Current Medical Research & Opinion 0300-7995 doi:10.1185/03007995.2013.867842

Vol. 30, No. 4, 2014, 667–684

Article FT-0302.R1/867842 All rights reserved: reproduction in whole or part not permitted

py Un t rig au fo t ht di hor r S sp ize a la d le © y, u s 20 vi e o ew p r 14 r C o an h d p ibi om In rin ted m fo rm t a . Au e si th rc aU ng or i le is al K co ed D py us is Lim fo ers tr ite rp c i b a er n d so d ut na ow io l u nl n se oa d,

N. Barnes

Abstract

GSK Stockley Park, West Uxbridge, Middlesex, United Kingdom Formerly at: Department of Respiratory Medicine, London Chest Hospital (Barts Health NHS Trust), London, United Kingdom

P.M.A. Calverley

Division of Infection and Immunity, Clinical Sciences Centre, University Hospital Aintree, Liverpool, United Kingdom

A. Kaplan

University of Toronto, Canada and Bedford Park Family Medical Centre, Richmond Hill, Ontario, Canada

K.F. Rabe

University Kiel, Department of Medicine, Germany LungenClinic Grosshansdorf, Grosshansdorf, Germany Address for correspondence: N. Barnes, GSK Stockley Park, West Uxbridge, Middlesex, UB11 1BT, United Kingdom. [email protected]

No

Co

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Original article Chronic obstructive pulmonary disease and exacerbations: clinician insights from the global Hidden Depths of COPD survey

Keywords: Clinician-reported – COPD – Exacerbation – Survey

Accepted: 11 November 2013; published online: 12 December 2013 Citation: Curr Med Res Opin 2014; 30:667–684

Objective: This real-life, global study aimed to investigate current views of and clinical practice in the management of COPD and its exacerbations, among clinicians from both the primary and secondary care settings. Methodology: We devised an online questionnaire about COPD management and invited 13,613 general practitioners (GPs) and respiratory specialists to respond. Participating clinicians, recruited from an established research panel, treated a minimum of 10 (GPs) or 20 (respiratory specialists) patients with COPD per month. Completed responses were collected from 1400 clinicians from 14 countries. Results: A third of GPs and respiratory specialists reported that the main goal of COPD management was to improve patients’ quality of life; only 14% of GPs thought that the prevention of exacerbations was a priority. The study showed a strong preference for inhaled corticosteroids in combination with other treatments, rather than as sole therapy, in line with global guidelines. Fewer GPs than respiratory specialists routinely recommended anticholinergics, pulmonary rehabilitation or oxygen therapy. Clinicians reported that 55% (GPs) and 57% (respiratory specialists) of their COPD patients had experienced an exacerbation in the previous 12 months. Although higher than those reported in clinical trials, these rates were lower than patients’ own estimates from a corresponding patient survey, even in mild COPD patients (62%; 80% in severe patients). Despite this, 74% of GPs and 67% of respiratory physicians reported satisfaction with therapies to prevent exacerbations. Conclusions: This global survey revealed that clinicians’ main goal when managing COPD was to improve the lives of their patients, and that few viewed reducing exacerbations as a priority. Despite a relatively high level of adherence to treatment recommendations, it appears that clinicians, particularly GPs, underestimate the frequency and impact of exacerbations. These results suggest a need to raise awareness of exacerbations among both GPs and respiratory specialists.

Introduction Exacerbations contribute to chronic obstructive pulmonary disease (COPD) morbidity and mortality1. Patients with frequent exacerbations are at high risk of future exacerbations2 and accelerated disease progression1. ! 2014 Informa UK Ltd www.cmrojournal.com

Global Hidden Depths of COPD survey: clinician results Barnes et al.

667

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Current Medical Research & Opinion Volume 30, Number 4

April 2014

COPD management guidelines such as the UK National Institute for Health and Care Excellence guidelines3, the American Thoracic Society and European Respiratory Society guidelines4, the Canadian Thoracic Society guidelines5 and the Australian and New Zealand COPDX Plan6 state that exacerbations are associated with a high risk of lung function decline and mortality, poor health-related quality of life and increased health resource utilization. The guidelines stress the importance of accurate assessment and early intervention for preventing or minimizing such risks in COPD patients experiencing exacerbations. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) position paper recommends the assessment of future risk of disease progression, especially of exacerbations, as part of the COPD management strategy7. Despite the renewed focus on exacerbations within clinical guidelines, there are limited data regarding clinicians’ real-life experience of COPD management or their adherence to current recommendations. The Resource Network Needs Assessment (RNNA) survey of 1051 healthcare professionals from the United States highlighted gaps in the understanding and implementation of COPD guidelines, such as the overuse of ineffective therapies and the feeling that patients with COPD ‘brought it upon themselves’8. The RNNA study8 and other national surveys carried out in Belgium9, Switzerland10 and Germany11 also report a lack of clinician adherence to guideline recommendations with regards to the use of pharmacological therapies and pulmonary rehabilitation in COPD. The global Hidden Depths of COPD survey aimed to add to the current knowledge of COPD management in real-life settings by asking clinicians about their perceptions of COPD, in particular exacerbations, their goals of treatment, the impact of disease and the implications for healthcare resources. This study also examined the differences in current treatment practices in primary and secondary care.

Methods The global Hidden Depths of COPD survey was carried out between 09 July and 02 September 2010 in 14 countries: Australia, Brazil, Canada, China, Denmark, France, Germany, Italy, the Netherlands, Poland, South Korea, Spain, Turkey and the United Kingdom. These countries were chosen to provide a geographical and economic spread wider than that captured by earlier surveys, representative of the worldwide clinical experience of COPD. The survey was developed by an international Steering Committee comprised of doctors and respiratory specialists, in conjunction with independent research specialists, 668

Global Hidden Depths of COPD survey: clinician results Barnes et al.

