Adherence to a COPD treatment guideline among patients in Hong Kong

Figures & data

Figure 1 COPD grouping and pharmacological management recommended by GOLD guideline 2011.

Notes: Adapted from Global initiative for chronic obstructive lung disease (GOLD). Global strategy for the diagnosis, management and prevention of chronic pulmonary disease, 2011 with permission.^{7 a}Treatment options within each choice are mentioned in alphabetical order and therefore not necessarily in order of preference. ^bAlternative treatment to be used alone or in combination with other options in the first and second choices. ^cGOLD 1: FEV₁ ≥80% predicted, GOLD 2: 50%≤ FEV₁ ≤80% predicted, GOLD 3: FEV₁ ≤50% predicted and GOLD 4: FEV₁ <30% predicted or FEV₁ predicted plus chronic respiratory failure.
Abbreviations: CAT, COPD Assessment Test; FEV₁, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroids; LABA, long-acting β₂-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council; PDE4i, phosphodiesterase 4 inhibitors; prn, as needed (pro renata); SABA, short-acting β₂-agonist; SAMA, short-acting muscarinic antagonist.

Table 1 Definition of overtreatment and undertreatment for different groups of COPD patients

Overtreatment (presence of these medication combinations)
Group A	LABA + LAMA, any ICS, any PDE4i
Group B	Any ICS, any PDE4i
Group C	LABA + LAMA + ICS
	LAMA + ICS
Undertreatment (absence of these medication combinations)
Group B	LABA, LAMA
Group C	LAMA, LABA + ICS, LABA + LAMA
Group D	LABA + ICS, LAMA alone
	LABA + LAMA + ICS
	LABA + ICS + PDE4i
	LAMA + LABA, LAMA + PDE4i
	LAMA + ICS

Notes: “Overtreated” group applies to patients of groups A, B and C using a pharmacological treatment combination more than recommended by the guideline, and “undertreatment” group applies to patients of groups B, C and D using a suboptimal pharmacological treatment combination. ICS alone are considered as undertreatment in groups B, C and D and as overtreatment in group A.

Abbreviations: ICS, inhaled corticosteroids; LABA, long-acting β₂-agonist; LAMA, long-acting muscarinic antagonist; PDE4i, phosphodiesterase 4 inhibitors.

Figure 2 Enrollment and outcomes.

Table 2 Baseline sociodemographics and clinical characteristics

Variable	Mean ± SD	n (%)
Age, years	73.7±8.5
Gender
Male		413 (92.2)
Female		35 (7.8)
Smoking status
Current smoker		65 (14.5)
Ex-smoker		361 (80.4)
Nonsmoker		23 (5.1)
Smoking packs/year (non-smokers excluded)	39.5±32.3
Working status
Employed		39 (8.7)
Unemployed		6 (1.3)
Retired		401 (89.9)
Body weight, kg	56.4±11.0
Body height, cm	162.2±7.3
BMI, kg/m^2	21.4±3.8
Pre-BD FEV1/L	1.0±0.5
Pre-BD FEV1/% predicted	47.2±19.7
Post-BD FEV1/L	1.1±0.5
Post-BD FEV1/% predicted	50.8±21.7
CAT score	13.2±8.1
mMRC dyspnea score	2.1±1.0
Number of exacerbations in the last 12 months	1.6±1.9
≥2 exacerbations in the last 12 months		165 (37.4)
Baseline COPD group
A		5 (1.1)
B		164 (36.4)
C		8 (1.8)
D		273 (60.7)

Abbreviations: BD, bronchodilator; BMI, body mass index; CAT, COPD Assessment Test; FEV₁, forced expiratory volume in 1 second; mMRC, modified Medical Research Council; SD, standard deviation.

