Management of COPD in the UK primary-care setting: an analysis of real-life prescribing patterns

Abstract

Background

Despite the availability of national and international guidelines, evidence suggests that chronic obstructive pulmonary disease (COPD) treatment is not always prescribed according to recommendations. This study evaluated the current management of patients with COPD using a large UK primary-care database.

Methods

This analysis used electronic patient records and patient-completed questionnaires from the Optimum Patient Care Research Database. Data on current management were analyzed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) group and presence or absence of a concomitant asthma diagnosis, in patients with a COPD diagnosis at ≥35 years of age and with spirometry results supportive of the COPD diagnosis.

Results

A total of 24,957 patients were analyzed, of whom 13,557 (54.3%) had moderate airflow limitation (GOLD Stage 2 COPD). The proportion of patients not receiving pharmacologic treatment for COPD was 17.0% in the total COPD population and 17.7% in the GOLD Stage 2 subset. Approximately 50% of patients in both cohorts were receiving inhaled corticosteroids (ICS), either in combination with a long-acting β₂-agonist (LABA; 26.7% for both cohorts) or a LABA and a long-acting muscarinic antagonist (LAMA; 23.2% and 19.9%, respectively). ICS + LABA and ICS + LABA + LAMA were the most frequently used treatments in GOLD Groups A and B. Of patients without concomitant asthma, 53.7% of the total COPD population and 50.2% of the GOLD Stage 2 subset were receiving ICS. Of patients with GOLD Stage 2 COPD and no exacerbations in the previous year, 49% were prescribed ICS. A high proportion of GOLD Stage 2 COPD patients were symptomatic on their current management (36.6% with modified Medical Research Council score ≥2; 76.4% with COPD Assessment Test score ≥10).

Conclusion

COPD is not treated according to GOLD and National Institute for Health and Care Excellence recommendations in the UK primary-care setting. Some patients receive no treatment despite experiencing symptoms. Among those on treatment, most receive ICS irrespective of severity of airflow limitation, asthma diagnosis, and exacerbation history. Many patients on treatment continue to have symptoms.

Keywords:

• COPD
• UK primary-care setting
• prescribing patterns
• inhaled corticosteroids
• bronchodilators

Supplementary materials

Figure S1 Model of symptom/risk evaluation of COPD.

Notes: When assessing risk, choose the highest risk according to GOLD stage or exacerbation history (one or more hospitalizations for COPD exacerbations should be considered high risk). GOLD 1, 2, 3, and 4 correspond to mild (FEV₁ ≥80% predicted), moderate (50% ≤ FEV₁ <80% predicted), severe (30% ≤ FEV₁ <50% predicted), and very severe (FEV₁ <30% predicted) airflow limitation, respectively. Reproduced from the Global Strategy for Diagnosis, Management and Prevention of COPD 2014. Copyright © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from http://www.goldcopd.org.¹

Abbreviations: CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; mMRC, modified Medical Research Council.

Figure S2 Modified Medical Research Council questionnaire for assessing the severity of breathlessness.

Reproduced from the Global Strategy for Diagnosis, Management and Prevention of COPD 2014. Copyright © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from http://www.goldcopd.org.¹

Abbreviation: mMRC, modified Medical Research Council.

Figure S3 COPD Assessment Test.

Notes: The COPD Assessment Test score is calculated as the sum of the responses present. If more than two responses are missing, a score cannot be calculated; when one or two items are missing their scores can be set to the average of the nonmissing item scores. Reproduced with permission. COPD Assessment Test and CAT logo is a trade mark of the GlaxoSmithKline group of companies. © 2009 GlaxoSmithKline group of companies. All rights reserved.²

Table S1 Characteristics of patients with COPD who were responders or nonresponders to the study questionnaires

References

• Global Initiative for Chronic Obstructive Lung Disease (GOLD 2014)Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: Updated 2014Global Initiative for Chronic Obstructive Lung Disease2014 Available from: http://www.goldcopd.org/uploads/users/files/GOLD_Report_2014.pdfAccessed June 18, 2014
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Acknowledgments

The analyses reported in this manuscript were funded by Novartis Pharma AG (Basel, Switzerland) and were conducted by Research in Real-Life Ltd (Cambridge, UK), an independent company. The authors were assisted in the preparation of the manuscript by Roberta Sottocornola, a professional medical writer contracted to CircleScience (Tytherington, UK), part of KnowledgePoint360, an Ashfield Healthcare Communications (Ashby de la Zouch, UK) company. Writing support was funded by Novartis Pharma AG.

Disclosure

DP has served on advisory boards for Aerocrine, Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, and Teva. He has consultant arrangements with Almirall, Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Meda, Mundipharma, Napp, Novartis, Pfizer, and Teva. He or his research team has received grants (or grants pending) and support for research in respiratory disease from the following organizations in the last 5 years: UK National Health Service, British Lung Foundation, Aerocrine, AstraZeneca, Boehringer Ingelheim, Chiesi, Eli Lilly, GlaxoSmithKline, Meda, Merck, Mundipharma, Novartis, Orion, Pfizer, Respiratory Effectiveness Group, Takeda, Teva, and Zentiva. He has received unrestricted funding for investigator-initiated studies from Aerocrine, AKL Ltd, Almirall, Boehringer Ingelheim, Chiesi, Meda, Mundipharma, Napp, Novartis, Orion, Takeda, Teva, and Zentiva. He has received funding for patient enrollment or completion of research from Almirall, Chiesi, Teva, and Zentiva. He has received payments for lectures/speaking from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Meda, Merck, Mundipharma, Novartis, Pfizer, Skyepharma, Takeda, and Teva; travel/accommodations/meeting expenses from Aerocrine, Boehringer Ingelheim, Mundipharma, Napp, Novartis, and Teva; manuscript preparation from Mundipharma and Teva; and development of educational materials from GlaxoSmithKline and Novartis. He has patents and shares with AKL Ltd and owns 80% of Research in Real-Life Ltd and its subsidiary social enterprise Optimum Patient Care.

GB has received lecture fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, and Pfizer. He is a member of advisory boards for AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis.

KG-J has spoken on behalf of, or acted as a consultant for, Almirall, Chiesi, AstraZeneca, GlaxoSmithKline, Boehringer Ingelheim, Merck Sharp & Dohme, Napp/Mundipharma, and Novartis.

RJ has been paid to take part in educational activities related to COPD for Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Nutricia, and Pfizer in the last 3 years. He is consultant to COPDexchange educational programs supported by Boehringer Ingelheim, to the iCOPD project supported by Almirall, and to Health Intelligence.

MM has received speaker fees from AstraZeneca, Bayer Schering, Boehringer Ingelheim, Merck Sharp and Dohme, Novartis, Pfizer, Takeda-Nycomed, and Talecris-Grifols and consulting fees from Almirall, AstraZeneca, Bayer Schering, Boehringer Ingelheim, GlaxoSmithKline, Merck Sharp and Dohme, Novartis, Pfizer, Talecris-Grifols, and Takeda-Nycomed.

AR has received reimbursement for attending symposia, fees for speaking, fees for organizing education, funds for research, and fees for consulting from AstraZeneca, Boehringer Ingelheim/Pfizer, Chiesi, GlaxoSmithKline, Novartis, and Nycomed/Tanaka.

DW, CH, VLA, RS, and KB are employees of Research in Real-Life Ltd, which has conducted paid research in respiratory disease on behalf of the following organizations in the past 5 years: Aerocrine, AKL Ltd, Almirall, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Meda, Mundipharma, Napp, Novartis, Orion, Takeda, Teva, Zentiva.