with input and guidance from Takeda Pharmaceuticals International GmbH and FD Sante´. Clinicians were contacted via a pre-existing online panel of over 500,000 physicians working in a variety of urban and rural settings, who had registered to participate in market research surveys. The research panel has been verified for quality by the Market Research Association. An online approach was used to ensure that the methodology was globally consistent. Responder bias is inherent in this type of questionnaire; however, this innovative, Internet-based method, commonly used in consumer research, avoided potential biases within specialist centres or regions as well as biases related to disease severity or treatment. A total of 13,613 respiratory specialists and general practitioners (GPs) with an interest in respiratory medicine were invited to participate in the survey. Information about the survey (field of expertise and completion time) was provided to potential participants; however, clinicians were not informed about the survey subject. Incentives were offered in line with the research panel standards. Mean incentives were £26.54 for GPs and £28.46 for respiratory specialists. Once respondents had accepted the invitation to participate in the survey, they were sent a unique Uniform Resource Locator (URL), which permitted single access to the questionnaire. Respondents were initially targeted by specialty and screened to ensure they met the recruitment criteria, i.e. GPs saw a minimum of 10 patients with COPD per month and respiratory specialists a minimum of 20 patients per month. Respondents were unable to review or edit their answers to previous questions, and the survey used an adaptive question approach to minimize unnecessary questioning and shorten completion times. A number of questions were open-ended, which resulted in some of the completed surveys containing unanswered questions. Where applicable, respondents were offered the choice of responding to questions using the ‘don’t know’ option to avoid forcing inaccurate responses. The full survey and screening approach can be viewed in the Appendix. Prior to the launch of the full questionnaire, the survey was ‘soft-launched’ to a limited number of respondents (50–100 per country). The first 10 completed surveys were used to test the data and survey mechanism for ease of use and sense/logic; the average time for completion was checked against the original estimate. Data were stored in compliance with the UK Data Protection Act (1998) on secure servers that could only be accessed by relevant researchers. The research was implemented by professional market researchers in accordance with the Legal and Ethical Guidelines issued by the British Healthcare Business Intelligence Association (BHBIA) and was conducted in accordance with codes of conduct regarding anonymity, confidentiality and ethical practice. It was www.cmrojournal.com ! 2014 Informa UK Ltd

Current Medical Research & Opinion Volume 30, Number 4

therefore exempt from ethics approval under the UK Governance arrangements for research ethics committees.

Statistical analysis The collected data were processed and tabulated into electronic data tables. Descriptive statistics are presented.

Results Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Patient assessment and COPD diagnosis Of the 1997 clinicians who responded, 1662 fulfilled the recruitment criteria (Figure 1). Completed online responses were collected from 1400 clinicians (using a cut-off of 100 responses per country), of whom 893 (64%) were GPs and 507 (36%) were respiratory specialists. GPs reported that they saw on average 47 COPD patients per month, and respiratory specialists 105 COPD patients per month. The perceptions of patients’ COPD severity upon diagnosis varied considerably between clinician groups: GPs reported 21% of their patients as having severe or very severe COPD, compared with 45% for respiratory specialists (Table 1). Both GPs 13,613 invitations issued

No response = 11,616

Responses = 1997

Screened out = 335

April 2014

and respiratory specialists most commonly used a chest X-ray to diagnose COPD (76% and 78%, respectively), followed by spirometry (73% and 75%, respectively) and a lung function test (54% and 75%, respectively) (more than one answer was allowed; Table 1). Clinicians’ selfrecalled assessment of patient smoking status at diagnosis was similar between the two groups (Table 2). GPs and respiratory specialists reported cardiac/coronary artery disease/angina (77% and 83%, respectively) and hypertension (72% and 73%, respectively) as the most common comorbidities (Figure 2). Depression, diabetes, cancer and osteoporosis were more commonly reported as comorbidities by specialists than by GPs. Male impotence and arthritis were more commonly reported as comorbidities by GPs than by specialists.

Treatment and management of COPD A third of GPs and respiratory specialists reported that the primary aim of COPD management was to help or improve patient quality of life (Figure 3). Twenty percent of GPs and 28% of specialists considered symptom control their Table 1. Diagnosis of COPD and assessment of disease severity.

Responder type, n (%) No. patients seen per month by clinician, mean (SE) COPD severity on diagnosis, mean proportion of patients (SE) Mild Moderate Severe Very severe Tools used for diagnosis, n (%) Chest X-ray Spirometry test Lung function test Arterial blood gas Other

GP

Respiratory Specialist

893 (64) 47 (2.3)

507 (36) 105 (4.7)

42 (0.7) 35 (0.6) 15 (0.3) 6 (0.2)

19 (0.7) 36 (0.6) 29 (0.6) 16 (0.5)

676 (76) 652 (73) 486 (54) 167 (19) 46 (5)

393 (78) 381 (75) 382 (75) 268 (53) 72 (14)

SE ¼ standard error.

Table 2. Clinician assessment of patient smoking status at diagnosis. Eligible = 1662

Incomplete responses = 262

Completed responses = 1400

Figure 1. Clinician survey responses.

! 2014 Informa UK Ltd www.cmrojournal.com

Responder type, n (%) Smoking status, mean proportion of patients (SE) Heavy smoker (20 cigarettes/day) Moderate (10–20 cigarettes/day) Light (510 cigarettes/day) Non-smoker but used to smoke Non-smoker, never smoked Not known

GP

Respiratory Specialist

893 (64)

507 (36)

41 (0.7) 26 (0.4) 12 (0.3) 14 (0.4) 5 (0.2) 2 (0.3)

37 (0.9) 24 (0.6) 11 (0.3) 21 (0.7) 5 (0.3) 1 (0.2)

SE ¼ standard error.

Global Hidden Depths of COPD survey: clinician results Barnes et al.

669

Current Medical Research & Opinion Volume 30, Number 4

April 2014

77% 83% 72% 73%

Cardiac/coronary artery disease/angina Hypertension 54% 60% 48% 54% 48% 44% 38% 50% 37% 52% 35% 43%

Anxiety Sleep apnoea Arterial disease (non-cardiac) Diabetes Depression

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Leg muscle weakness 27%

Cancer

48% 28%

Osteoporosis

39% 32% 32% 30% 30% 31%

Hyperlipidaemia/high cholesterol Heartburn Male impotence Sinus disease Arthritis

7% 7% 9% 3% 3%

Cataracts Glaucoma

15% 17% 15% 16%

0

20

GPs Respiratory Specialists

40

60

80

100

Figure 2. Comorbidities in patients with COPD.

first priority. Preventing exacerbations was considered to be a first priority by 14% of GPs and 19% of respiratory specialists, and a second priority by 23% of GPs and 27% of respiratory specialists. Smoking cessation was routinely recommended by almost all clinicians (95% and 98% of GPs and respiratory specialists, respectively) (Table 3). Clinicians routinely prescribed inhaled corticosteroids in combination with short- and long-acting beta agonists (SABAs and LABAs, respectively), oral steroids or antibiotics. GPs reported less use of anticholinergic agents (66%), oxygen (46%) and pulmonary rehabilitation (48%) than respiratory specialists (87%, 72% and 76%, respectively). Both GPs and respiratory specialists reported low use of inhaled corticosteroids alone (27% and 13%, respectively). The majority of clinicians considered the currently available therapies to be effective for the control of mild COPD symptoms (83% of GPs, 77% of respiratory specialists), but only half of clinicians thought that current therapies used to control severe COPD symptoms were effective (53% of GPs and 55% of specialists) (Table 4). Over two thirds of clinicians (74% of GPs and 67% of respiratory specialists) considered current therapies to be effective in preventing COPD exacerbations. 670

Global Hidden Depths of COPD survey: clinician results Barnes et al.

