Study Underscores Deficits in Management of COPD in Primary Care

Many patients with chronic obstructive pulmonary disease (COPD) managed in US primary care receive some form of maintenance therapy, yet a portion still face exacerbation burden, according to an observational registry study published in Annals of Family Medicine.

“Our findings highlight the high exacerbation, symptom, and treatment burdens experienced by COPD patients managed in US primary care, and the need for more real-life effectiveness trials to support decision making at the primary care level,” wrote study authors.

Approximately 80% of patients with COPD in the US are managed by their family physician or general internist, but many primary care clinicians are unfamiliar with COPD management guidelines.

“To improve COPD management in primary care, it is first necessary to describe the patient population using clinically relevant variables which can be collected practically and monitored longitudinally. Our study is the first to do that, comprehensively describing US COPD patients managed in primary care,” stated authors.

Researchers examined electronic health records (EHRs) of 17 192 patients treated at primary care clinics in 5 states between June 2019 and November 2020 using a dataset maintained by the nonprofit organization DARTNet Institute, called the COPD Optimum Patient Care DARTNet Research Database (COPD-RD). Investigators also analyzed EHR data from 1354 patients from the COPD-RD-derived Advancing the Patient Experience COPD (APEX-COPD) registry.

Overall, the majority of participants were women (56%), aged 55-84 years (81%; average age of diagnosis, ≥35 years), White (64%), current smokers or previous smokers (88%), and overweight or obese (69%). Among both cohorts, hypertension was the predominant comorbidity, followed by diabetes mellitus, depression, and osteoarthritis.

Findings

Exacerbation was prevalent with 38% (6579/17 192) of patients experiencing ≥1 exacerbations in the previous year. Among APEX-COPD participants, 50% reported having ≥1 exacerbations and 20% were hospitalized for COPD in the last 12 months.

Among APEX-COPD participants, 43% reported that COPD had a high or very high impact on their health, and 45% could not walk at a normal pace without experiencing breathlessness.

These findings on exacerbation were surprising to the authors as 88% of patients received some from of maintenance therapy, predominately inhaled corticosteroid (ICS) with long-acting β2-agonist (LABA) and ICS with LABA and long-acting muscarinic antagonist (LAMA).

Investigators wrote that these findings may indicate that patients were not receiving appropriate treatment or were not adherent with their medication regimens. The results may also suggest that more focus on nonpharmacologic treatment options is needed to reduce symptom burden, such as smoking cessation as more than 31% of patients continued to smoke in the previous year. The team added that more physician education is required to diagnose and treat COPD earlier to delay a decline in lung function.

The results may also point to the over-treatment of COPD in primary care. Overall, 27% of patients were on triple therapy (ICS/LABA/LAMA)—which current guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend for patients with persistent exacerbations—and 30% were on ICS/LABA (recommended as an initial treatment for GOLD Group D patients). The team noted, however, that it is important to recognize that GOLD treatment recommendations are based on evidence from randomized controlled trials (RCTs) which may not be an accurate representation of patients with COPD in real-life.

“Taken together, these findings indicate further opportunity for medication optimization in the primary care setting for COPD patients and call for more real-life effectiveness trials, or broader inclusion criteria for RCTs to provide real-life evidence of response to and appropriateness of treatment and to inform COPD management guidelines,” concluded authors.

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