis included COPD patients aged ≥40 years initiating TIO+OLO or TT from 01 Jan 2014 to 31 Mar 2018 (treatment initiation date = index date). 12 months pre-index and ≥30 days post-index continuous medical/pharmacy coverage was required. Cohorts were propensity score matched 1:1. Multivariable analyses were used to estimate adjusted annualized post-index mean costs after matching. RESULTS: Among patients naïve to maintenance treatment, TIO+OLO patients had lower mean COPD-related total ($9,422 vs. $16,753; p<0.001), medical ($5,845 vs. 10,009; p<0.001) and pharmacy ($3,669 vs. $7,084; p<0.001) costs. TIO+OLO patients with no exacerbations had significantly lower mean COPD-related total costs ($7,342 vs $16,005; p<0.001) than patients who initiated TT, with lower medical ($3,675 vs. $9,199; p<0.001), and pharmacy ($3,685 vs. $7,032; p<0.001) costs. Among patients in the 'single' exacerbation group, TIO+OLO patients also had lower mean COPD-related total ($8,398 vs. $15,058; p<0.001), medical ($4,954 vs. $8,422; p<0.02) and pharmacy ($3,545 vs. $6,912; p<0.001) costs than TT patients. Among patients in the 'multiple/severe' group, TIO+OLO patients had lower mean COPD-related pharmacy costs ($3,761 vs. $7,249; p<0.001) but no significant difference in total costs ($17,262 vs. 22,979; p=0.1). CONCLUSIONS: Patients initiating TIO+OLO who were either naïve to maintenance treatment, and/or had no or single exacerbations prior to initiation had significantly lower medical and pharmacy costs versus those initiating TT. CLINICAL IMPLICATIONS: This real-world cost analysis illustrates the financial impact of prescribing TT, inconsistent with GOLD recommendations. DISCLOSURES: Employee relationship with Optum Please note: 09/2014 to present Added 05/04/2021 by Amy Anderson, source=Web Response, value=Salary Optum research sponsor relationship with Boehringer Ingelheim Please note: 2017 to current Added 05/04/2021 by Amy Anderson, source=Web Response, value=Research funding to Optum Employee relationship with Optum Please note: 11/2006 to current Added 04/26/2021 by Ami Buikema, source=Web Response, value=Salary Optum research sponsor relationship with Boehringer Ingelheim Please note: 2017 to current Added 04/26/2021 by Ami Buikema, source=Web Response, value=Research funding to Optum Employee relationship with Boehringer Ingelheim Corporation Please note: 2015-2021 Added 04/26/2021 by jess franchino-elder, source=Web Response, value=Salary No relevant relationships by Monica Frazer, source=Web Response no disclosure on file for Lisa Le;Employee relationship with Boehringer Ingelheim Pharmaceuticals, Inc. Please note: 08/07/17 to current Added 04/26/2021 by Swetha Palli, source=Web Response, value=Salary Employee relationship with Boehringer Ingelheim Pharmaceuticals, Inc. Please note: Aug 2017 - Current Added 04/26/2021 by Swetha Palli, source=Web Response, value=Salary

PRS26 Comparison of Guidelines on Diagnostic Criteria and Recommended Treatment Pathways for COPD Patients in Latin America – A Systematic Review

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines periodically review recommended practices for diagnosing and treating chronic obstructive pulmonary disease (COPD). Country-specific COPD guidelines are available; however, there are differences regarding optimum diagnostic and treatment strategies. This systematic review aimed to map and compare guidance on diagnostic criteria and recommended treatment pathways for COPD patients in Latin America (LA), using GOLD as the standard. Electronic searches for guidelines, consensus, or protocols for COPD across 20 LA countries were conducted in October 2019 across seven databases (MEDLINE via Pubmed, BVS, LILACS, ScIELO, Scopus, Web of Science, Embase), websites of medical societies, and government agencies of each country. 14 guidelines were included, 2 regional and 12 country-specific (Argentina, Brazil, Chile, Colombia, El Salvador, Mexico, and Peru). Half were from government agencies and 4 were from medical societies. For diagnosis, 8 guidelines included risk factors or signs/symptoms as diagnostic criteria. Ten guidelines recommended spirometry for COPD diagnosis, in line with GOLD recommendations. Seven guidelines had instructions for diagnosing an exacerbation, while 6 contained guidance for classifying exacerbation severity, with the main strategies including an increase in symptom occurrence and the characteristics of the required treatment. Recommended treatment for COPD was defined through disease severity in 11 guidelines, similar to GOLD guidelines. For bronchodilation strategies, 9 guidelines recommend dual therapy, whilst only 5 recommend triple therapy (long-acting β2 agonist – long-acting muscarinic antagonist – inhaled corticosteroid) for symptomatic patients. Four guidelines specifically recommend triple therapy for exacerbating patients. COPD guidelines were not available in some LA countries. Few of the available guidelines recommended triple therapy as a treatment strategy. Identifying these characteristics enable better understanding of current clinical practices and highlight an urgent need for further standardization in COPD guidelines in LA, especially for patients with symptomatic/severe disease.

