Practice patterns in the management of chronic obstructive pulmonary disease in primary practice: the CAGE study.
BACKGROUND
The information on usual care for patients with chronic obstructive pulmonary disease (COPD) in primary care is limited in Canada.


OBJECTIVE
To evaluate primary care practice in patients with COPD in Quebec and Ontario compared with recommended care.


METHODS
The COPD Care Gap Evaluation (CAGE) was a prospective, cross-sectional study. Physicians' self-reported data of enrolled COPD patients were compared with the recommended care for the level of disease severity (using the Canadian Thoracic Society classification by symptoms) and stability, derived from Canadian Thoracic Society COPD guidelines. Pharmacological treatment, spirometric confirmation of diagnosis and nonpharmacological management, including smoking cessation counselling, influenza immunization and referral for pulmonary rehabilitation, were assessed.


RESULTS
Participating physicians (n=161; 44 in Quebec, 117 in Ontario) recruited 1090 patients (320 in Quebec, 770 in Ontario). The mean (+/- SD) age of the patients was 69.9+/-10.4 years; 60% were male and 40% were currently smoking. Pharmacological treatment that matched guideline recommendations was identified in 34% of patients. Discrepancies between reported and recommended treatment stemmed from nonprescription of long-acting bronchodilators (LABDs) for patients with moderate (27%) and severe (21%) COPD, nonprescription of two long-acting beta agonists (a beta(2)-agonist and an anticholinergic) for patients with severe COPD (51%), and prescription of inhaled corticosteroids (63%) and LABDs (47%) for patients with mild COPD for which the treatment is not recommended. Spirometric confirmation of diagnosis, as recommended by the guidelines, was reported in 56% of patients. For nonpharmacological management, smoking cessation counselling (95%) and influenza immunization (80%) were near optimal. Referral for pulmonary rehabilitation (9%) was not common. Differences between provinces were seen mainly in the prescription of short-acting bronchodilators (89% in Quebec, 76% in Ontario) and LABDs (60% in Quebec, 80% in Ontario).


CONCLUSIONS
Substantial gaps between recommended and current care exist in the management of COPD patients in primary care practice. Undertreatment of patients with severe COPD has potential clinical implications, including loss of autonomy and hospitalization.
Bourbeau
J
J
Montreal Chest Institute, McGill University Health Center, Montreal, Canada. jean.bourbeau@mcgill.ca
Sebaldt
R J
RJ
Day
A
A
Bouchard
J
J
Kaplan
A
A
Hernandez
P
P
Rouleau
M
M
Petrie
A
A
Foster
G
G
Thabane
L
L
Haddon
J
J
Scalera
A
A
D000368:Aged; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D002170:Canada; D003430:Cross-Sectional Studies; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis* / Q000628:therapy*; D012720:Severity of Illness Index; D013147:Spirometry; D016896:Treatment Outcome
D001993:Bronchodilator Agents; D005938:Glucocorticoids