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Abstract

Summary: Despite the popularity of chronic obstructive pulmonary disease (COPD) guidelines, studies have reported important deficits among primary care physicians (PCPs) with respect to diagnosis and treatment of COPD; as a consequence, COPD remains underrecognized and undertreated. Methods: This was a multicenter pilot study to assess prescribing practices for COPD by PCPs according to COPD guidelines. This was a 2-phase study: In phase 1, PCPs from 27 Mexican cities, referred patients for evaluation, including spirometry and in phase 2, PCPs from 10 of those same cities were asked to answer a questionnaire on COPD practice guidelines. Results: A total of 2293 subjects were included in phase 1; 472 (20.6%) had a FEV₁/FVC <70%. Only 39% of patients with 30% ≤ FEV₁ < 50% and 22% with FEV₁ <30% were receiving combination therapy (long-acting bronchodilator + inhaled steroid). In phase 2, we recruited 999 PCPs; 72.5% of them said that they had read a COPD guideline and 59.4% answered that they used one in their practice. When asked which guideline(s) they used, we had 86 different responses with GOLD (Global Initiative for Chronic Obstructive Lung Disease; 34.1%) being the most common, followed by GINA (Global Initiative for Asthma; 12.8%). When asked why they did not used a guideline, we got 33 different answers; “never read them” was the most frequent answer (41.8%) followed by “lack of access to them” (18.2%) and “not enough time to read them” (6.0%). Conclusion: Despite the existence and availability of evidence-based guidelines, only a minority of primary health care COPD patients in Mexico are receiving state-of-the-art treatment at the primary care level.

Keywords

chronic obstructive pulmonary disease (COPD)prescription practices guidelines continuous medical education primary care

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and its prevalence and burden are projected to increase in the coming decades.¹

Worldwide, primary care physicians (PCPs) treat the majority of patients with respiratory diseases, including COPD; since clinical management that follows evidence-based guidelines yields better results for patients, it is important that PCPs are well acquainted with local and international COPD guidelines diagnosis, management, and prevention recommendations.²

However, despite the popularity of COPD guidelines, several studies have reported important deficits among PCPs with respect to diagnosis and treatment of COPD and the practical implementation of educational measures; as a consequence, COPD remains underrecognized and undertreated.^3-5

Our objective was to determine through a baseline pilot study to what degree Mexican PCPs are acquainted with and use COPD guidelines in their daily practice. In a 2-phase study, we initially assessed the prescription practices for COPD by PCPs in Mexico and then their knowledge and utilization of COPD guidelines for the diagnosis, management, and prevention of the disease.

Study Population and Methods

As mentioned, this was a 2-phase study. The methods for phase 1 have already been published.⁶ Briefly, this phase was conducted from March to October 2008. Subjects were recruited in 27 cities from 20 different Mexican states. Cities were selected based on the availability of a certified respiratory therapist to apply a questionnaire and perform spirometry. PCPs at each city were invited to participate in a case-finding strategy to identify individuals with possible COPD. PCPs at each city were contacted through their local medical society and invited to participate in a case-finding strategy to identify individuals with possible COPD among their patients. Participants answered a self-administered 4-item questionnaire on COPD risk factors (smoking, exposure to biomass smoke, and/or dusts) and COPD symptoms (cough, sputum production, and dyspnea); those with any positive answer were referred for spirometry. After obtaining written informed consent they were invited to answer the Spanish version of PLATINO⁷ questionnaire. Dyspnea was assessed by the modified Medical Research Council (mMRC) dyspnea scale.⁸ Pre- and postbronchodilator spirometry measurements were taken with a portable, battery-operated spirometer (Easy-One, NDD Medical Technologies, Chelmsford, MA and Zurich, Switzerland). Spirometry was conducted according to the quality criteria of the American Thoracic Society/European Respiratory Society.⁹ Reference equations were those from the National Health and Nutrition Examination Survey–III for Mexican Americans.¹⁰ We used the GOLD (Global Initiative for Chronic Obstructive Lung Disease)¹ criteria FEV₁/FVC (forced expiratory volume in 1 second/forced vital capacity) postbronchodilator <0.7 to define COPD. The analysis of data regarding treatment was limited to the prescribing practices where there is an established consensus on optimal treatment.