Exacerbations Fifty-five percent of GPs and 57% of respiratory specialists reported that very severe COPD patients had experienced an exacerbation over the previous 12 months (Table 5). The majority of clinicians thought that patients took a few weeks or more to recover from exacerbations, and only 16% of GPs and 27% of respiratory specialists thought that exacerbation recovery took months or more (Table 5). Six percent of GPs and 8% of respiratory specialists thought that their patients never recovered. Twenty-two percent of GPs and 28% of respiratory specialists reported that exacerbations in patients with moderate COPD resulted in hospitalization. These percentages were higher for severe COPD patients (45% of GPs and 52% of respiratory specialists) (Table 5). When patients experienced an exacerbation, their most common reaction, as reported by clinicians, was to ‘wait and see’ (58% of GPs and 67% of respiratory specialists) (Table 5). When patients do respond to an exacerbation, they typically contact/visit their GP (68% of GPs and 56% of respiratory specialists) (Figure 4). A larger proportion of specialists than GPs thought a COPD patient would go to

www.cmrojournal.com ! 2014 Informa UK Ltd

Current Medical Research & Opinion Volume 30, Number 4

32%

GPs: Help/improve quality of life

20%

GPs: Control symptoms

14%

14%

GPs: Preventing exacerbations

16%

23%

19%

Specialists: Preventing exacerbations

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

27%

28%

Specialists: Control symptoms

27%

15%

GPs: Slowing disease progression

22%

12%

Specialists: Slowing disease progression

19%

17%

GPs: Improving lung function

Specialists: Improving lung function

26%

33%

Specialists: Help/improve quality of life

7%

GPs: Prevent complications

2%

Specialists: Prevent complications

4%

6%

7%

April 2014

9%

First priority

Second priority

Figure 3. COPD management priorities. Table 3. Clinician recommendations of therapies and management options for COPD.

Responder type, n (%) Therapies and treatments routinely recommended, n (%) Quitting smoking Cut down on smoking Inhaled corticosteroids in combination Long-acting beta agonist Anticholinergics Antibiotics Short-acting beta agonist Inhaled corticosteroids alone Oral/parenteral steroids Oxygen Pulmonary rehabilitation Physical exercise Breathing exercise Eating healthier/better diet

GP

Respiratory Specialist

893 (64)

507 (36)

852 (95) 315 (35) 767 (86) 666 (75) 593 (66) 494 (55) 475 (53) 239 (27) 393 (44) 410 (46) 433 (48) 564 (63) 567 (63) 451 (51)

496 (98) 107 (21) 447 (88) 412 (81) 440 (87) 283 (56) 298 (59) 66 (13) 197 (39) 363 (72) 386 (76) 345 (68) 334 (66) 254 (50)

the hospital emergency department in response to an exacerbation (52% and 39%, respectively) (Figure 4). Both clinician groups felt that hospitalization for a COPD exacerbation would have a greater long-term ! 2014 Informa UK Ltd www.cmrojournal.com

impact on patient conditions than hospitalization for asthma or pneumonia, though they felt that hospitalization for myocardial infarction or stroke would have an even greater impact (Table 4). For example, 41% of GPs and 56% of respiratory specialists felt that there could be long-term consequences from hospitalizations due to COPD exacerbations, while 76% of GPs and 71% of respiratory specialists felt that hospital admission for myocardial infarction would have a major impact on patients’ long-term health (Table 4).

Patient management and impact of disease About half of GPs (58%) and respiratory specialists (50%) felt that patients ‘had brought their COPD upon themselves’ (Table 4). A higher percentage of GPs (62%) than respiratory specialists (46%) thought that patients did not do enough to manage their condition and did not listen to advice given (Table 4). However, a large proportion of the clinicians surveyed (76% of GPs and 84% of respiratory specialists) felt that there was a lot of advice that could be given to patients. Around two thirds of GPs and respiratory specialists Global Hidden Depths of COPD survey: clinician results Barnes et al.

671

Current Medical Research & Opinion Volume 30, Number 4

April 2014

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Table 4. Clinician views on COPD management and impact of disease.

Responder type, n (%) Clinician view on effectiveness of current therapies in mild COPD, n (%) To control symptoms To control disease progression Clinician view on effectiveness of current therapies in severe COPD, n (%) To control symptoms To control disease progression Clinician view on how effective current therapies are for preventing exacerbations, n (%) Clinician view on COPD patients and management (net agree), n (%) Patients have brought it upon themselves Patients generally don’t do enough to alleviate their condition Patients tend to listen to the advice I give them about the management of COPD There is a lot of advice I can give to patients in relation to COPD There is little that can be done for a patient with COPD Clinician view on long-term impact (major or very major) of an acute hospital admission on patient conditions, n (%) Asthma attack COPD exacerbation Myocardial infarction Pneumonia Stroke Table 5. Clinician views on the impact of exacerbations on COPD patients. GP

Respiratory Specialist

Responder type, n (%) 893 (64) 507 (36) Clinician estimate of proportion of patients with an exacerbation in prior 12 months, % Very severe 55 57 Severe 46 45 Moderate 29 26 Mild 17 11 Time to return to normal post-exacerbation (typical moderate-to-severe patient), n (%) Never 57 (6) 40 (8) Longer 36 (4) 19 (4) Within a few months 103 (12) 118 (23) Within a month 178 (20) 102 (20) Within a few weeks 424 (47) 208 (41) Within a week 76 (9) 19 (4) Within a few days 19 (2) 1 (0) Typical patient reaction to the onset of an exacerbation, n (%) Do nothing 6 (1) 7 (1) Wait and see 518 (58) 339 (67) Take action right away 369 (41) 161 (32) Proportion of exacerbations resulting in hospitalization Severe COPD patients 45% Moderate COPD patients 22%

52% 28%

Fear of premature death from an exacerbation (typical moderate-tosevere patient), n (%) Very scared 240 (27) 137 (27) Quite scared 497 (56) 295 (58) Not particularly scared 141 (16) 61 (12) Not at all scared 5 (1) 6 (1)

(63% and 68%, respectively) routinely recommended that their COPD patients take more exercise and perform breathing exercises to help manage symptoms. Only 16% of GPs and 10% of respiratory specialists 672

Global Hidden Depths of COPD survey: clinician results Barnes et al.

GP

Respiratory Specialist

893 (64)

507 (36)

737 (83) 628 (70)

391 (77) 317 (63)

473 (53) 308 (34) 661 (74)

281 (55) 188 (37) 342 (67)

518 (58) 556 (62) 536 (60) 677 (76) 140 (16)

253 (50) 232 (46) 382 (75) 427 (84) 50 (10)

124 (14) 369 (41) 680 (76) 238 (27) 755 (85)

64 (13) 285 (56) 361 (71) 84 (17) 439 (87)

felt there was little that could be done for a patient with COPD (Table 4). Both GPs and specialists recognized the impact of COPD on patient activities and quality of life, and agreed that this impact increased during an exacerbation (Figure 5). Two thirds of clinicians felt that patients’ everyday activities, such as walking or sleeping, were significantly affected by exacerbations (Figure 5). Clinicians were in agreement that patients were concerned for their long-term health; 83% of GPs and 85% of respiratory specialists thought that patients with moderate-to-severe COPD were fearful of premature death from an exacerbation (Table 5).