Effect of compliance with GOLD treatment recommendations on COPD health care resource utilization, cost, and exacerbations among patients with COPD on maintenance therapy.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report for the management of chronic obstructive pulmonary disease (COPD) focuses on reducing existing symptoms, decreasing the risk of future exacerbations, and improving health status by recommending specific drug therapy based on exacerbation risk and symptoms. However, disparities exist between evidence-based recommendations and clinical practice. Research that quantifies the real-world effect of COPD regimen alignment with the GOLD recommendations on clinical and economic outcomes is needed. OBJECTIVE: To compare COPD-related health care resource utilization (HRU) and costs, as well as exacerbation rates, among patients with COPD on maintenance therapy based on 2017 GOLD treatment recommendation compliance status per GOLD ABCD risk group classification in a U.S. commercially insured/Medicare Advantage population. METHODS: This retrospective cohort study utilized administrative claims data in the HealthCore Integrated Research Database. The COPD population was identified using a previously validated claims-based predictive model. Among this population, patients with ≥ 1 claim for a COPD maintenance medication (earliest maintenance fill-date = index date) between January 1, 2014, and March 31, 2017, were identified. Patients were required to be aged ≥ 40 years, have ≥ 12 months of pre-index and ≥ 30 days of post-index health plan enrollment, with no diagnosis for asthma, cystic fibrosis, and/or lung cancer at any time from January 1, 2013, to March 31, 2018. Patients were categorized into exacerbation risk/symptomatology groups according to the 2017 GOLD ABCD assessment recommendations and were then classified into treatment-compliance status based on their maintenance therapy. Multivariable analyses were conducted to examine post-index COPD-related HRU, costs, and exacerbations by compliance status. RESULTS: The primary analytical study sample included 38,382 patients in the GOLD A/B group and 6,525 in the GOLD C/D group. Patients were further categorized into GOLD A (n = 19,345), B (n = 19,037), C (n = 1,865), and D (n = 4,670). GOLD-compliant regimens were observed in 32.9% of patients in the GOLD A/B group and in 58.9% of patients in the GOLD C/D group. Inhaled corticosteroid-containing regimens were the most commonly observed noncompliant regimen. Patients on compliant regimens had significantly fewer COPD-related inpatient and emergency department visits and therefore had significantly lower COPD-related medical costs in both the GOLD A/B and C/D cohorts. Similar results were observed for individual GOLD cohorts B, C, and D. These savings were offset by increased pharmacy expenditures. Being on GOLD guideline-compliant regimens significantly reduced the risk of exacerbation by 8% (hazard ratio [HR] = 0.92; P < 0.0001) in the GOLD A/B cohort and by 12% (HR = 0.88; P = 0.0005) in the GOLD C/D cohort, and was also associated with a significantly reduced exacerbation rate in the GOLD A/B (rate ratio [RR] = 0.93; P < 0.0001) and GOLD C/D (RR = 0.93; P = 0.0129) groups. CONCLUSIONS: This study suggests a continuing trend of high prevalence of suboptimal prescriber compliance to GOLD treatment recommendations. Treatment regimens compliant with GOLD recommendations were associated with improvement in exacerbations, reduced COPD-related HRU, and COPD-related medical cost offsets. DISCLOSURES: This study was funded by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). BIPI was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. Palli and Shaikh are employees of BIPI. Willey is an employee of HealthCore, which was contracted by BIPI to conduct this study. Zhou was an employee of HealthCore at the time of study execution. Data were presented in part during an AMCP webinar (recording not made public) held in lieu of the Spring 2020 AMCP conference, which was canceled due to the COVID-19 pandemic.