Phase 2 was carried out from March through November 2011. During a national continuous medical education program on COPD for PCPs and immediately prior to the start of the day lectures, a 10-item questionnaire (see the appendix) was applied to explore the degree of knowledge on COPD guidelines. Physicians were recruited at 10 Mexican cities. The study was approved by the ethics committee of the Baja California (Mexico) State Health Services.

Statistical Analysis

A commercial statistical software package (SPSS version 18) was used to analyze the data. The χ² test was used to compare proportions and t test was used to compare means. Significance level was set at <.05.

Results

In the first phase, 2293 subjects were included; 472 (20.6%) had a FEV₁/FVC <70%; 123 (26.1%) had severe COPD (30% ≤ FEV₁ < 50% predicted) and 36 (7.6%) had very severe COPD (FEV₁ < 30% predicted). Treatment regimens for both groups are shown in Table 1. No significant differences in prescribed treatment were found among groups with severe a very severe disease.

Table 1.

Pharmacologic Treatment for Severe and Very Severe COPD in Mexico.

Variable	30% ≤ FEV₁ < 50% of Predicted; n (%)	FEV₁ < 30% of Predicted; n (%)	P
Number of subjects	123	36
Receiving treatment for COPD	97 (79)	33 (92)	.13
Combined therapy (ICS + LABA)	48 (39)	8 (22)	.09
Long-acting anticholinergics (LAMA)	10 (8)	4 (11)	.81
Triple therapy (ICS + LABA + LAMA)	11 (9)	5 (14)	.57

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in 1 second; ICS, inhaled corticosteroids; LABA, long-acting β-2 adrenergic bronchodilators; LAMA, long-acting anticholinergics.

In phase 2, we recruited 999 PCPs. They had practiced medicine for 22.3 ± 11.1 years (median = 25 years, range = 1-53 years); 724 (72.5%) of them said that they had read a COPD guideline and 593 (59.4%) answered that they used one in their practice. When asked which guideline(s) they used, we had 86 different responses with GOLD (202 PCPs; 34.1%) being the most commonly mentioned, followed by GINA (Global Initiative for Asthma; 76 PCPs; 12.8%), Mexican COPD Guideline (46 PCPs; 7.7%), and the CAT (COPD Assessment Test) questionnaire (22 PCPs; 3.8%). Reasons for not using any guideline included the following: “never read them” (170 PCPs; 41.8%) followed by “lack of access to them” (74 PCPs; 18.2%), “not enough time to read them” (24 PCPs; 6.0%), and “because they are too long” (19 PCPs; 4.6%). There were no significant difference according to years of practice: Physicians who had read the guidelines had practiced medicine for 21.8 ± 11.1 years versus 23.5 ± 11.0 years for those who had not read them (P = .24), and 21.7 ± 11.1 years of practice for those who reported using the guidelines versus 23.1 ± 11.0 years for those who reported not using any guideline (P = .30). When asked about suggestions to draft a better guideline, we got 98 different answers; a chapter on treatment was the most common answer (428 PCPs; 42.8%), followed by chapter on diagnosis (287 PCPs; 28.7%) and a chapter on COPD symptoms (272 PCPs; 27.3%).

Discussion

Worldwide, COPD remains underrecognized and undertreated and is rarely regarded as a high-priority health issue.¹¹ Although several national and international societies have provided detailed guidelines regarding the diagnosis and treatment of COPD, the degree of awareness and use of these guidelines in clinical practice are unclear.¹² These evidence-based resources are free and easily accessible via the Internet, and many have been recently issued or updated, integrating new scientific findings and reflecting the availability of emerging therapeutic options.¹³

One of the barriers for an evidence-based approach to COPD by general practitioners in Mexico is the limited awareness of these guidelines among primary care physicians; in our survey, just 60% of the PCPs responded that they use a clinical guideline for diagnosis and treatment of COPD, with GOLD being the most frequently referenced; 40% of those surveyed did not use a guideline because they were unaware of their existence. Also, almost 13% mentioned that they use the GINA asthma guideline to treat their COPD patients, and some PCPs answered they use the assessment questionnaire CAT as a guideline. When asked in the questionnaire about ideas to draft a better guideline, basically all the suggested topics are already included in all current guidelines; this implies they have not read them. In a recent COPD case-finding study where Mexican PCPs referred their patients for evaluation,⁶ only 11.3% of patients reported having undergone spirometry in the past despite being symptomatic and/or having a history of exposure to risk factors for COPD, and just 13.8% of those with proven airflow obstruction had been previously diagnosed clinically with COPD by their PCPs. In contrast, 40% of those subjects who reported being clinically diagnosed with COPD by their PCPs had a normal spirometry. For those already diagnosed with COPD, treatment regimen is frequently incompatible with international COPD guidelines. Although there is a consensus that COPD patients with a FEV₁ <50% should be receiving combination therapy (long-acting bronchodilators plus inhaled corticosteroids), just more than a third of severe cases, and one fifth of very severe cases in our study were being treated according to local and international guidelines. Our results are comparable to adherence to COPD guidelines reported elsewhere.^3-5

