Adherence to GOLD guidelines in COPD patients at a tertiary hospital
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Date
2020
Authors
Kaftel, Steven
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Abstract
ABSTRACT
Background: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines,
updated in 2019, provide a framework to classify chronic obstructive pulmonary disease (COPD)
severity. In so doing, it guides practitioner’s choice of therapy for the individualized patient. The
GOLD guidelines classify patients into one of four groups: A, B, C, or D. This is based on
symptoms, as well as exacerbations or hospitalizations. Inhaled corticosteroids (ICS) should be
reserved for GOLD C and D patients who have frequent exacerbations (≥2/year).
Aims: The primary objective of this research is to document adherence to GOLD treatment
guidelines in COPD patients at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH)
respiratory clinic. The secondary objective of the study is to investigate whether a statistically
significant association exists between GOLD category and lack of adherence to guidelines, as well
as GOLD category and inappropriate use of ICS.
Methods: A retrospective record review of patients with COPD attending respiratory clinic over
a three month period at CMJAH was conducted. Descriptive analysis of the data was carried out
as follows: categorical variables were summarized by frequency and percentage tabulation and
illustrated by means of bar charts. Continuous variables were summarized by the mean, standard
deviation, and their distribution illustrated by means of histograms. The Chi Square test was used
to assess the relationships between categorical variables and the Fisher’s exact test when the
sample size was small.
Results: A total of 146 patients were included in the study. In 54.1% of cases the modified Medical
Research Council (mMRC) classification of breathlessness was not recorded in the notes. The
majority of the patients (72.6%) were classified as Group B. Furthermore, 87.7% of the total
patient cohort were using ICS or ICS/long acting beta 2 agonist (LABA) combination therapy, and
61.0% of patients were using triple therapy: long acting muscarinic antagonist (LAMA), LABA, and ICS. Only 24.7% of patients were found to be receiving treatment adherent to GOLD
guidelines with respect to appropriate use of ICS. There was a significant association between
GOLD category and a lack of adherence to GOLD treatment guidelines (p<0.0001) with nonadherence to guidelines being much higher in group B with a significant percentage of patients
(87%) on inappropriate ICS therapy.
Conclusions: Adherence to GOLD guidelines and therapeutic algorithms was lacking in this
cohort of patients studied. The mMRC classification of breathlessness was poorly recorded in the
patients’ notes despite the fact that it forms a core part of the GOLD classification. In addition, the
majority of patients are treated with ICS therapy. This may be as a result of the lack of the
appropriate patient classification according to the GOLD criteria. This limitation has probably
resulted in the injudicious use of ICS therapy with the potential for an increased risk of side effects
such as pneumonia. In order to prevent this, we should be implementing strategies to ensure that
the GOLD classification is correctly recorded at each clinic visit by means of a standard data
collection sheet. This will prevent over treatment of patients, reduce the use of unnecessary
inhalers and the cost thereof in a resource constrained setting, as well as potentially reduce the
complications and side effects of ICS therapy. The use of serum eosinophil counts as a validated
biomarker may help to guide practitioners to decide which patients to attempt withdrawal of ICS therapy
Description
A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine, 2020