Adherence to the GOLD Guidelines in Primary Care: Data from the Swiss COPD Cohort

Abstract

(1) Introduction: Chronic obstructive pulmonary disease (COPD) and its associated morbidity and mortality are a global burden on both affected patients and healthcare systems. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) issues guidelines with the aim of improving COPD management. Previous studies reported significant variability in adherence to these recommendations. The objective of this study was to evaluate Swiss primary practitioners' adherence to the GOLD guidelines for the pharmacological treatment of stable COPD. (2) Methods: We studied patients who were included in the Swiss COPD cohort study, an ongoing prospective study in a primary care setting, between 2015 and 2022. The key inclusion criteria are age ≥ 40 years, FEV1/FVC ratio < 70%, and a smoking history of at least 20 pack-years. Adherence to the GOLD guidelines was assessed per visit and over time. (3) Results: The data of 225 COPD patients (mean age 67 ± 9 years, 64% male) and their respective 1163 visits were analyzed. In 65% of visits (726/1121), treatment was prescribed according to the GOLD guidelines. Non-adherence was most common in GOLD groups A and B (64% and 33%) and mainly consisted of over-treatment (two long-acting bronchodilators in group A (98/195, 50%) and ICS in groups A (21/195, 11%) and B (198/808, 25%)). In group D, the prescriptions conformed with the guidelines in 99% of cases (109/108). Guideline adherence was associated with high symptom load (COPD Assessment Test) (OR 1.04, p = 0.002), high number of exacerbations (OR = 2.07, p < 0.001), asthma overlap (OR 3.36, p = 0.049), and diabetes mellitus (OR 2.82, p = 0.045). (4) Conclusion: These results confirm a conflict between the GOLD recommendations and primary practice, mainly concerning over-treatment in GOLD groups A and B. Patients with high symptom load, high exacerbation risk, asthma overlap, and diabetes mellitus are more likely to be treated in conformity with the guidelines. Further research is needed to uncover the reasons for the discrepancies and to design strategies for improvement.

Keywords: COPD; GOLD guidelines; adherence; bronchodilators; inhaled corticosteroids; primary care.

Figure 1

The ABCD assessment tool [9]. FEV1: Forced expiratory volume in one second; FVC: forced vital capacity; GOLD: Global Initiative for Chronic Obstructive Lung Disease; CAT: COPD Assessment Test; mMRC: modified Medical Research Council score.

Figure 2

Flow chart for patient and visit selection process. COPD: Chronic Obstructive Pulmonary Disease; GOLD: Global Initiative for Chronic Obstructive Lung Disease.

Figure 3

Pharmacological COPD treatment regimen in each GOLD group per visit (n = 1121 visits, 33 visits omitted due to missing GOLD group information, 9 visits omitted due to missing treatment information). GOLD: Global Initiative for Chronic Obstructive Lung Disease; SABA: short-acting β2-agonist; LABA: long-acting β2-agonist; LAMA: long-acting muscarinic antagonist; ICS: inhaled corticosteroid.

Figure 4

Adherence to GOLD guidelines for each GOLD group per visit in percent (n = 1121 visits, 33 visits omitted due to missing GOLD group information, 9 visits omitted due to missing treatment information). * ICS was considered adherent in groups A and B if the patient had a documented asthma diagnosis.

Figure 5

Guideline adherence in each GOLD group per visit over time (2015–2022) (n = 1121 visits, 33 visits omitted due to missing GOLD group information, 9 visits omitted due to missing treatment information). Due to low number of visits, GOLD groups C and D were combined into C/D.

Figure 6

Predictors for guideline adherence (multivariable logistic regression). Red dashed line represents odds ratio of 1. (A): On visit basis (n = 1121 visits, 33 visits omitted due to missing GOLD group information, 9 visits omitted due to missing treatment information). (B): On patient basis (n = 225 patients). OR: Odds ratio; CI: Confidence interval; CAT: COPD Assessment Test; mMRC: modified Medical Research Council score; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; PAOD: peripheral arterial occlusive disease. Significance codes: * p < 0.05, ** p < 0.01, *** p < 0.001.