Studies in primary care have demonstrated problems with provision of most treatments including medications, vaccination, and smoking cessation advice.¹⁴ A recent study in Mexico⁶ showed that although more than 60% of smokers received medical advice on smoking cessation, only 9.3% had received some type of intervention (behavioral or pharmacological). As shown, only 35% of COPD patients with FEV₁ <50% in our study were receiving a combination of inhaled corticosteroid plus a long-acting bronchodilator; in contrast, a study from the United Kingdom reported that 60% of COPD patients from primary care practices were receiving inhaled steroids, of which only 23% met the indication of FEV₁ <50%.¹⁴

The reported barriers to recognition and diagnosis of COPD have included guideline length, physicians’ work overload, the multiple morbidities in most COPD patients, the failure of patients to report symptoms, and lack of knowledge and inadequate training in COPD diagnosis and management. It also seems that those who read them do not fully understand their content and purpose.²

To date, the continuous medical education literature suggests that the most effective strategies contain several design elements, such as a rigorous and accurate assessment of need, use of active and varied learning approaches, and an evidence-based curriculum that focuses on overcoming barriers to change. Additionally, a change in physician practice is more likely with interventions that are multifaceted, interactive, and consistent with the perceived needs of the learner.^15,16

However, the problem of missed diagnosis and inappropriate treatment is multifactorial, and cannot be attributed only to lack of acquaintance of PCPs with COPD guidelines. The diagnosis of COPD requires spirometry, a study that is not widely available in Mexico (a recent multinational survey¹⁷ reported that only 34% of Mexican PCPs used spirometry as a diagnostic test for COPD before starting treatment). Also, inhaled corticosteroids at the recommended doses required for COPD are not available in the 2 largest public health systems in the country; therefore PCPs cannot prescribe them even if they consider that there was an indication for such drugs.

In conclusion, despite the existence of evidence-based guidelines, only a minority of primary health care COPD patients in Mexico are receiving state-of-the-art treatment. These deficiencies in guideline conformity might be best addressed through targeted continuing education measures. These results suggest significant opportunities for education and improvement in use of tools to improve COPD recognition and management. Nevertheless, even if PCPs are well acquainted with state-of-the-art recommendations for diagnosis and treatment of COPD, spirometry and necessary therapeutic agents must be made widely available in the public health system (which provides health care for more than 80% of the population) if we want to have an impact on missed diagnosis and suboptimal treatment of this disease.

Footnotes

Appendix

Authors’ Note

GlaxoSmithKline Mexico did not participate in the study design, in the collection, analysis, and interpretation of data, in the writing of the manuscript, or in the decision to submit the manuscript for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:

We express our appreciation to GlaxoSmithKline (GSK) Mexico for the research grant that made this project possible.

Author Biographies

Rafael Laniado-Laborín is a specialist in pulmonary medicine with a MPH in epidemiology. Professor at the Faculty of Medicine, Universidad Autónoma de Baja California. Member of the National System of Researchers (Sistema Nacional de Investigadores, CONACYT, México)

Adrian Rendón is a specialist in pulmonary critical care medicine. Professor at the Faculty of Medicine, Universidad Autónoma de Nuevo León. Member of the National System of Researchers (Sistema Nacional de Investigadores, CONACYT, México)

Juan Manuel Alcantar-Schramm is a primary care physician and member of the research staff of Dr Laniado-Laborín

Rebeca Cazares-Adame is a primary care physician and member of the research staff of Dr Laniado-Laborín

Otto Bauerle is a specialist in pulmonary critical care. His main research interests are pulmonary hypertension and COPD

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