Consistency of chronic obstructive pulmonary disease regimens for patients visiting community pharmacies with the Global Initiative for Chronic Obstructive Lung Disease recommendations

ObjectiveDespite evidence-based Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations, outcomes are poor. GOLD uses chronic obstructive pulmonary disease (COPD) assessment test (CAT) scores with exacerbation history to categorize COPD severity into A, B, C, and D severity groups. Therapy is group-specific; monotherapy/dual long-acting bronchodilators (LABDs) therapy is preferred to inhaled corticosteroids (ICS). Pharmacist-accessible data could be used to identify evidence-based interventions to improve outcomes. The primary objective was to analyze previously collected data to compare the consistency of patient-described COPD regimens with GOLD therapeutic recommendations to identify potential pharmacist interventions. MethodsCross-sectional, nonrandomized design using a written questionnaire and CAT scores. Dispensing data from 35 Missouri community pharmacies initially identified participants aged 40 years or older with 1 or more COPD medications dispensed in the past year. Those self-reporting COPD, emphysema, or chronic bronchitis completed a demographic survey with medication history, including oral corticosteroid and antibiotic use, and CAT scores. Proportion of days covered (PDC) was calculated for any COPD maintenance medication dispensed over 1 year. The participants’ COPD was categorized into A, B, C, and D severity groups. The reported medication regimens were categorized into consistent with, escalated from, or less than initial first-line/alternative recommended therapy for the A, B, C, and D severity groups. ResultsThe participants totaled 709 (group A: 6%; group B: 35%; group C: 4%; group D: 55%). Of the regimens, 41% were consistent with, 34% were escalated from, and 24% were less than initial first-line/alternative GOLD recommendations. Most (96%) of the participants were highly symptomatic. Regimens containing ICS: (67.5%); ICS plus LABD (37.2%) exceeded dual LABD (4.2%). The average PDC was 0.43 ± 0.37; only 28.7% were adherent (PDC ≥ 0.80). ConclusionsParticipants with self-reported COPD were highly symptomatic and nonadherent; undertreatment was noted. Community pharmacists could provide therapeutic interventions consistent with GOLD A, B, C, and D severity groups, promote dual LABD versus ICS therapies, and optimize adherence.

Comparative Effectiveness of Initial LAMA versus LABA in COPD: Real-World Cohort Study

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations for the initial bronchodilator to use in newly diagnosed chronic obstructive pulmonary disease (COPD) are based on trials of patients with longstanding disease and treatment. We compared the real world effectiveness of initial treatment with long-acting muscarinic agents (LAMA) versus long-acting beta2-agonists (LABA) on the incidence of exacerbations in newly diagnosed patients. We identified a cohort of patients with COPD, new users of a LAMA or LABA (not combined with an inhaled corticosteroid (ICS)) during 2002–2018, age 50 or older, from the UK’s CPRD database, and followed for one year. The hazard ratio (HR) of exacerbation estimated using the Cox regression model, weighted by fine stratification of propensity scores. The cohort included 40,538 initiators of LAMA and 10,680 of LABA. The adjusted hazard ratio (HR) of a first moderate or severe exacerbation comparing LAMA with LABA initiation was 0.96 (95% CI: 0.90–1.02), while for severe exacerbation it was 0.92 (95% CI: 0.75–1.12). The incidence of exacerbation on LAMA was significantly lower than on LABA (HR 0.88; 95% CI: 0.80–0.96) among patients with a prior exacerbation, and the HR of exacerbation increased with percent predicted FEV1. This study in the real world clinical setting of COPD treatment found that using a LAMA or a LABA (no ICS) as the initial bronchodilator is generally as effective at reducing exacerbation incidence and frequency. However, a LAMA may be more effective in patients with prior exacerbations, which supports the GOLD recommendations for newly diagnosed COPD. The role of airway obstruction on the effectiveness of bronchodilators warrants further investigation.

Prescribing pathways to triple therapy in patients with chronic obstructive pulmonary disease in the United States.

