Chronic obstructive pulmonary disease and ...

Just Accepted by Current Medical Research & Opinion Chronic obstructive pulmonary disease and exacerbations: Clinician insights from the global Hidden Depths of COPD survey N Barnes, PMA Calverley, A Kaplan, KF Rabe doi: 10.1185/03007995.2013.867842 Abstract

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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 1,400 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.

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

Running title:


Global Hidden Depths of COPD Survey: Clinician results

Authors: N Barnes1*, PMA Calverley2, A Kaplan3, KF Rabe4

1

Department of Respiratory Medicine, London Chest Hospital (Barts Health NHS Trust), Bonner Road, London, E2 9JX, United Kingdom§

2

Division of Infection and Immunity, Clinical Sciences Centre, University Hospital Aintree, Lower Lane, Liverpool L9 7AL, United Kingdom

3

University of Toronto, Canada and Bedford Park Family Medical Centre, 17 Bedford Park Avenue, Richmond Hill, Ontario, Canada, L4C 2N9

4

University Kiel, Department of Medicine, Germany and LungenClinic Grosshansdorf, members of the German Center for Lung Research, D-22927 Grosshansdorf, Germany

* Corresponding author

§

Address at the time of manuscript preparation. Neil Barnes’ current address is: GSK Stockley Park,

West Uxbridge, Middlesex, UB11 1BT, United Kingdom.

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Email addresses: NB: [email protected] PMAC: [email protected] AK: [email protected]


KFR: [email protected]

Word count: abstract = 296; body text = 3,980 Number of Tables: 5 Number of Figures: 5 Previous presentation: Abstract 56, 2nd IPCRG Scientific Meeting, 26–27 May 2011, Amsterdam and CHEST 2011, 22–26 October, Honolulu, Hawaii

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Abstract 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 1,400 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

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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.

Keywords: COPD, exacerbation, clinician-reported, survey

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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.


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 1,051 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 COPD patients “brought it upon themselves”8. The RNNA study8 and other national surveys carried out in Belgium9, Switzerland10 and Germany11 also

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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 on their patients 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, with input and guidance from Takeda Pharmaceuticals International GmbH and FD Santé.

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.

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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 online supplement.

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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 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 Patient assessment and COPD diagnosis Of the 1,997 clinicians who responded, 1,662 fulfilled the recruitment criteria (Figure 1). Completed online responses were collected from 1,400 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

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reported 21% of their patients as having severe or very severe COPD, compared with 45% for respiratory specialists (Table 1). Both GPs 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 co-morbidities (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 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 9

combination with short- and long-acting beta agonists (SABAs and LABAs), 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.

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’ rather than to prescribe further treatment (58% of GPs and 67% of respiratory specialists) (Table 5).

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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 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 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 (63% and 68%, respectively) routinely recommended that their COPD patients

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take more exercise and perform breathing exercises to help manage symptoms. Only 16% of GPs and 10% of respiratory specialists 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 on themselves, compared with 88% of clinicians who took part in the RNNA survey8.

Clinicians were aware of common COPD co-morbidities, 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

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Endpoints (ECLIPSE) study14 and The Health 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 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, overuse 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 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 PDE4 inhibitor roflumilast, which was not widely available when the survey was carried 13

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 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 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

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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 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

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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.

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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 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.

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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 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 surveys and are not likely to introduce any severe bias or diminish the validity of the conclusions.

Conclusions

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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 (compared to 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.

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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.

Declaration of financial/ other relationships

NB has received honoraria for giving talks for the following companies: GlaxoSmithKline, AstraZeneca, Chiesi, Boehringer Ingelheim, Novartis, Teva and Takeda. PMAC has served on Scientific Advisory Boards of AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis and Takeda-Nycomed and has received research funding from AstraZeneca, BoehringerIngelheim, GlaxoSmithKline and Takeda. AK has served on advisory boards for Boehringer Ingelheim, Astra Zeneca, Takeda, Graceway, Novartis, Pfizer and Purdue. He has been given honoraria for giving talks for the above companies and Merck Frosst and Sanofi. KR has received research funding from Novartis, AstraZeneca, MSD and Takeda. He has also provided consultation services for AstraZeneca, Chiesi, Novartis, MSD and GlaxoSmithKline.

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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.


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.

Acknowledgments The authors thank ICM Research who managed the data collection, funded by Takeda Pharmaceuticals International GmbH. 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.

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Tables

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=standard error

Table 1: Diagnosis of COPD and assessment of disease severity

893 (64)

Respiratory Specialist 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)

GP Responder type, n (%) Smoking status, mean proportion of patients (SE) Heavy smoker (≥20 cigarettes/day) Moderate (10–20 cigarettes/day) Light (