COPD patients’ characteristics, usual care, and adherence to guidelines: the Greek UNLOCK study
Received 26 August 2018
Accepted for publication 23 January 2019
Published 1 March 2019 Volume 2019:14 Pages 547—556
Checked for plagiarism Yes
Review by Single-blind
Peer reviewer comments 4
Editor who approved publication: Dr Richard Russell
Ioanna Tsiligianni,1 Maria Kampouraki,2 Despo Ierodiakonou,3 Ioannis Poulonirakis,4 Polyvios Papadokostakis5
On behalf of the Greek UNLOCK team
1Department of Social Medicine, Faculty of Medicine, University of Crete, Herkalion, Crete, Greece; 2Primary Care Practice, Health Center of Moires, Heraklion, Crete, Greece; 3Heraklion University Hospital, Heraklion, Crete, Greece; 4Primary Care Practice, Health Center of Agia Varvara, Heraklion, Crete, Greece; 5Primary Care Practice, Garipa, Herkalion, Crete, Greece
Purpose: GOLD guidelines classify COPD patients into A–D groups based on health status as assessed by COPD Assessment Test (CAT) or mMRC tools and exacerbations and recommend single or dual long-acting bronchodilators as maintenance therapy, with additional inhaled corticosteroids (ICS) if the disease remains uncontrolled. We aimed to classify primary care COPD patients into A–D groups, assess usual treatment and adherence to guidelines, potential mismatches between CAT- and mMRC-based classification and described symptoms within groups.
Patients and methods: A total of 257 primary care COPD patients were enrolled between 2015 and 2016 in Greece. Physicians used structured interviews to collect cross-sectional data including demographics, symptoms, CAT, mMRC scores, and medications. Patients were classified into A–D groups based on CAT and mMRC, and prevalence of symptoms and medication was estimated within A–D groups. Interviews with physicians were also performed to explore additional issues about treatment and adherence to guidelines.
Results: Mean (SD) age was 65 (12.3) years with 79% males. The majority of patients reported uncontrolled symptoms (91% and 61% with ≥10 CAT or ≥2 mMRC scores, respectively). Thirty-seven percentage had ≥2 exacerbations in the past year. Group B was the largest followed by Groups D, A, and C. Patients were classified as more severe by CAT than by mMRC. In all groups, the majority were treated with combined long-acting beta agonist/ICS (>50%). When patients were asked to report their main symptoms, dyspnea and cough were the most important symptoms mentioned, and there was a great variation between the A–D groups. However, Groups A–C reported mainly morning symptoms, whereas Group D suffered symptoms all day. Physicians reported a significant number of barriers to implementing guidelines, eg, frequent lack of guideline updates, access to diagnostic procedures, and prescription-reimbursement issues.
Conclusion: Our study confirms poor adherence to guidelines regarding treatment with an overuse of ICS and important barriers to implementation. A mismatch in classification occurs depending on the tool used, which can mislead clinicians in their choice of treatment.
Keywords: adherence, COPD, GOLD guidelines, usual care, classification, CAT, mMRC, symptoms
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