Table 3 Use of pharmacological and nonpharmacological treatments by COPD grouping at different visits (by class of treatment)

Visit	Visit 1								Visit 2								Visit 3
COPD group	A (n=5)		B (n=164)		C (n=8)		D (n=273)		A (n=4)		B (n=169)		C (n=1)		D (n=235)		A (n=3)		B (n=169)		C (n=3)		D (n=207)
Drugs	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Any SABA	5	100.0	156	95.1	8	100.0	266	97.4	3	75.0	147	87.0	1	100.0	210	89.4	3	100.0	156	92.3	3	100.0	198	95.7
Any SAMA	3	60.0	57	34.8	0	0.0	80	29.3	1	25.0	46	27.2	1	100.0	64	27.2	1	33.3	53	31.4	0	0.0	43	20.8
LABA only	1	20.0	1	0.6	0	0.0	1	0.4	0	0.0	0	0.0	1	100.0	3	1.3	1	33.3	2	1.2	0	0.0	2	1.0
LAMA only	0	0.0	6	3.7	0	0.0	6	2.2	0	0.0	1	0.6	0	0.0	4	1.7	0	0.0	2	1.2	0	0.0	3	1.4
ICS only	1	20.0	25	15.2	1	12.5	13	4.8	0	0.0	11	6.5	0	0.0	15	6.4	0	0.0	22	13.0	0	0.0	8	3.9
Any LABA	4	80.0	110	67.1	6	75.0	240	87.9	3	75.0	126	74.6	1	100.0	184	78.3	3	100.0	130	76.9	3	100.0	185	89.4
Any LAMA	2	40.0	82	50.0	7	87.5	174	63.7	2	50.0	88	52.1	0	0.0	136	57.9	2	66.7	90	53.3	3	100.0	149	72.0
Any ICS	4	80.0	144	87.8	8	100.0	262	96.0	3	75.0	147	87.0	0	0.0	202	86.0	2	66.7	152	89.9	3	100.0	193	93.2
ICS + LABA	1	20.0	43	26.2	0	0.0	81	29.7	1	25.0	49	29.0	0	0.0	57	24.3	0	0.0	46	27.2	0	0.0	43	20.8
LABA + LAMA	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0	2	0.9	0	0.0	4	2.4	0	0.0	4	1.9
LABA + LAMA + ICS	2	40.0	66	40.2	6	75.0	158	57.9	2	50.0	77	45.6	0	0.0	122	51.9	2	66.7	78	46.2	3	100.0	136	65.7
LABA + LAMA + PDE4i	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0	1	0.4	0	0.0	1	0.6	0	0.0	2	1.0
Any theophylline	1	20.0	44	26.8	2	25.0	76	27.8	1	25.0	53	31.4	0	0.0	52	22.1	1	33.3	42	24.9	0	0.0	55	26.6
Any PDE4i	1	20.0	0	0.0	0	0.0	17	6.2	0	0.0	9	5.3	0	0.0	10	4.3	0	0.0	5	3.0	0	0.0	21	10.1
Any montelukast	0	0.0	1	0.6	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0	1	0.4	0	0.0	0	0.0	0	0.0	0	0.0

Abbreviations: ICS, inhaled corticosteroids; ICS + LABA, LABA with ICS together in single or separate inhaler devices; LABA, long-acting (3₂-agonist; LABA + LAMA, LABA with LAMA together in single or separate inhaler devices; LABA + LAMA + ICS, LABA, LAMA and ICS together in single or separate devices; LABA + LAMA + PDE4i, LABA and LAMA together in single or separate inhaler device with PDE4i; LAMA, long-acting muscarinic antagonist; PDE4i, phosphodiesterase 4 inhibitors; SABA, short-acting (3₂-agonist; SAM A, short-acting muscarinic antagonist.

Table 4 Reasons for change of pharmacological therapy

Treatment changed	Visit 1 (n=446)	Visit 2 (n=407)	Visit 3 (n=380)
Number of patients who had treatment changed (%)	123 (27.6)	123 (30.2)	107 (28.2)
Reasons
Insufficient disease control, n (%)	104 (84.6)	89 (72.4)	78 (72.9)
Tolerability issues, n (%)	9 (7.3)	14 (11.4)	11 (2.9)
Compliance issues, n (%)	1 (0.8)	2 (1.6)	5 (1.3)
Inhaler device issues, n (%)	6 (4.9)	7 (5.7)	4 (1.1)
Others, n (%)	9 (7.3)	14 (11.4)	10 (2.6)

Note: Some patients had more than one reason for change of therapy.