Discussion The global Hidden Depths of COPD survey reported clinicians’ perceptions and attitudes towards COPD and its management. By comparison with previous studies8,10,12, we found a higher level of awareness of COPD diagnosis and management among respondents. Clinicians were less likely to blame patients for their poor health: around half of GPs and respiratory specialists felt that patients had brought their COPD upon themselves, compared with 88% of clinicians who took part in the RNNA survey8. Clinicians were aware of common COPD comorbidities, which were generally similar to those reported in clinical studies, such as the Estudio de Comorbilidad en pacientes EPOC hospitalizados en Servicios de Medicina Interna (ECCO)13, the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study14 and The Health www.cmrojournal.com ! 2014 Informa UK Ltd

Current Medical Research & Opinion Volume 30, Number 4

April 2014

88% NET: Contact healthcare professional

92% 68%

Contact/go to see their GP

56% 39%

Go to the emergency department at hospital

52% 12%

Contact/go to see a respiratory specialist

44%

51%

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Take a higher dose of a medication they would normally take

49% 25% 25%

Cut down on smoking

19% Take a medication they wouldn’t normally take

17% GPs 16% 14%

Rest/stay in bed

Respiratory Specialists

10% 9%

Stop smoking

7% 6%

Contact relatives/friends 0

20

40

60

50

100

Figure 4. Patient response to an exacerbation.

Improvement Network (THIN) database15. However, over 70% of clinicians in the Hidden Depths of COPD survey reported cardiac disease or hypertension in COPD patients, whereas heart trouble was reported in 26% of COPD patients in the ECLIPSE study14 and the hypertension rate was 55% in the ECCO study13. Comorbidities such as cardiovascular disease, diabetes, osteoporosis, malignancy and depression, which become more prevalent as COPD progresses16, were reported more commonly by respiratory specialists than by GPs. As well as reflecting the higher proportion of patients with severe COPD referred for specialist care, this difference may indicate an increased awareness and focus on COPD-related comorbidities among respiratory specialists. The survey showed a greater level of agreement between clinical practice and COPD treatment guidelines than reported by previous studies, which revealed confusion about treatment choices, over-use of inhaled corticosteroids9,12, over-use of oral steroids and under-use of pulmonary rehabilitation8,11,12,17,18. For example, a Swiss study investigating the impact of GPs’ adherence to guidelines on patient outcomes found that almost half of all patients surveyed received an inappropriate treatment for ! 2014 Informa UK Ltd www.cmrojournal.com

the stage of their COPD (47% at baseline and 44% at 1 year follow-up10). A study assessing adherence to the GOLD recommendations among German pulmonary specialists found that long-acting bronchodilators were the most commonly prescribed treatment, with two thirds of respondents prescribing LABA in combination with an anticholinergic in more than half of their severe COPD patients12. These observations are in line with a US patient survey reporting that only 55% of patients with COPD were treated according to guideline recommendations19. In the current survey, we assessed clinicians’ use of the treatments recommended by GOLD, with the exception of the phosphodiesterase 4 inhibitor roflumilast, which was not widely available when the survey was carried out. The results showed a strong preference for inhaled corticosteroids in combination with other treatments, rather than as sole therapy, in line with global guidelines7. LABAs were favoured over SABAs, again in line with global guidelines7. Awareness of the value of pulmonary rehabilitation was higher than in other studies12,17,18, especially among respiratory specialists, though there was scope for better access and greater utilization of this Global Hidden Depths of COPD survey: clinician results Barnes et al.

673

Current Medical Research & Opinion Volume 30, Number 4

April 2014

GPs - Committing to future events: Impact of an exacerbation 2%

25%

50% 47%

GPs - Committing to future events: Impact of COPD 6% Specialists - Committing to future events: Impact of an exacerbation 1% 17% Specialists - Committing to future events: Impact of COPD 3%

GPs - Walking: Impact of an exacerbation 1%

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

GPs - Speech: Impact of an exacerbation

29%

40%

48%

40% 62%

23%

GPs - Sleeping: Impact of COPD 4%

41% 61%

46%

Specialists - Sleeping: Impact of COPD 5%

Significantly affected

1% 2% 6% 1%

66% 40%

Cannot do at all

4%1%

7% 1% 47%

52%

1%

10% 1%1%

67%

25%

3% 15%

47%

GPs - Sleeping: Impact of an exacerbation 2%

8% 52%

22%

Specialists - Sleeping: Impact of an exacerbation 1%

4%

67%

9%

27%

7%

66%

47%

Specialists - Speech: Impact of COPD

5% 9%

57%

Specialists - Speech: Impact of an exacerbation 7%

Somewhat affected

47%

24%

GPs - Speech: Impact of COPD

Not at all affected

33%

34%

Specialists - Walking: Impact of COPD 1%

5% 5%4%

38% 44%

GPs - Walking: Impact of COPD 3% Specialists - Walking: Impact of an exacerbation

18%

1% 2%

Don't know/Not available

Figure 5. Impact of COPD and exacerbations on a typical moderate-to-severe patient.

treatment approach. There were regional differences in the utilization of pulmonary rehabilitation, with the lowest rates of utilization reported by clinicians from South Korea (9%) and Turkey (37%), and the largest by clinicians from the UK (86%), Brazil (77%) and France (72%). As well as reflecting regional variability in clinical practice and adherence to guidelines, these differences may be due in part to the accessibility of the local rehabilitation service. The main priorities for treatment expressed in the current survey – improvement in quality of life, controlling symptoms and preventing exacerbations – were similar to those reported by other studies11,12. However, GPs in the current survey prioritized symptom control over exacerbation prevention, suggesting that they were less aware of the long-term impact of exacerbations on their patients. The differences between GPs and respiratory specialists in terms of priorities, prescription patterns and views on 674

Global Hidden Depths of COPD survey: clinician results Barnes et al.

exacerbations may be partly due to the lower proportion of severe COPD patients that GPs reported seeing in their practice, as severe COPD patients were typically referred to respiratory specialists. The fact that clinicians consider current therapies to be more effective for mild COPD than for severe disease is not surprising. However, their apparent satisfaction with current therapies for preventing exacerbations (74% of GPs and 67% of respiratory physicians) may be harder to understand when set against their estimate of exacerbation frequency, and the even higher burden of exacerbations reported in the global Hidden Depths of COPD patient survey20. This type of discrepancy is frequent in surveys of patients with COPD, who report that their disease is well controlled despite a high rate of exacerbations, and may reflect a low level of expectation from treatment8,20. Clinicians estimated that about 30% of their mild or moderate COPD patients and 55–57% of their most severe www.cmrojournal.com ! 2014 Informa UK Ltd