Background:Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend triple therapy (TT) for chronic obstructive pulmonary disease (COPD) patients based on severity. TT utilization by severity is infrequently studied in real-world settings and may deviate significantly from current clinical recommendations. This study describes prescribing pathways to TT among patients with COPD in the United States.Methods:This study analyzed Geisinger Health System electronic medical records from 1 January 2004 to 30 November 2016. Two retrospective cohorts of COPD patients were included: (1) incident COPD, and (2) incident TT users. COPD treatment patterns, including time to TT, were summarized. Time to TT was estimated using Kaplan–Meier methods. Predictors of the relative hazard for TT among incident COPD patients were estimated using Cox proportional hazards regressions.Results:Incident COPD and TT cohorts included 57,141 and 8173 patients, respectively. TT was used by 9.6% of incident COPD patients. In the year before TT, 34.3% of incident TT patients received treatment combinations recommended before TT according to GOLD recommendations, which mainly included: long-acting muscarinic antagonists (LAMAs), long-acting beta agonists (LABAs) + LAMAs, and inhaled corticosteroids + LABAs. Among incident TT patients, median time from COPD diagnosis to TT exceeded 2 years. The hazard for TT over time was associated with lower forced expiratory volume in 1 s values, more frequent exacerbations, current/previous smoking, and comorbid lung conditions such as pulmonary vascular disease, acute respiratory failure, and lung cancer. About 15–20% of the incident TT patients stepped down to a one- or two-drug regimen. Median time to TT discontinuation or step-down were 2 and 9 months, respectively.Conclusion:The study has revealed discrepancies in the treatment of COPD patients between GOLD guidelines and actual clinical practices in the United States. Pathways to TT differed from recommended therapy regimes. Further studies are needed to understand barriers to the use of guideline-recommended TTs by healthcare providers. The reviews of this paper are available via the supplemental material section.

COPD in Germany: Use of Diagnostic Measures Including Blood Eosinophil Counts in Daily Practice.

Background Accumulating evidence on the role of blood eosinophils as a biomarker prompted the Global Initiative for Chronic Obstructive Lung Disease (GOLD) committee to refine the existing treatment algorithm by incorporating eosinophil counts into treatment recommendations. However, there is a lack of data on when, why and how frequently such blood tests and other measures are being performed by German private respiratory specialists. Methods A questionnaire evaluating doctors’ opinions on the use of diagnostic measures at initial diagnosis and during follow-up, including blood eosinophil count in patients with COPD, was completed by 27 respiratory specialists. Medical records from the past 12 months of 251 patients treated by the same physicians were reviewed retrospectively to investigate the use of these measures. Results Body plethysmography (100 % of doctors) and chest X-ray (96.3 %) were the most commonly used measures according to the doctor’s questionnaire; other measures were COPD assessment test (CAT; 85.2 %) and blood eosinophil count (81.5 %). The evaluation of patients’ medical records revealed that body plethysmography was performed in 72.7 %, the CAT in 61.8 % and chest X-ray in 40.6 % of patients. Blood eosinophil count was measured in 7.2 %. Conclusions In line with the GOLD recommendations, these results confirm that lung function, imaging and patient-reported outcome questionnaires play a crucial role in managing COPD. Our analyses reveal that measurement of the blood eosinophil count gained importance due to physicians’ increased awareness of these cells as a useful biomarker. However, this test seems to be performed mainly for initial diagnosis and not on a regular basis.

Adherence to GOLD Recommendations among Swiss Pulmonologists and General Practitioners

Significant variability in adherence to COPD management recommendations has been reported. We aimed to evaluate real-life COPD pharmacotherapy prescribing patterns and adherence to the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) global strategy in Switzerland. A questionnaire-based survey was conducted among Swiss general practitioners (GPs) and pulmonologists (PULs) from May 1 to November 30, 2017. Participants were invited to complete a questionnaire on their next 5–10 consecutive patients already receiving a pharmacological treatment for COPD. They were requested to assess dyspnea using the modified Medical Research Council (mMRC) dyspnea scale and to determine whether a treatment adjustment was indicated. Fifty-three PULs and 39 GPs completed questionnaires on 511 COPD patients. Dyspnea with mMRC grade ≥2 was reported in 62.5% of the patients, and 31.9% had had at least two exacerbations (or at least one with hospital admission) in the last 12 months. The vast majority (87.1%) of GOLD A patients were overtreated. In the GOLD B group, 52.2% of prescriptions were concordant with GOLD 2017 recommendations, but 37% of patients were overtreated. Among GOLD C patients, 49.2% received GOLD-adherent treatment and 47.5% were overtreated. In the GOLD D category, 78.8% of the patients received a treatment consistent with recommendations but 15.2% were undertreated. After reassessment of patient status, treatment was modified in 50.3% of the patients. This study confirms that discordance of real-world prescription patterns with international guidance is frequent. Further educational efforts are required to improve adherence to COPD management recommendations.