Table 5 Adherence rate to GOLD guideline 2011

Visit	COPD groups	Total number of patients	Adherent, n (%)	Overtreated, n (%)	Undertreated, n (%)
1	Overall	450	262 (58.2)	130 (28.9)	58 (12.9)
	A	5	1 (0.2)	4 (0.9)	N/A
	B	164	7 (1.6)	119 (26.4)	38 (8.4)
	C	8	0 (0.0)	7 (1.6)	1 (0.2)
	D	273	254 (56.4)	N/A	19 (4.2)
2	Overall	409	195 (47.7)	140 (34.2)	74 (18.1)
	A	4	1 (0.2)	3 (0.7)	N/A
	B	169	1 (0.2)	137 (33.5)	31 (7.6)
	C	1	0 (0.0)	0 (0.0)	1 (0.2)
	D	235	193 (47.2)	N/A	42 (10.3)
3	Overall	382	197 (51.6)	136 (35.6)	49 (12.8)
	A	3	1 (0.2)	2 (0.5)	N/A
	B	169	4 (1.0)	131 (34.3)	34 (8.9)
	C	3	0 (0.0)	3 (0.8)	0 (0.0)
	D	207	192 (50.3)	N/A	15 (3.9)

Note: The rate of guideline adherence and undertreatment remains similar over 12 months, but there was an increasing trend of overtreatment.

Abbreviations: GOLD, Global Initiative for Chronic Obstructive Lung Disease; N/A, not applicable.

Table 6 Adherence rate to GOLD guideline 2011 and exacerbation rate

Treatment adherence	Total	No exacerbation	Exacerbation occurred	Comparison with adherence group on exacerbation
Adherence group	183	57	126	N/A
Overtreatment group	86	51	35	p<0.001a
Undertreatment group	41	34	7	p<0.001a

Note:

a Patients in the adherence group had more exacerbations than those overtreated or undertreated.

Abbreviations: GOLD, Global Initiative for Chronic Obstructive Lung Disease; N/A, not applicable.

Table 7 Summary of comorbidities by baseline COPD groupings

Comorbidity, n (%)	Baseline COPD group by GOLD guideline 2011				p-value	Total (N=450)
	A (n=5)	B (n=164)	C (n=8)	D (n=273)
Any comorbidities	3 (60.0)	122 (74.4)	6 (75.0)	233 (85.3)	0.033a,b 0.005a,c	364 (80.9)
HT	1 (20.0)	68 (41.5)	3 (37.5)	111 (40.7)	0.920c	183 (40.7)
DM	2 (40.0)	14 (8.5)	1 (12.5)	36 (13.2)	0.163c	53 (11.8)
Old TB	0 (0.0)	18 (11.0)	3 (37.5)	29 (10.6)	1.000c	50 (11.1)
IHD	0 (0.0)	12 (7.3)	0 (0.0)	35 (12.8)	0.080c	47 (10.4)
BPH	0 (0.0)	16 (9.8)	0 (0.0)	30 (11.0)	0.749c	46 (10.2)
Hyperlipidemia	0 (0.0)	9 (5.5)	1 (12.5)	18 (6.6)	0.688c	28 (6.2)
Cardiac arrhythmia	0 (0.0)	8 (4.9)	0 (0.0)	20 (7.3)	0.420c	28 (6.2)
Malignancy other than lung cancer	0 (0.0)	5 (3.0)	2 (25.0)	18 (6.6)	0.125c	25 (5.6)
Heart failure	1 (20.0)	3 (1.8)	0 (0.0)	19 (7.0)	0.022a,c	23 (5.1)
Old CVA	0 (0.0)	9 (5.5)	0 (0.0)	13 (4.8)	0.822c	22 (4.9)
Bronchiectasis	0 (0.0)	2 (1.2)	0 (0.0)	7 (2.6)	0.494c	9 (2.0)
Lung cancer	0 (0.0)	1 (0.6)	0 (0.0)	6 (2.2)	0.264c	7 (1.6)
Others	0 (0.0)	45 (27.4)	4 (50.0)	86 (31.5)		135 (30.0)

Notes: Patients of groups B and D had a higher prevalence of comorbidities than those of groups A and C. Comparison between groups A and C was not performed due to the small number of patients.

a Clinically significant.

b Comparison between all COPD groups.

c Comparison between groups B and D.

Abbreviations: BPH, benign prostatic hyperplasia; CVA, cerebrovascular accident; DM, diabetes mellitus; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HT, hypertension; IHD, ischemic heart disease; TB, tuberculosis.

global initiative for chronic obstructive lung disease (GOLD). CommitteeGlobal Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease2011 Available from: http://www.goldcopd.org/Guidelines/guidelines-resources.htmlAccessed August 13, 2013

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