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Current Medical Research & Opinion Volume 30, Number 4

COPD patients had experienced an exacerbation during the previous 12 months in the Hidden Depths of COPD survey. These ‘real-world’ levels of exacerbation are higher than those reported by clinical trials. For example, in the ECLIPSE study, 22% of patients with GOLD stage 2 disease, 33% with GOLD stage 3, and 47% with GOLD stage 4 had frequent exacerbations (two or more in the first year of follow-up)2. Patients’ estimates of exacerbation frequency are even higher. In the global Hidden Depths of COPD patient survey, 62% of COPD patients with MRC 1 or 2 breathlessness and 80% of those with MRC 3, 4 or 5 breathlessness had had an exacerbation in the previous year20. These rates are comparable with those reported in the Perception of Exacerbations of Chronic Obstructive Pulmonary Disease (PERCEIVE) study, in which 89% of patients reported at least one episode of ‘flare-up’ of symptoms during the preceding year (although no official definition of exacerbations was given)21. These data highlight the difference between the experience of exacerbations in the real world and in a research setting, as well as the difference between physicians’ and patients’ assessments of exacerbations. Based on the current (clinician) survey, as well as the corresponding patient survey, a patient’s view of exacerbations is that they occur frequently, and patients do not necessarily take action or report them to their physicians. A high proportion of clinicians in the global Hidden Depths of COPD survey believed that patients adopt a ‘wait and see’ approach to their exacerbations. For patients who seek care following an exacerbation, clinicians estimated that hospitalization is required in about a quarter for milder cases, and around half of those with severe COPD. The PERCEIVE survey also highlighted the considerable healthcare demands of exacerbations, with 89% of patients requiring a physician consultation for exacerbations, and 21% needing hospital admission21. Exacerbations resulted in a mean of 5.1 visits to the doctor per patient per year. Management of exacerbations, particularly of those requiring hospitalization, accounts for between 35% and 45% of the mean annual direct medical costs for patients with COPD21–23. However, clinicians in our survey appeared to underestimate the impact of exacerbation-related hospitalizations on patients’ long-term health, compared with hospitalizations for other serious illnesses. This was particularly true for primary care physicians, a majority of whom did not feel that hospitalizations due to COPD exacerbations had long-term consequences. The reality is rather different. There is evidence showing that mortality at 12 months following hospitalization for a COPD exacerbation is approximately double that following admission for acute myocardial infarction (20–40% versus 10–20%)24. In addition, up to 50% of ! 2014 Informa UK Ltd www.cmrojournal.com

April 2014

those surviving their first COPD-related hospitalization have been reported to require readmission within 6 months25. Half of GPs and respiratory specialists in our survey predicted that a patient with moderate-to-severe COPD would take a few weeks to recover following an exacerbation, indicating they were aware of the prolonged time to recovery following exacerbations in some COPD patients. However, evidence from other studies suggests that recovery is incomplete for a significant proportion of COPD exacerbations and takes longer than 35 days in approximately a quarter of patients26,27. Both GPs and specialists recognized the impact of exacerbations on patients’ quality of life and the concerns patients had for their future. The clinicians’ awareness of patients’ fear of dying prematurely as a result of COPD, or from an exacerbation, reflects the findings of the Hidden Depths of COPD patient survey20. This may be due to an increased focus on palliative and end-of-life care, which is now recognized as an important component of the treatment of COPD patients, particularly those with severe disease28. While guidelines recommend that clinicians initiate discussions about palliative and end-of-life care7,29, it has recently been suggested that, rather than identifying a specific timepoint for transition to palliative care, physicians should asses their patients’ need for supportive and palliative care at key disease milestones, in particular after hospital admission for an acute exacerbation30. Our study has a number of limitations. As is the case with self-recall surveys, the answers represent participants’ personal perceptions, and the extent to which they can be generalized is limited. Of the 14 countries included in the survey, 9 were from Europe; the USA was not included, which may limit direct comparisons with US cohort studies such as the RNNA survey8. In addition, as this was not a database trial, it did not allow for a systematic investigation of regional differences in treatment patterns (e.g. academic versus community setting, primary versus specialist care). Although beyond the scope of our study, this is an interesting topic for further research, which may help identify areas for improvement in the local and global management of COPD. The timing of the Hidden Depths of COPD study may also have had an impact: the updated GOLD position paper7, which places a high importance on reducing exacerbations and risk in COPD, was published in 2011, after data collection for our survey had been completed. However, the impact of the updated recommendations on real-life clinical practice would have been limited, as the overall level of adherence to guidelines among clinicians is unlikely to have changed substantially over such a short period of time. Finally, as a result of the pre-set cut-off of 100 responses per country, the overall response rate of this survey was 10.3%. Despite this relatively low Global Hidden Depths of COPD survey: clinician results Barnes et al.

675

Current Medical Research & Opinion Volume 30, Number 4

April 2014

rate, the sample size and geographical spread were comparable with, or larger than, those of similar surveys8,10,12,18. Awareness of the study limitations helps to place our results in perspective; however, such limitations are inherent to this type of survey and are not likely to introduce any severe bias or diminish the validity of the conclusions.

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Conclusions Our survey suggests that adherence to COPD treatment guidelines by respiratory specialists and GPs is improving and that clinicians feel positive about their potential to help COPD patients. Both respiratory specialists and GPs prioritized patient quality of life as an aim of COPD management, but GPs were less likely than specialists to prioritize the prevention of exacerbations, which may need to be addressed further in light of the renewed focus on exacerbations in the updated GOLD position paper7. While recognizing the significant burden of COPD and exacerbations, clinicians appeared to underestimate both the frequency of exacerbations (when compared with real-world patient reports) and their long-term impact (by comparison with other serious diseases). Given that exacerbations act as a marker for future disease progression7, it is important that clinicians accurately assess the frequency of exacerbations in their COPD patients.

Transparency Declaration of funding The Hidden Depths of COPD survey was sponsored by an educational grant from Takeda Pharmaceuticals International GmbH. A steering committee of COPD experts including primary and secondary care physicians designed the survey in conjunction with six representatives of the sponsor. This included the original study design and concept, the plan for the analyses, full access to the data and responsibility for decisions with regard to publication. Authors’ contributions: All authors have made substantial intellectual contributions to the conception and design of the survey and the analysis and interpretation of the data. They have all been involved in drafting the manuscript or revising it critically for important intellectual content. Declaration of financial/other relationships N.B. has received honoraria for giving talks for the following companies: GlaxoSmithKline, AstraZeneca, Chiesi, Boehringer Ingelheim, Novartis, Teva and Takeda. P.M.A.C. has served on Scientific Advisory Boards of AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis and Takeda and has received research funding from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline and Takeda. A.K. has served on advisory boards for Boehringer Ingelheim, AstraZeneca, 676

Global Hidden Depths of COPD survey: clinician results Barnes et al.

