Subutilization of COPD guidelines in primary care: a pilot study.

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.

High altitude and chronic obstructive pulmonary disease prevalence: a casual or causal correlation?

INTRODUCTION: Studies on the relationship of chronic obstructive pulmonary disease (COPD) prevalence and altitude have reported contrasting results. The aim of this COPD case-finding study was to include a larger number of geographical sites to determine if there is an association between altitude and COPD prevalence. PATIENTS AND METHODS: Individuals aged 40 or older with known COPD risk factors, whether symptomatic or not, were referred by primary-care physicians. After obtaining written informed consent, they were invited to answer a questionnaire and undergo pre- and post-bronchodilator spirometry. RESULTS: Subjects were recruited in 27 Mexican cities, within an altitude range from 1 to 2,680 m above sea level. We found a weak (-0.31; P<.0001) although significant negative correlation between altitude and COPD prevalence. The COPD rate for cities located ≤1,000 m was 32.7% vs 16.4% for cities located >1,000 m (P<.0001); the rate for cities located at ≤2,000 m was 22.7% vs 15.6% for those >2,000 m; in the multiple logistic regression analysis, older age, male sex, tobacco habit, pack-years of smoking, years of exposure to biomass smoke and city altitude over sea level were significantly associated with COPD prevalence. CONCLUSIONS: Our data shows a significant inverse correlation between prevalence/severity of COPD and altitude.

Primary care physician perceptions on the diagnosis and management of chronic obstructive pulmonary disease in diverse regions of the world.

Chronic obstructive pulmonary disease (COPD) is a multicomponent disorder that leads to substantial disability, impaired quality of life, and increased mortality. Although the majority of COPD patients are first diagnosed and treated in primary care practices, there is comparatively little information on the management of COPD patients in primary care. A web-based pilot survey was conducted to evaluate the primary care physician's, or general practitioner's (GP's), knowledge, understanding, and management of COPD in twelve territories across the Asia-Pacific region, Africa, eastern Europe, and Latin America, using a 10-minute questionnaire comprising 20 questions and translated into the native language of each participating territory. The questionnaire was administered to a total of 600 GPs (50 from each territory) involved in the management of COPD patients and all data were collated and analyzed by an independent health care research consultant. This survey demonstrated that the GPs' understanding of COPD was variable across the territories, with large numbers of GPs having very limited knowledge of COPD and its management. A consistent finding across all territories was the underutilization of spirometry (median 26%; range 10%-48%) and reliance on X-rays (median 14%; range 5%-22%) for COPD diagnosis, whereas overuse of blood tests (unspecified) was particularly high in Russia and South Africa. Similarly, there was considerable underrecognition of the importance of exacerbation history as an important factor of COPD and its initial management in most territories (median 4%; range 0%-22%). Management of COPD was well below guideline-recommended levels in most of the regions investigated. The findings of this survey suggest there is a need for more ongoing education and information, specifically directed towards GPs outside of Europe and North America, and that global COPD guidelines appear to have limited reach and application in most of the areas studied.