National Survey of Guideline-Compliant COPD Management Among Pneumologists and Primary Care Physicians

Figures & data

Table 3 Assessment of the benefits of various therapeutic measures

	Improves mortality		Reduces exacerbations		Slows Progression		Improves symptoms		Improves quality of life		No effect
Therapy	PNEU	PCP	PNEU	PCP	PNEU	PCP	PNEU	PCP	PNEU	PCP	PNEU	PCP
SABD	5.3%	8.4%	7.2%	17.3%	4.5%	7.6%	95%	91.8%	60.7%	65%	3.9%	3.1%
LABD	19.8%	35%	47.6%	57.4%	26.2%	40.9%	94.7%	86.8%	91.1%	86.4%	0%	1%
ICS	15%	34.4%	90.8%	74.5%	28.7%	51.9%	63.5%	83.1%	60.4%	72.6%	2.5%	1.9%
OCS	9.7%	18.5%	41.2%	47.7%	14.8%	29.2%	73%	78%	50.7%	52.5%	13.1%	9.5%
Oxygen	81.9%	54.9%	10%	17.5%	8.4%	10.5%	68.2%	80%	82.5%	78.4%	1.1%	6%
Reha	32.9%	37.4%	44.3%	51.9%	29%	42%	71.3%	70.4%	88.9%	81.9%	3.3%	4.9%
SMOK	84.1%	80.9%	75.2%	76.5%	91.6%	84.4%	76%	72%	76.9%	75.7%	0.6%	1%
p-Value	0.053		0.01		< 0.0001		0.054		0.90		0.61

Question: What consequences for patients do you associate with the following therapeutic measures? For the assessment questions multiple answers were possible. SABD: short-acting bronchodilators (sympathomimetics and/or anticholinergics), LABD: long-acting bronchodilators (sympathomimetics and/or anticholinergics); ICS: inhaled corticosteroids; OCS: oral corticosteroids, Reha: pulmonary rehabilitation programs, SMOK: smoking cessation. Significant differences between pneumologists (PNEU) and PCP were found for evaluation of the therapeutic impact on reduction of exacerbations and progression of the disease. There was also a trend for group differences in the evaluation of the therapeutic benefits on survival and symptoms. N = 486 PCP, 359 pneumologists.

Table 1 Demographic data of the participating physicians

Variable	Pneumologists	Primary care physicians (PCP)
Age
30–40 years	5.6%	14.8%
41–50 years	45.4%	40.1%
51–60 years	34.8%	30.2%
Over 60 years	13.6%	14.0%
Gender
Male/female	81.3%/17.8%	60.7%/38.7%
Practice
Single-physician practice/group practice	64.6%/34.9%	64.6%/33.9%
Location
City (> 200,000 inhabitants)/ surrounding area	46.5%/51.8%	44.2%/54.3%
Length of time in practice
Less than 10 years	38.2%	35.2%
11–20 years	47.6%	45.1%
More than 20 years	13.4%	18.9%

486 PCP and 359 pneumologists participated in the study. Information was unavailable in fewer than 2% of cases.

Table 2 Diagnostic criteria for classifying COPD

	Pneumologists	PCP	P-value
In your opinion the diagnosis of COPD is based on:
Cough/sputum production for three months over a two-year period	38.2%	49.6%	0.001
Tiffenau index less than 70%	53.8%	39.5%	< 0.0001
FEV1 less than 1.5 liters	1.7%	3.9%
Tiffenau index less than 90%	2.5%	1.6%
Chest x-ray with signs of hyperinflation	0.3%	1.0%
Blood gas analysis showing hypoxemia and/or hypercapnia	1.4%	3.5%
In your opinion moderate COPD is defined as follows:
Tiffenau index less than 70% and FEV1 less than 80% of normal/**	36.2%	32.1%	0.21
Primarily on the basis of clinical symptoms	8.4%	23.7%	< 0.0001
FEV1 less than 1.0 liters	1.1%	1.2%
Tiffenau index less than 50%	3.3%	6.8%
Tiffenau index less than 70% and FEV1 less than 50% of normal**	49.3%	35.2%	< 0.0001
In your opinion severe COPD is defined as follows:
Tiffenau index less than 70% and FEV1 less than 30% of normal**	56.5%	43.4%	0.0002
Primarily on the basis of clinical symptoms	8.9%	24.5%	< 0.0001
FEV1 less than 1.0 liters	2.8%	2.7%
Tiffenau index less than 50%	7.2%	8.8%
Tiffenau index less than 70% and FEV1 less than 50% of normal	23.4%	20.2%	0.26

