Adherence to guidelines for chronic obstructive pulmonary disease (COPD) may be improved by integrating respiratory specialists into general practitioner (GP) practices, according to study findings published in Thorax.
The pragmatic, cluster, randomized controlled INTEGR COPD study (ClinicalTrials.gov Identifier: NCT03482700) sought to determine whether integration of specialists (ie, consultant physicians, trainee respiratory physicians, and respiratory physiotherapists) into primary care affected guideline adherence.
A total of 18 practices in East Birmingham, United Kingdom, participated in the study. The practices were stratified based on the number of patients on their COPD registers and by patient list size. Eligible patients in these practices (ie, those with a documented COPD diagnosis) were then randomly assigned to either the intervention or usual care (control) arm.
Usual care included an annual COPD review. For patients in the control arm, this involved clinical and spirometry assessment completed by a GP or practice nurse at the GP practice; patients in the intervention cohort had their annual COPD review completed by a respiratory specialist.
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The provision of guideline-adherent care led to an impact on quality of life, COPD exacerbations, and COPD-related hospitalizations; however, further studies with larger cohorts are needed to determine if this impact is clinically significant.
Guideline adherence was evaluated as a binary outcome; participants who received at least 4 items in a “guideline care bundle” were regarded as having guideline-adherent care.
A total of 1242 patients were included in the intention-to-treat analysis between December 2017 and May 2019 — 656 from control practices (mean [SD] age, 69.7 [10.7] years; 52% male) and 586 from intervention practices (mean age, 67.8 [10.9] years; 52% male).
A greater increase in guideline adherence occurred in the intervention group compared with the control group. The odds ratio (OR) of adherence to 2017 and 2019 guidelines at 12 months was 4.14 (95% CI, 2.14-8.03) and 5.29 (95% CI, 2.76-10.13), respectively, in favor of the intervention group and was statistically significant (P <.001).
The intervention group had a lower COPD Assessment Test (CAT) score at follow-up, with a difference between groups of −1.78 (95% CI, −2.82 to −0.73; P =.001). A statistically significant difference with fewer hospitalizations occurred in the control group at follow-up, with an incidence rate ratio for intervention to control of 1.86 (95% CI, 1.38-2.52; P <.001).
No statistically significant difference was observed for the number of exacerbations at follow-up in the control vs intervention groups, although exacerbation frequency was poorly recorded, which disproportionately affected control practices.
Guideline adherence was associated with a statistically significant but not clinically significant decrease in CAT score and COPD exacerbation frequency.
A study limitation is that housebound patients were ineligible to participate. Other limitations include missing CAT scores and COPD exacerbation data, and the inability to blind clinicians, who were thus aware of the study’s allocation of patients to the control vs intervention arm.
“The provision of guideline-adherent care led to an impact on quality of life, COPD exacerbations, and COPD-related hospitalizations; however, further studies with larger cohorts are needed to determine if this impact is clinically significant,” the investigators stated.
Disclosure: The trial was funded by a noncommercial grant awarded by AstraZeneca. Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