PRS18 The Clinical and Cost IMPACT of Adherence to Chronic Obstructive Pulmonary Disease Guideline Recommendations in England: A Cost Consequence MODEL

The objective of this study was to model the clinical and economic impact of adapting current clinical practice in the management of patients with chronic obstructive pulmonary disease (COPD) to treatment according to national and international guideline recommendations. A cost-consequence model was developed that uses a treatment-mapping matrix to hypothetically redistribute patients with COPD undergoing long-acting inhaler therapy from their current treatment pathway (actual prescribing patterns) to an alternative treatment pathway that aligns with the National Institute of Health and Care Excellence (NICE) or Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations. Actual prescribing patterns were derived using data from the Clinical Practice Research Datalink. The clinical outcomes and costs associated with the alternative pathway over a one year time horizon were estimated from published English sources. Compared with actual prescribing patterns, treatment according to recommendations results in a estimated annual reduction in expenditure of £47 million (NICE) and £43.5 million (GOLD); this is equivalent to an ∼8% saving. Considerable savings arose from a reduction in pneumonia cases and associated treatment costs. If patients are treated according to either NICE or GOLD recommendations, there were potential savings of £240 thousand (10%) for mild/moderate pneumonia and £15 million (18%) for severe pneumonia. Due to the redistribution of patients with low prior exacerbations or milder symptoms from triple therapy to other long acting inhaler therapies, there was a potential minimal increase in costs associated with exacerbations (∼1%). Compared with current clinical practice in England, treating patients with COPD according to national and international recommendations may improve patient outcomes and reduce the financial burden on the healthcare system. In addition, given the COVID-19 related impact on the NHS, benefits of reduced hospitalization could be realized by following COPD treatment guidelines.

Association of Guideline-Recommended COPD Inhaler Regimens With Mortality, Respiratory Exacerbations, and Quality of Life: A Secondary Analysis of the Long-Term Oxygen Treatment Trial

Although inhaled therapy reduces exacerbations among patients with COPD, the effectiveness of providing inhaled treatment per risk stratification models remains unclear. Are inhaled regimens that align with the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy associated with clinically important outcomes? We conducted secondary analyses of Long-term Oxygen Treatment Trial (LOTT) data. The trial enrolled patients with COPD with moderate resting or exertional hypoxemia between 2009 and 2015. Our exposure was the patient-reported inhaled regimen at enrollment, categorized as either aligning with, undertreating, or potentially overtreating per the 2017 GOLD strategy. Our primary composite outcome was time to death or first hospitalization for COPD. Additional outcomes included individual components of the composite outcome and time to first exacerbation. We generated multivariable Cox proportional hazard models across strata of GOLD-predicted exacerbation risk (high vslow) to estimate between-group hazard ratios for time to event outcomes. We adjusted models a priori for potential confounders, clustered by site. The trial enrolled 738 patients (73.4%men; mean age, 68.8 years). Of the patients, 571 (77.4%) were low risk for future exacerbations. Of the patients, 233 (31.6%) reported regimens aligning with GOLD recommendations; most regimens (54.1%) potentially overtreated. During a 2.3-year median follow-up, 332 patients (44.9%) experienced the composite outcome. We found no difference in time to composite outcome or death among patients reporting regimens aligning with recommendations compared with undertreated patients. Among patients at low risk, potential overtreatment was associated with higher exacerbation risk (hazard ratio, 1.42; 95%CI, 1.09-1.87), whereas inhaled corticosteroid treatment was associated with 64%higher risk of pneumonia (incidence rate ratio, 1.64; 95%CI, 1.01-2.66). Among patients with COPD with moderate hypoxemia, we found no difference in clinical outcomes between inhaled regimens aligning with the 2017 GOLD strategy compared with those that were undertreated. These findings suggest the need to reevaluate the effectiveness of risk stratification model-based inhaled treatment strategies.

Initiation of triple therapy maintenance treatment among patients with COPD.

Triple therapy is indicated for patients with very severe chronic obstructive pulmonary disease (COPD). Use of this treatment in the appropriate patient population is important to ensure optimal outcomes. This study quantified the use of triple therapy and assessed concordance with 2013-2016 Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations within a national health plan. Retrospective cohort study using data from a large national health plan. To estimate the prevalence of triple therapy using claims data, patients in the first of 2 cohorts were indexed on their first diagnosis of COPD between January 1, 2012, and December 31, 2014, and required to have 24 months postindex continuous enrollment. To assess concordance with GOLD recommendations, a second cohort was created and indexed on the date of triple therapy initiation between January 1, 2013, and November 30, 2016, and required to have 12 months preindex and 1 month postindex continuous enrollment. For both cohorts, patients were aged 40 years or older, with no International Classification of Diseases code for asthma, cystic fibrosis, or lung cancer during the study period. In the first cohort of 92,248 patients with COPD receiving any COPD maintenance medication, 17% were prescribed triple therapy. In the second cohort (n = 19,645), the majority (60%) of patients on triple therapy were classified as GOLD group A or B (ie, no evidence of any exacerbation or only 1 exacerbation not resulting in hospitalization at baseline). Results showed that triple therapy was often prescribed among patients classified as GOLD group A or B. Additional research is required, however, to further assess whether these patients may have had an exacerbation that was not evident in claims data. Treatment of COPD should be individualized to optimize outcomes and reduce adverse events.