Takeda, Graceway, Novartis, Pfizer and Purdue. He has been given honoraria for giving talks for the above companies and Merck Frosst and Sanofi. K.F.R. has received research funding from Novartis, AstraZeneca, MSD and Takeda. He has also provided consultation services for AstraZeneca, Chiesi, Novartis, MSD and GlaxoSmithKline. CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships. Acknowledgments The authors thank ICM Research who managed the data collection. They acknowledge Jenny Bryan, freelance medical writer, and Helen Clark from FTI Consulting, who provided medical writing services on behalf of Takeda Pharmaceuticals International GmbH. They also thank Ileana Stoica (senior medical writer) at Synergy Vision, UK, for the provision of medical writing, which was funded by Takeda Pharmaceuticals International GmbH. Previous presentation: Abstract 56, 2nd IPCRG Scientific Meeting, 26–27 May 2011, Amsterdam; and CHEST 2011, 22–26 October, Honolulu, Hawaii.

References 1. Soler-Cataluna JJ, Martinez-Garcia MA´, Roman Sa´nchez P, et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 2005;60:925-31 2. Hurst JR, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med 2010;363:1128-38 3. National Clinical Guideline Centre – Acute and Chronic Conditions RCoP. NICE Chronic obstructive pulmonary disease (update): full guideline. 2010 4. American Thoracic Society/European Respiratory Society Task Force. Standards for the Diagnosis and Management of Patients with COPD. Version 1.2. 2004 5. O’Donnell DE, Hernandez P, Kaplan A, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2008 update – highlights for primary care. Can Respir J 2008;15(SupplA):1-8A 6. McKenzie DK, Frith PA, Burdon JGW, et al. The COPDX Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2003. Med J Aust 2003;178:S1-40 7. The Global Initiative for Chronic Obstructive Lung Disease (GOLD). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Revised 2011. Available at: http://www.goldcopd.org/guidelinesglobal-strategy-for-diagnosis-management.html [last accessed Nov 2013] 8. Barr RG, Celli BR, Martinez FJ, et al. Physician and patient perceptions in COPD: the COPD Resource Network Needs Assessment Survey. Am J Med 2005;118:1415-24 9. Decramer M, Bartsch P, Pauwels R, et al. Management of COPD according to guidelines. A national survey among Belgian physicians. Monaildi Arch Chest Dis 2003;59:62-80 10. Jochmann A, Scherr A, Jochmann DC, et al. Impact of adherence to the GOLD guidelines on symptom prevalence, lung function decline and exacerbation rate in the Swiss COPD cohort. Swiss Med Wkly 2012;142:w13567 (1-7) 11. Glaab T, Banik N, Rutschmann OT, et al. National survey of guideline-compliant COPD management among pneumologists and primary care physicians. COPD 2006;3:141-8 12. Glaab T, Vogelmeier C, Hellmann A, et al. Guideline-based survey of outpatient COPD management by pulmonary specialists in Germany. Int J COPD 2012;7:101-8

www.cmrojournal.com ! 2014 Informa UK Ltd

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Current Medical Research & Opinion Volume 30, Number 4

13. Almagro P, Lopez Garcia F, Montero L, et al. Comorbidity and gender-related differences in patients hospitalized for COPD. The ECCO study. Respir Med 2010;104:253-9 14. Agusti A, Calverley PM, Celli B, et al. Characterisation of COPD heterogeneity in the ECLIPSE cohort. Respir Res 2010;11:122 15. Feary JR, Rodrigues LC, Smith CJ, et al. Prevalence of major comorbidities in subjects with COPD and incidence of myocardial infarction and stroke: a comprehensive analysis using data from primary care. Thorax 2010;65:956-62 16. van der Molen T. Co-morbidities of COPD in primary care: frequency, relation to COPD, and treatment consequences. Prim Care Respir J 2010;19:326-34 17. Rutschmann OT, Janssens JP, Vermeulen B, et al. Knowledge of guidelines for the management of COPD: a survey of primary care physicians. Respir Med 2004;98:932-7 18. Steurer-Stey C, Dallalana K, Jungi M, et al. Management of chronic obstructive pulmonary disease in Swiss primary care: room for improvement. Qual Prim Care 2012;20:365-73 19. Mularski RA, Asch SM, Shrank WH, et al. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest 2006;130:1844-50 20. Barnes N, Calverley PM, Kaplan A, et al. Chronic obstructive pulmonary disease and exacerbations: patient insights from the global Hidden Depths of COPD survey. BMC Pulm Med 2013;13:54 21. Miravitlles M, Anzueto A, Legnani D, et al. Patient’s perception of exacerbations of COPD – the PERCEIVE study. Respir Med 2007;101:453-60

April 2014

22. Andersson F, Borg S, Jansson S-A, et al. The costs of exacerbations in chronic obstructive pulmonary disease (COPD). Respir Med 2002; 96:700-8 23. Miravitlles M, Ferrer M, Pont A, et al. Effect of exacerbations on quality of life in patients with chronic obstructive pulmonary disease: a 2 year follow up study. Thorax 2004;59:387-95 24. Halpin D. Mortality in COPD: inevitable or preventable? Insights from the cardiovascular arena. COPD 2008;5:187-200 25. Connors AFJ, Dawson NV, Thomas C, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med 1996;154:959-67 26. Seemungal TA, Donaldson GC, Bhowmik A, et al. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000;161:1608-13 27. Perera WR, Hurst JR, Wilkinson TM, et al. Inflammatory changes, recovery and recurrence at COPD exacerbation. Eur Respir J 2007;29:527-34 28. Curtis JR. Palliative and end-of-life care for patients with severe COPD. Eur Respir J 2008;32:796-803 29. Celli BR, Macnee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932-46 30. Pinnock H, Kendall M, Murray SA, et al. Living and dying with severe COPD: multi-perspective longitudinal qualitative study. BMJ 2011;342:d142

Appendix Screening and profiling S1: What is your job title? General practitioner (GP) Primary care physician (PCP) Family care physician (FCP) Respiratory specialist Respiratory nurse Pneumologist Pulmonologist Respirologist Other

1 2 3 4 5 6 7 8 9

CLOSE

S2: Which, if any, of the following respiratory/breathing problems do you currently see patients with? Chronic bronchitis Emphysema COPD Asthma Pneumonia Lung cancer Sarcoidosis Other (specify)

1 2 3 4 5 6 7 8

MUST CODE AT LEAST ONE OF THESE THREE TO CONTINUE

S3: For the purposes of this survey we will be referring to all cases of chronic bronchitis and emphysema as coming under the heading of COPD. With this in mind, could you tell us how many patients you see in a typical month (allowing for seasonal variations) who are suffering from COPD? WRITE IN NUMBER, MUST SEE MINIMUM OF 10 (GPS) 20 (RESPIRATORY SPECIALISTS) PATIENTS IN A MONTH TO CONTINUE

! 2014 Informa UK Ltd www.cmrojournal.com

Global Hidden Depths of COPD survey: clinician results Barnes et al.

