title: Inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD.
abstract: BACKGROUND
  Prescriber disagreement is among the reasons for poor adherence to COPD treatment guidelines; it is yet not clear whether this leads to adverse outcomes. We tested whether undertreatment according to the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines led to increased exacerbations.
  
  
  METHODS
  Records of 878 patients with spirometrically confirmed COPD who were followed from 2005 to 2010 at one Veterans Administration (VA) Medical Center were analyzed. Analysis of variance was performed to assess differences in exacerbation rates between severity groups. Logistic regression analysis was performed to assess the relationship between noncompliance with guidelines and exacerbation rates.
  
  
  RESULTS
  About 19% were appropriately treated by guidelines; 14% overtreated, 44% under-treated, and in 23% treatment did not follow any guideline. Logistic regression revealed a strong inverse relationship between undertreatment and exacerbation rate when severity of obstruction was held constant. Exacerbations per year by GOLD stage were significantly different from each other: mild 0.15, moderate 0.27, severe 0.38, very severe 0.72, and substantially fewer than previously reported.
  
  
  CONCLUSIONS
  The guidelines were largely not followed. Undertreatment predominated but, contrary to expectations, was associated with fewer exacerbations. Thus, clinicians were likely advancing therapy primarily based upon exacerbation rates as was subsequently recommended in revised GOLD and other more recent guidelines. In retrospect, a substantial lack of prescriber adherence to treatment guidelines may have been a signal that they required re-evaluation. This is likely to be a general principle regarding therapeutic guidelines. The identification of fewer exacerbations in this cohort than has been generally reported probably reflects the comprehensive nature of the VA system, which is more likely to identify relatively asymptomatic (ie, nonexacerbating) COPD patients. Accordingly, these rates may better reflect those in the general population. In addition, the lower rates may reflect the more complete preventive care provided by the VA.
authors.affiliation: Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Medical Center, Northport; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY.
authors.forename: Hussein D
authors.initials: HD
authors.lastname: Foda
authors.affiliation: Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Medical Center, Northport; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY.
authors.forename: Anthony
authors.initials: A
authors.lastname: Brehm
authors.affiliation: MPH Program, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND.
authors.forename: Karen
authors.initials: K
authors.lastname: Goldsteen
authors.affiliation: Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY; Department of Preventative Medicine and Program in Public Health, Stony Brook University Medical Center, Stony Brook, NY, USA.
authors.forename: Norman H
authors.initials: NH
authors.lastname: Edelman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D018450:Disease Progression; D017723:Drug Utilization Review; D005260:Female; D005541:Forced Expiratory Volume; D019983:Guideline Adherence / Q000592:standards*; D054625:Healthcare Disparities / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards*; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013147:Spirometry; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs
chemical_list: D001993:Bronchodilator Agents
keywords: COPD exacerbations; COPD in US Veterans Affairs Medical Centers; COPD treatment guidelines