Tiffenau index: FEV₁/VC. FEV₁: forced expiratory volume in one second, VC: vital capacity. Only one answer to each of the questions on COPD diagnostic criteria was possible. *GOLD Guideline (2004). **GOLD Guideline (2001) and German Guideline. Moderate COPD was defined as Tiffenau index less than 70% and FEV₁ < 80% and ≥30% predicted. Statistically significant group differences (p ≤ 0.0001) were found for each category of question (basis of diagnosis, definition of moderate and severe COPD). N = 486 PCP, 359 pneumologists.

Figure 2 PCPs' and pneumologists' treatment for ≥50% of their patients with moderate COPD (Figure 2a) and severe COPD (Figure 2b). OCS: oral corticosteroids, SABD: short-acting bronchodilators (ß2-agonists and/or anticholinergics), LABA: long-acting ß2-agonists; LAMA: long-acting anticholinergics; ICS: inhaled corticosteroids, LABD: long-acting bronchodilators (ß2-agonists and/or anticholinergics), Pulm. Reha: pulmonary rehabilitation, Influenza vacc.: Influenza vaccination. N = 486 PCP (grey columns), 359 pneumologists (black columns). *p < 0.001, ⁺p < 0.05.

Figure 1 Question: What are the two main features of COPD therapy to be improved for you personally? With regard to treatment goals, an improvement in clinical parameters, such as quality of life and reduction of exacerbations, was rated higher by the physicians than improvement in pulmonary function. On the other hand, a favorable effect on cough/sputum production and mortality played a relatively minor role. N = 486 PCP (grey columns), 359 pneumologists (black columns). *p < 0.001, ⁺p < 0.005.

Table 4 Criteria for long-term therapy (> 3 months) with inhaled and oral steroids

	Inhaled steroids		Oral steroids
	Pneumologists	PCP	Pneumologists	PCP
COPD with FEV1 < 50% and repeated exacerbations	69.6%*	46.1%	27.6%	31.1%
Good response to inhaled or oral steroids in pulmonary function tests	35.9%	34.2%	18.7%	17.3%
Symptomatic improvement achieved with inhaled steroids	87.2%	81.7%	—	—
Only in cases of deteriorations	5.3%	10.9%	61%	53.7%
Problems with the use of inhaled steroids	—	—	17.8%	22.2%
No long-term use of inhaled or oral steroids	1.1%	0.9%	33.7% +	25.3%

Question: What criteria do you apply when you prescribe long-term treatment with inhaled/oral steroids? Multiple answers were permitted to the questions concerning criteria. From the physicians' point of view, symptomatic improvement is the leading criterion for long-term therapy with inhaled steroids, followed by the current guideline recommendations (*p < 0.0001). Only a subset of the physicians do not use any oral steroids in long-term therapy in compliance with the guidelines, (+p = 0.0078). N = 486 PCP, 359 pneumologists.

Figure 3 Question: Which national and international guidelines on the diagnosis and treatment of COPD are most relevant for you? This was a single-answer question. Pneumologists (black columns) were more adherent to guidelines than PCP (grey columns) and preferred using the GOLD guidelines whereas PCP tended to apply the German national COPD guideline. The current British NICE guidelines had no relevance for German physicians. N = 486 PCP, 359 pneumologists. *p < 0.0001, +p = 0.001.

Table 5 Possible advantages and disadvantages of evidence-based clinical guidelines (modified from 5, 7, 15)

Advantages	Disadvantages
Improved medical care	Incorrect, contradictory or outdated guidelines
Quality standards for clinical practice	“Blind” faith in guidelines
Time-saving orientation and self-checking	Poor acceptance (“cookbook medicine,” time-consuming)
Identification of research gaps	Loss of physician's autonomy
Financial savings	Relevance in medical liability cases?
Legal certainty	Unclear individual benefit, e.g., in elderly people with multiple concomitant diseases