677

Current Medical Research & Opinion Volume 30, Number 4

April 2014

S4: Which of the following tests do you normally use when diagnosing COPD? Spirometry test Lung function test Chest X-ray or CT scan Arterial blood gas test Other (specify)

1 2 3 4 5

Diagnosis and profiling

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

P1a: When you initially diagnose patients with COPD, what proportion fall into each of the following categories? Write in % Mild (spirometric FEV1 reading of 80% or above) Moderate (spirometric FEV1 reading of 50–79%) Severe (spirometric FEV1 reading of 30–49%) Very severe (spirometric FEV1 reading of less than 30%) Don’t know/can’t remember

P1b: When you initially diagnose patients with COPD, what proportion fall into each of the following categories? Write in % Not troubled by breathlessness except on strenuous exercise Short of breath when hurrying or walking up a slight hill Walks slower than contemporaries on level ground because of breathlessness, or have to stop for breath when walking at pace Stop for breath after walking about 100 m or after a few minutes on level ground Too breathless to leave the house, or breathless when dressing or undressing

P2: When you initially diagnose patients with COPD, what proportion fall into each of the following categories Write in % Heavy smoker (þ20 cigarettes per day) Moderate smoker (10–20 cigarettes per day) Light smoker (less than 10 per day) Non-smoker, but used to smoke Non-smoker, never smoked Don’t know/can’t remember

P3: Which comorbidities do you see most commonly in COPD patients? MULTICODE Anxiety Arthritis Arterial disease (non-cardiac) Cancer Cardiac/coronary artery disease/angina Cataracts Diabetes Depression Glaucoma Osteoporosis Heartburn Hyperlipidaemia/high cholesterol Hypertension Leg muscle weakness Male impotence Sinus disease Sleep apnoea

678

Global Hidden Depths of COPD survey: clinician results Barnes et al.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

www.cmrojournal.com ! 2014 Informa UK Ltd

Current Medical Research & Opinion Volume 30, Number 4

April 2014

P4: Typically how do most of your moderate-to-severe COPD patients end up being diagnosed with the condition? It is discovered as part of a routine check-up They sought help/advice from their doctor They have an episode/attack that requires medical attention without being admitted to hospital They have an episode/attack that requires them to be admitted to hospital Other (specify)

1 2 3 4 5

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

P5: From the following list can you indicate to what extent you feel your typical moderate-to-severe COPD patients are directly affected or restricted in their ability to undertake or participate in? Not at all affected

Somewhat affected

Significantly affected

Cannot do at all

Don’t know

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Walking Climbing stairs Playing with children/grandchildren Sex life Their relationship with their partner Sleeping Ability to socialize freely Speech Sport and exercise Work Ability to go on holiday/travel Ability to commit to future events Getting dressed Housework Gardening

P6: How serious a condition do you think COPD is on the following measures? (i) Quality of life for patients (ii) Impact on society (iii) Cost of healthcare provision

Not at all serious condition Not particularly serious condition A fairly serious condition A very serious condition Don’t know

P6i

P6ii

P6iii

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

P7: How worried do you think your typical moderate-to-severe COPD patients are about their long-term health? Extremely worried Somewhat worried Neither worried nor unworried Not particularly worried Not at all worried Don’t know/can’t remember

1 2 3 4 5 6

P8: To what extent, if at all, do you think your typical moderate-to-severe COPD patients are scared that their COPD might end their life prematurely? Not at all scared Not particularly scared Quite scared Very scared Don’t know

! 2014 Informa UK Ltd www.cmrojournal.com

1 2 3 4 5

Global Hidden Depths of COPD survey: clinician results Barnes et al.

679

Current Medical Research & Opinion Volume 30, Number 4

April 2014

Management of COPD

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

M1: Which, if any, of the following therapies, methods or treatments do you routinely recommend to help patients manage or control their COPD? Prescription medication – long-acting beta agonist Prescription medication – short-acting beta agonist Prescription medication – anticholinergics Prescription medication – inhaled corticosteroids alone Prescription medication – inhaled corticosteroids in combination Prescription medication – oral/parenteral steroids Prescription medication – antibiotics Other prescription medication Oxygen Quitting smoking Cutting down on smoking Eating healthier/better diet Breathing exercise Physical exercise Natural remedies and/or alternative medicine Pulmonary rehabilitation Other (please specify) Nothing

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

ASK THOSE WHO PRESCRIBE MEDICATION AT M1 M2a: What proportion of your COPD patients do you believe do not take their prescription medication for COPD as prescribed? WRITE IN % ASK THOSE WHO SAY MORE THAN 0% AT M2a M2b: Typically how do you think COPD patients are taking their medication outside of the recommended prescription? MULTICODE Use less frequently than they should Use more frequently than they should Take less than the recommended amount Take more than the recommended amount None of the above

1 2 3 4 5

ASK THOSE SAYING LESS FREQUENTLY/LESS THAN THE RECOMMENDED AMOUNT M2c: What do you think are the main reasons COPD patients are using their prescription medication less frequently/less than the recommended amount than they should? MULTICODE They forget to take it They are worried about taking it because of the fear of side effects They do not like taking it because of their experience of side effects They do not like taking it because of the taste or administration procedure They don’t like using prescription medication unless it’s really necessary They only take what they feel they need at the time They do not think the medication is helping Other reason (specify)

1 2 3 4 5 6 7 8

ASK THOSE SAYING MORE FREQUENTLY/MORE THAN THE RECOMMENDED AMOUNT M2d: What do you think are the main reasons COPD patients are using their prescription medication more frequently/ more than the recommended amount than they should? MULTICODE They use it when the symptoms get worse They use it to help them breathe more freely They don’t worry about possible side effects They have been advised to They need to in order to get any benefit from the medication

680

Global Hidden Depths of COPD survey: clinician results Barnes et al.

1 2 3 4 5

www.cmrojournal.com ! 2014 Informa UK Ltd

Current Medical Research & Opinion Volume 30, Number 4

They just take what they feel they need at the time Other reason (specify)

April 2014

6 7

M3a: How effective do you think current management routines are in controlling the symptoms of COPD?