Management of COPD in Anhui Province: compliance with GOLD guidelines

Abstract Background COPD is a major public health concern of global scope, especially in China. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines are international and national recommendations to manage COPD. Little is known about level of adherence of COPD management among exacerbated COPD inpatients to GOLD guidelines in China. The current study aimed to compare COPD management (vaccination and treatment of COPD exacerbation) among hospitalized patients in Anhui Province with GOLD guidelines and identify risk factors influencing vaccination coverage and guideline-compliant care. Methods A retrospective clinical audit of medical records was conducted in a hospital in Anhui Province in China, involving 1132 patients hospitalized with exacerbated COPD within 2016-2017. Descriptive analysis was conducted to evaluate compliance to GOLD recommendations (version 2017). Logistic regression was conducted to detect the association between guideline-consistent care and variables. Results Extreme deficiency in the vaccination coverage (0%) was found. Regarding pharmacological management, some adherence to prescribing short-acting bronchodilators timely (43.5%) and prescribing long-acting bronchodilators (55.0%) was observed; nonetheless, only 26.1% of patients received systemic corticosteroids or antibiotics for the recommended duration (&amp;lt;7 days) and only 17.0% did not receive methylxanthines. Age, education level, occupational status and disease severity were independently associated with guideline-consistent treatment. Conclusions The implementation of GOLD recommendations in Anhui Province was unsatisfactory. Interventions to increase the vaccination coverage among COPD patients and to optimize the treatment of COPD exacerbation are imperative, requiring efforts at the hospital and policy levels. Key messages This is the first clinical audit study investigating the COPD management among hospitalized COPD patients in China. The implementation of GOLD recommendations in Anhui Province was unsatisfactory.

Combined aclidinium bromide and long-acting beta2-agonist for chronic obstructive pulmonary disease (COPD).

Combined aclidinium bromide and long-acting beta2-agonist for chronic obstructive pulmonary disease (COPD).

Pharmacological approach and adherence to treatment recommendations in frequently and non-frequently exacerbating COPD patients from Italy: MISTRAL - The prospective cohort, observational study

BackgroundSeveral documents and guidelines provide recommendations for effective management of COPD patients. However, there is often a significant imbalance between recommended treatment of COPD patients and the actual care provided both in primary care and specialty setting. This imbalance could result in a significant negative impact on patients' health status and quality of life, leading to increased hospitalisations and health resource utilisation in COPD patients MethodsMISTRAL was an observational, longitudinal, prospective cohort study, designed to assess the overall pharmacological approach of COPD in routine clinical practice in Italy. Eligible patients were divided into two cohorts based on their exacerbation history in the year prior to the enrolment, frequent exacerbators (FEs; ≥2 exacerbations), and non-frequent exacerbators (NFEs; ≤1 exacerbation). The primary objective was to assess adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 treatment recommendations in FEs and NFEs at baseline and follow-up visits ResultsOf the 1489 enrolled patients, 1468 (98.6%; FEs, 526; NFEs, 942) were considered evaluable for analyses. At baseline, 57.8% of patients were treated according to GOLD 2011 recommendations; a greater proportion of FEs were treated according to GOLD recommendations, compared with NFEs patients at baseline (77.1% versus 46.7%; P < 0.0001), and all study visits. At baseline, GOLD group D patients were the most adherent (81.2%) to treatment recommendations, while group A patients were the least adherent (30.3%) at baseline, attributed mainly to overuse of inhaled corticosteroids in less severe GOLD groups. Triple therapy with long-acting muscarinic antagonist (LAMA) + long-acting β2-agonist/inhaled corticosteroid (LABA/ICS) was the most frequent prescribed treatment at all study visits, irrespective of patient's exacerbation history. Changes in treatment were more frequent in FEs versus NFEs ConclusionsThe Mistral study reports a scarce adherence to the GOLD 2011 treatment recommendations in routine clinical practice in Italy. The adherence was particularly low in less severe, non-frequent exacerbating patients mostly for ICS overuse, and was higher in high-risk, frequent exacerbating COPD patients