Real-life GOLD 2011 implementation: the management of COPD lacks correct classification and adequate treatment.

Chronic obstructive pulmonary disease (COPD) is a serious, yet preventable and treatable, disease. The success of its treatment relies largely on the proper implementation of recommendations, such as the recently released Global Strategy for Diagnosis, Management, and Prevention of COPD (GOLD 2011, of late December 2011). The primary objective of this study was to examine the extent to which GOLD 2011 is being used correctly among Czech respiratory specialists, in particular with regard to the correct classification of patients. The secondary objective was to explore what effect an erroneous classification has on inadequate use of inhaled corticosteroids (ICS). In order to achieve these goals, a multi-center, cross-sectional study was conducted, consisting of a general questionnaire and patient-specific forms. A subjective classification into the GOLD 2011 categories was examined, and then compared with the objectively computed one. Based on 1,355 patient forms, a discrepancy between the subjective and objective classifications was found in 32.8% of cases. The most common reason for incorrect classification was an error in the assessment of symptoms, which resulted in underestimation in 23.9% of cases, and overestimation in 8.9% of the patients' records examined. The specialists seeing more than 120 patients per month were most likely to misclassify their condition, and were found to have done so in 36.7% of all patients seen. While examining the subjectively driven ICS prescription, it was found that 19.5% of patients received ICS not according to guideline recommendations, while in 12.2% of cases the ICS were omitted, contrary to guideline recommendations. Furthermore, with consideration to the objectively-computed classification, it was discovered that 15.4% of patients received ICS unnecessarily, whereas in 15.8% of cases, ICS were erroneously omitted. It was therefore concluded that Czech specialists tend either to under-prescribe or overuse inhaled corticosteroids

Original version of the Czech Republic map in SVG format.

<p>Original version of the Czech Republic map in SVG format.</p

Use of ICS in monotherapy or combination therapy.

<p>Use of ICS in monotherapy or combination therapy.</p

Numbers of COPD specialists involved in the research by country regions of the Czech Republic.

<p>Numbers of COPD specialists involved in the research by country regions of the Czech Republic.</p

Effect of number of COPD patients seen in a month on a discrepancy between subjectively classified patients into GOLD 2011 groups and classification achieved by objective assessment using software.

<p>Effect of number of COPD patients seen in a month on a discrepancy between subjectively classified patients into GOLD 2011 groups and classification achieved by objective assessment using software.</p

Contribution to the misclassification of an individual clinical component interpreted within the GOLD 2011 classification matrix.

<p>The percentage indicates relative frequency of misclassified cases attributable to a given clinical component. A sole effect is responsible for misclassified cases due to an obvious error in interpretation of one specific primary clinical parameter. The combined effect is responsible for misclassified cases due to an obvious error in interpreting both clinical criteria on the same axis (mMRC dyspnea scale and CAT respective bronchial obstruction and number of COPD exacerbations/year). <i>Statistical probabilities were calculated of pair-wise contrasts as follows; mMRC dyspnea scale vs. CAT (p>0.05), mMRC dyspnea scale vs. bronchial obstruction based on post bronchodilator FEV1 (p<0.0001), mMRC dyspnea scale vs. number of exacerbations/year (p<0.0001), CAT vs. bronchial obstruction (p<0.0001), CAT vs. number of exacerbations/year (p<0.0001), bronchial obstruction vs. number of exacerbations/year (p<0.0001).</i></p