In a mild case In a moderate case In a severe case In a very severe case

Not at all effective

Not particularly effective

Neither effective nor ineffective

Quite effective

Very effective

1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

M3b: And how effective do you think current management routines are in controlling the disease progression of COPD?

In a mild case In a moderate case In a severe case In a very severe case

Not at all effective

Not particularly effective

Neither effective nor ineffective

Quite effective

Very effective

1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

M4: Typically how many times in a 12-month period do you see your moderate-to-severe COPD patients regarding their COPD? WRITE IN M5: Typically how open do you think your COPD patients are with you regarding the severity of their condition? Completely open, they tell you everything Mostly open, they tell you most things They tell you some things but hide or downplay others Not particularly open, they don’t tend to tell you the truth Not at all open, they hide most things from you Don’t know

1 2 3 4 5 6

M6: What are your top two priorities when managing moderate-to-severe COPD patients?

Improving lung function Preventing exacerbations Slowing disease progression Control symptoms Help/improve quality of life Prevent complications Other (specify)

Priority 1

Priority 2

1 2 3 4 5 6 7

1 2 3 4 5 6 7

M7: For the following list of statements can you indicate to what extent you agree or disagree with each of the following about your COPD patients?

Patients suffering from COPD have brought it upon themselves Patients don’t generally do enough to alleviate the condition Patients tend to listen to or follow the advice I give them about managing their COPD There is lots of advice I can give to patients in relation to their COPD There is little that can be done for a patient with COPD

Disagree strongly

Disagree slightly

Neither agree nor disagree

Agree slightly

Agree strongly

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

M8: What do your moderate–severe COPD patients say to you is the worst thing about having COPD? OPEN-ENDED

! 2014 Informa UK Ltd www.cmrojournal.com

Global Hidden Depths of COPD survey: clinician results Barnes et al.

681

Current Medical Research & Opinion Volume 30, Number 4

April 2014

Exacerbations The sudden worsening of symptoms, sometimes referred to as an attack or crisis, is known as an exacerbation. This is as an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnoea, cough and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD. For the purposes of this survey, an exacerbation is defined as a worsening of at least one symptom lasting for at least 48 hours. E1: Roughly what proportion of each of your COPD patients have experienced an exacerbation in the last 12 months?

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Write in % Mild COPD patients Moderate COPD patients Severe COPD patients Very severe COPD patients Don’t know/can’t remember

E2: Approximately how long does it take a typical moderate-to-severe COPD patient to get back to the same level of physical activity and capability they had prior to the onset of an exacerbation? Within a few days Within a week Within a few weeks Within a month Within a few months Longer They never get back to the same level of physical activity and capability they had before

1 2 3 4 5 6 7

E3a: Typically what do your COPD patients do when they start to experience an exacerbation? Take action right away Wait and see how their symptoms develop before taking action Do nothing

1 2 3

E3b: What is the typical COPD patient reaction to an exacerbation? MULTICODE Contact/go to see their GP Contact/go to see a respiratory specialist Go to the emergency department at hospital Contact relatives/friends Rest/stay in bed Take a medication they wouldn’t normally take Take a higher dose of a medication they would normally take Cut down on smoking Stop smoking Other (specify) Do nothing

1 2 3 4 5 6 7 8 9 10 11

ASK IF CODE ANY ANSWER FROM 1–3 AT E3b E3c: What are the main reasons you think patients seek medical attention or advice if they are experiencing an exacerbation? If their symptoms haven’t improved sufficiently after a day If their symptoms haven’t improved sufficiently after two days If their symptoms haven’t improved sufficiently after three or more days Their husband/wife/partner pressures them Other family member/friends/associates pressure them If they are finding it difficult to breath Their medication isn’t working effectively They have run out or are running low on medication They have been advised to seek medical attention whenever they have an attack Other reason (specify)

682

Global Hidden Depths of COPD survey: clinician results Barnes et al.

1 2 3 4 5 6 7 8 9 10

www.cmrojournal.com ! 2014 Informa UK Ltd

Current Medical Research & Opinion Volume 30, Number 4

April 2014

E4: What proportion of exacerbations in moderate COPD patients result in the patient being admitted to hospital? WRITE IN % E5: What proportion of exacerbations in severe COPD patients result in the patient being admitted to hospital? WRITE IN % E6: For the following list of conditions can you indicate how much you think an acute hospital admission impacts the longterm (12 months) health of a typical adult patient?

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Asthma (attack) COPD (exacerbation) Myocardial infarction Pneumonia Stroke

No long-term impact

A slight long-term impact

A moderate long-term impact

A major long-term impact

A very major long-term impact

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

E7: How effective do you think currently available medications or treatments are for preventing exacerbations in COPD sufferers? Very effective Quite effective Neither effective nor ineffective Not particularly effective Not at all effective Don’t know

1 2 3 4 5 6

E8: From the following list can you indicate to what extent you feel your typical moderate-to-severe COPD patients are directly affected or restricted in their ability to undertake or participate in when they are experiencing an exacerbation?

Walking Climbing stairs Playing with children/grandchildren Sex life Their relationship with their partner Sleeping Ability to socialize freely Speech Sport and exercise Work Ability to go on holiday/travel Ability to plan future events Getting dressed Housework Gardening

Not at all affected

Somewhat affected

Significantly affected

Cannot do at all

Don’t know

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

E9: What do your moderate–severe COPD patients say to you is the worst thing about having an exacerbation? OPENENDED E10: How do you manage patients who have frequent exacerbations, i.e. a minimum of two per year? OPEN-ENDED E11: To what extent, if at all, do you think your typical moderate-to-severe COPD patients are scared that their COPD might end their life prematurely when experiencing an exacerbation? Not at all scared Not particularly scared Quite scared Very scared Don’t know

! 2014 Informa UK Ltd www.cmrojournal.com

1 2 3 4 5

Global Hidden Depths of COPD survey: clinician results Barnes et al.

683

Current Medical Research & Opinion Volume 30, Number 4

April 2014

Demographics D1: Are you? Male Female

1 2

D2: How old are you? ENTER NUMBER OF YEARS D3: Which country are you based in for the majority of your work as a healthcare professional?

Curr Med Res Opin Downloaded from informahealthcare.com by Tufts University on 10/16/14 For personal use only.

Australia Brazil Canada Denmark France Germany Italy Netherlands Poland South Korea Spain Turkey United Kingdom China

684

Global Hidden Depths of COPD survey: clinician results Barnes et al.

1 2 3 4 5 6 7 8 9 10 11 12 13 14

www.cmrojournal.com ! 2014 Informa UK Ltd

Chronic obstructive pulmonary disease and exacerbations: clinician insights from the global Hidden Depths of COPD survey.

This real-life, global study aimed to investigate current views of and clinical practice in the management of COPD and its exacerbations, among clinic...
794KB Sizes 0 Downloads 0 Views